A nurse on a mental health unit is preparing to document an incident involving a client. Which considerations by the nurse will ensure competency in the documentation?

Choice A rationale
Maintaining an upright posture during a client interview is generally seen as a sign of attentiveness and professionalism. It shows that the nurse is focused on the conversation and respects the client’s concerns.
Choice B rationale
Sitting at a slight angle across from the clients is a part of active listening and is considered a positive nonverbal communication technique. It allows the nurse to maintain eye contact and observe the client’s nonverbal cues.

Choice C rationale
Maintaining eye contact throughout the interview is a positive nonverbal communication technique that shows the nurse is paying attention and is interested in what the client is saying. However, it’s important to note that in some cultures, direct eye contact may be considered disrespectful or intrusive.
Choice D rationale
Leaning away from the client throughout the interview can be perceived as a sign of disinterest or discomfort. It may give the impression that the nurse is not engaged in the conversation or is maintaining a distance from the client. This can hinder the development of a therapeutic nurse-client relationship.

Choice A rationale
The adolescent’s experimentation with drugs could be a coping mechanism to deal with the trauma of the sexual assault and the subsequent posttraumatic stress disorder (PTSD).
Substance use, including drug use, is often a maladaptive coping strategy used by individuals

who have experienced trauma to numb their feelings, escape from their reality, or attempt to regain control. This must indeed be a difficult time for both the adolescent and the parent.
Choice B rationale
While experimentation is a part of normal adolescent behavior, it is not normal or healthy for an adolescent to use drugs, especially in response to a traumatic event such as a sexual assault. Drug use can lead to addiction, health problems, and further psychological distress. Therefore, it is something to be concerned about and addressed appropriately.
Choice C rationale
While it is important to understand and address the parent’s concerns, the focus should be on the adolescent’s needs. The adolescent is dealing with the aftermath of a sexual assault and a diagnosis of PTSD, and is using drugs. These are serious issues that need to be addressed with professional help. The question of which behavior to address first should be determined based on the adolescent’s immediate safety and well-being.
Choice D rationale
It is not helpful to label the adolescent’s behavior as misbehavior or to compare them to their siblings. Each child is unique and may react differently to stress and trauma. Instead of focusing on rules and comparisons, it would be more beneficial to provide support, understanding, and appropriate professional help.