A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

The nurse establishes rapport with the client in an inpatient psychiatric setting.

The nurse documents accurately and honestly in the electronic health record.

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission.

The nurse refers to the policy of the inpatient psychiatric setting when uncertain of a standard of care.

Answer and Explanation

The Correct Answer is C

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

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Correct Answer is C

Explanation

What has it been like for you since your wife died? This statement shows empathy and invites the client to share his feelings and experiences.

It also acknowledges the client’s loss and validates his grief.

Choice A. Tell me how your wife died.

This statement is too intrusive and may cause the client to feel uncomfortable or defensive. It also focuses on the past event rather than the present situation.

Choice B. Have you considered attending a grief group? This statement is too premature and may imply that the nurse is trying to solve the client’s problem or dismiss his feelings.

It also assumes that the client needs or wants a grief group.

Choice D. You have wonderful children and grandchildren who are very supportive.

This statement is too superficial and may minimize the client’s grief or make him feel guilty. It also shifts the attention away from the client and his wife.

A. Speak loudly since the client is unable to observe nonverbal cues. B. Touch the client prior to speaking to gain the client’s attention. C. Orient the client to the arrangement of the room to promote independence. D. Keep the bed in the highest position to prevent the client from getting out of bed alone.

Correct Answer is C

Explanation

Orient the client to the arrangement of the room to promote independence. This strategy helps the client who is blind to navigate the environment safely and confidently. It also shows respect for the client’s autonomy and dignity.

Choice A is wrong because speaking loudly is not necessary for a client who is blind, unless they also have hearing impairment. Speaking loudly may imply that the client is less intelligent or capable, which is not true.

Choice B is wrong because touching the client prior to speaking may startle or frighten them. It is better to identify oneself verbally and ask for permission before touching the client.

Choice D is wrong because keeping the bed in the highest position may increase the risk of injury if the client tries to get out of bed alone. It also restricts the client’s mobility and independence, which may affect their self-esteem and quality of life.

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A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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