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 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.
Correct Answer is B
Explanation
A. Avoid eye contact with the client to prevent the client from feeling awkward. Avoiding eye contact may come off as dismissive and can hinder rapport-building.
B. Remain silent after asking the client a question to allow the client a chance to respond. Using therapeutic silence gives the client time to gather their thoughts and feel heard.
C. Ask questions that only require one-word answers to prevent anxiety about answering detailed questions. Open-ended questions encourage communication and help establish trust.
D. Have music on in the background to distract the client from being anxious. Music might be a distraction rather than a rapport-building tool, as it may prevent active listening.
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