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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Related Questions
Correct Answer is C
Explanation
A. "Implied consent cannot be assumed if a client is unable to communicate their wishes in an emergency situation." In emergencies, implied consent is assumed if immediate treatment is necessary to prevent harm.
B. "A nurse can explain the benefits and risks of treatment to a client to obtain informed consent." Only the provider (physician, NP, or PA) can obtain informed consent; the nurse can reinforce and clarify information but not obtain it.
C. "Informed consent must include information about potential alternative treatments that are available to the client." Informed consent requires the provider to discuss potential alternative treatments, risks, benefits, and consequences of refusal.
D. "Implied consent cannot be assumed until a client verbalizes their desire to receive treatment." Implied consent can be assumed based on actions, such as extending an arm for a blood draw.
Correct Answer is D
Explanation
A. Avoid including the client's religious affiliation when discussing treatment options. Religious beliefs can impact medical decisions, so omitting this information could overlook important care considerations.
B. Include each piece of collected demographic data during change-of-shift report. Not all demographic data are relevant to patient care, and oversharing may lead to unnecessary biases.
C. Record the client’s spirituality as normal in the plan of care. Spirituality is personal and subjective, so labeling it as “normal” is inappropriate and not bias-free.
D. Provide relevant demographics during a treatment team meeting. This ensures demographic information is included only when it impacts care, avoiding bias while maintaining patient-centered treatment.
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