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. "Reinforce the importance of treatment to a client who speaks a language different from the nurse." Effective communication requires using an interpreter rather than reinforcing information in a language the client may not understand.
B. "Minimize contact with a client who is angry." Avoiding an angry client can damage trust. The nurse should use therapeutic communication techniques to address their concerns.
C. "Use clinical terminology to help a client better understand their diagnosis." Clinical terminology can be confusing. The nurse should use simple, clear language to explain medical concepts.
D. "Fulfill a promise by allowing a client to visit with family members." Keeping promises builds trust and demonstrates reliability, a key component of the nurse-client relationship.
Correct Answer is D
Explanation
A. Interrupt the client's statement to clarify thoughts or ideas. Interrupting can make the client feel unheard and disrupt the flow of conversation.
B. Show emotion when a client is disclosing sensitive information. While empathy is important, the nurse should remain professional and composed to provide objective support.
C. Keep direct eye contact to a minimum. Avoiding eye contact may appear disinterested or disengaged.
D. Avoid looking at other clients on the unit. Maintaining focus on the client demonstrates active listening, engagement, and respect.
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