A nurse is supervising a group of staff members on a mental health unit. Which of the following actions require the nurse to complete an incident report?

An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom.

An assistive personnel applies physical restraints on a client who is aggressive

An assistive personnel tells the provider that a client is making other clients feel unsafe.

An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm.

Answer and Explanation

The Correct Answer is B

A. An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom: Reapplying a soft limb restraint in itself does not necessarily require an incident report. However, the application must follow proper protocols, and the nurse should ensure that the assistive personnel are trained and following the correct procedures.
B. An assistive personnel applies physical restraints on a client who is aggressive: Physical restraints should only be applied with a physician's order and in accordance with facility policies. If restraints are applied without proper authorization or protocol, an incident report must be completed.
C. An assistive personnel tells the provider that a client is making other clients feel unsafe: Reporting concerns to the provider about a client's behavior is part of proper communication and does not require an incident report.
D. An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm: This is an appropriate and necessary intervention for a client at risk of self-harm. It does not require an incident report, as the staff member is performing their duty to ensure the safety of the client.

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Free Nursing Study Resources

Correct Answer is ["B","E","F","G"]

Explanation

Rationale for correct choices:

Offer emergency contraception: In cases of sexual assault, emergency contraception should be offered as soon as possible to prevent pregnancy. This is a standard part of care for survivors of sexual violence, ideally within 72 hours after the assault.
Collect and preserve evidence: Collecting and preserving physical evidence is critical for legal and forensic purposes. This includes clothing, swabs, and other materials that may help in a potential investigation. The nurse should follow proper protocols to ensure evidence is preserved without contamination.
Administer sexually transmitted infection prophylaxis: Given the risk of sexually transmitted infections (STIs) following sexual assault, prophylaxis should be provided immediately, especially for high-risk infections such as chlamydia, gonorrhea, and HIV.
Document the assessment findings in written and photographic form: Proper documentation of the client's physical findings, including bruising, broken fingernails, and other injuries, is essential for both legal purposes and ongoing medical care.

Rationale for incorrect choices:

Allow the client to shower prior to their genital examination: The client should not be allowed to shower or change clothes before the genital examination or evidence collection, as this could wash away important forensic evidence, such as bodily fluids or hair.
Initiate a prescription for an antidepressant: While it is important to offer psychological support and follow-up care, prescribing an antidepressant should not be the immediate action. The client may require further assessment by a mental health professional to determine the most appropriate treatment.
Perform a rapid HIV test: While HIV exposure is a concern after sexual assault, a rapid HIV test immediately following an assault will likely be negative as there is an incubation period (window period) before antibodies can be detected. Post-exposure prophylaxis (PEP) for HIV is the more appropriate immediate intervention.

A. Helping a client fulfil a need that they are unable to complete independently B. Assuring that the health care provider tells the truth and does not mislead C. Avoiding intentionally or unintentionally harming clients D. Maintaining the premise that all clients are to be treated equally

Correct Answer is A

Explanation

A. Helping a client fulfill a need that they are unable to complete independently: Advocacy in healthcare involves supporting and promoting the rights of clients. It includes helping clients meet their needs, especially when they are unable to do so independently due to illness, circumstances, or limitations.
B. Assuring that the health care provider tells the truth and does not mislead: This refers to veracity, which involves truth-telling and honesty in communication with clients, but it does not fully capture the broader role of advocacy.
C. Avoiding intentionally or unintentionally harming clients: This defines nonmaleficence, an ethical principle focused on preventing harm. While important in healthcare, it is not specific to advocacy.
D. Maintaining the premise that all clients are to be treated equally: This refers to justice, an ethical principle that ensures fairness and equality in treatment. It is related to but distinct from advocacy, which is more focused on supporting the client's individual needs.

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A nurse is supervising a group of staff members on a mental health unit. Which of the following actions require the nurse to complete an incident report?

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Naxlex Comprehensive Predictor Exams

Based on the assessment findings, which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["B","E","F","G"]

Explanation

A nurse on a mental health unit is preparing an in-service about ethical concepts when providing client care. Which of the following definitions should the nurse include when discussing advocacy?

Correct Answer is A

Explanation

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