A nurse on a mental health unit is preparing to document an incident that occurred involving a client. Which of the following considerations by the nurse will ensure competency in the documentation?
The nurse describes what happened by providing general and broad details.
The nurse includes the client's own words when describing what happened.
The nurse describes what happened subjectively.
The nurse includes the opinions of other team members.
The Correct Answer is B
A. The nurse describes what happened by providing general and broad details. Incident reports should be factual, objective, and specific, not general or vague.
B. The nurse includes the client's own words when describing what happened. Including direct quotes from the client ensures accuracy and avoids interpretation or bias.
C. The nurse describes what happened subjectively. Incident reports must be objective, avoiding personal opinions or assumptions.
D. The nurse includes the opinions of other team members. Only document observable facts and direct quotes—opinions should not be included.
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Correct Answer is D
Explanation
A. Projection is a defense mechanism where a client attributes their own feelings to someone else (e.g., “I know you don’t like me” when they actually dislike the nurse).
B. Countertransference is the nurse’s emotional reaction toward the client, not the client’s reaction to the nurse.
C. Empathy involves understanding and sharing another person’s emotions, which is not what is happening in this scenario.
D. Transference occurs when a client projects feelings about another person onto the nurse (e.g., seeing the nurse as a loved one).
Correct Answer is B
Explanation
A. Not being chosen for a sports team: While disappointing, this is not considered an ACE because it does not involve abuse, neglect, or household dysfunction.
B. Experiencing physical abuse from a family member: Physical abuse is a recognized ACE, as it can lead to long-term psychological and physical health consequences.
C. Being teased by classmates : Bullying is harmful but is not classified as an ACE unless it involves severe abuse or trauma within the home.
D. Getting a low grade on a test: Poor academic performance is not considered an ACE unless it results from neglect, abuse, or extreme household dysfunction.
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