How should the nurse document the behavior of a patient with mental illness?

Very disruptive to a person in society

Differing from socially acceptable behavior

Causing the person to be involved in problems

Resulting from an inability to exercise control

Answer and Explanation

The Correct Answer is B

A. Very disruptive to a person in society: This description is judgmental and not specific to documenting behavior objectively.

B. Differing from socially acceptable behavior: Documenting behavior as differing from socially acceptable norms provides an objective, non-judgmental account of the patient’s behavior.

C. Causing the person to be involved in problems: This focuses on the outcomes of the behavior rather than describing the behavior itself.

D. Resulting from an inability to exercise control: This may imply a lack of control but does not objectively describe the behavior for documentation purposes.

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Correct Answer is C

Explanation

A. The sites of entry and exit: While important for assessing burn severity, immediate concern is not the primary issue.
B. Control of bleeding: Electrical burns do not typically cause significant external bleeding.
C. The likelihood of cardiac arrest: Electrical burns can cause cardiac arrhythmias or arrest, making this the primary concern.
D. The extent and depth of the burn While important for treatment, the immediate concern is cardiac arrest.

A. "What we say can be secret. What I write in the chart is available to the health team." B. "I am required to report any intent to hurt yourself or others." C. "Conversations between patient and nurse are confidential." D. "I can't help you unless you trust me."

Correct Answer is B

Explanation

A. "What we say can be secret. What I write in the chart is available to the health team." This response lacks clarity about legal and ethical obligations.
B. "I am required to report any intent to hurt yourself or others." This response clearly communicates the legal and ethical obligation to protect the patient and others from harm, while also acknowledging the importance of patient confidentiality in other situations.
C. "Conversations between patient and nurse are confidential." This is true, but it does not address exceptions such as harm to self or others.
D. "I can't help you unless you trust me." This does not address the patient's concerns about confidentiality directly.

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How should the nurse document the behavior of a patient with mental illness?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse arrives at an accident scene where the victim has just received an electrical burn. Which is the nurse's primary concern?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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