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A psychiatric-mental health nurse is documenting information in a patient’s medical record. Which of the following would be least likely to increase the nurse’s legal liability?
- A. `Patient reported that he was feeling better today than yesterday.
- B. `Administered haloperidol 10 mg IM stat as ordered for agitation.
- C. `Patient was talking with another staff member and started screaming.
- D. `Applied restraints to all four patient extremities.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Patient's self-report of feeling better is subjective and reflects the patient's perception, not the nurse's actions or decisions.
2. This documentation does not involve any direct intervention or action by the nurse, hence reducing legal liability.
3. It reflects positive progress in the patient's condition, which is generally a favorable indicator in psychiatric care.
4. It does not raise concerns about potential adverse outcomes or deviations from standard practice.
Summary:
- Choice A is least likely to increase legal liability as it is a subjective report by the patient.
- Choices B, C, and D involve direct actions or interventions by the nurse that could have legal implications and potential risks to patient safety.
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A nursing instructor has prepared a lecture about the scope and standards of practice of psychiatric nurses. The instructor determines that the teaching was effective when the students identify which of the following as common to both basic and advanced level practice?
- A. Case management
- B. Program development
- C. Clinical supervision
- D. Community interventions
Correct Answer: A
Rationale: The correct answer is A: Case management. This is common to both basic and advanced level practice for psychiatric nurses because it involves coordinating care, advocating for patients, and ensuring continuity of services. Basic level nurses may handle simpler cases, while advanced level nurses may manage more complex cases.
Choice B: Program development may be more common in advanced practice where nurses may be involved in creating new programs or services.
Choice C: Clinical supervision is typically a responsibility of advanced practice nurses who oversee and guide other staff members.
Choice D: Community interventions may also be more common in advanced practice where nurses may lead community-based initiatives.
A psychiatric-mental health nurse is providing care to a patient who has recently emigrated to the United States from Eastern Europe. Which of the following would be least effective in providing culturally competent care?
- A. Demonstrating a genuine interest in the patient
- B. Avoiding assumptions about the patient’s culture
- C. Speaking to the patient in his native language.
- D. Acquiring information about the patient’s country
Correct Answer: C
Rationale: The correct answer is C because speaking to the patient in his native language may not always guarantee effective communication. The patient may have acculturated to English and prefer to communicate in English. It is important to assess the patient's language preference first. Demonstrating genuine interest (A) is important for building trust. Avoiding assumptions (B) helps prevent stereotyping. Acquiring information about the patient's country (D) can enhance understanding of the patient's background.
A psychiatric-mental health nurse determines that a patient is competent when he is able to do which of the following?
- A. Speak coherent English.
- B. Communicate his or her choices.
- C. Write a `living will.
- D. Comply with the medical regimen.
Correct Answer: B
Rationale: The correct answer is B because competency involves the ability to communicate one's choices. Competency is determined by the patient's capacity to understand information, make reasoned decisions, and communicate preferences. This enables the patient to actively participate in their healthcare decisions. Choices A, C, and D are incorrect because speaking coherent English, writing a living will, and complying with a medical regimen do not solely demonstrate competency in decision-making and communication of choices. These actions may be important but do not encompass the full scope of competency in the context of psychiatric-mental health nursing.
A nursing instructor is preparing a class about rural cultures and the influence on mental health problems. Which of the following would the instructor include as impacting the use of mental health services for this group? Select all that apply.
- A. Limited access to care
- B. Lack of available resources
- C. Geographical similarities
- D. Diverse cultural groups
Correct Answer: A
Rationale: The correct answer is A: Limited access to care. Rural cultures often face barriers such as distance to healthcare facilities, shortage of mental health professionals, and lack of transportation. This limits their ability to access mental health services. Choice B is incorrect as lack of resources usually refers to financial resources, not necessarily availability of mental health services. Choice C is incorrect as geographical similarities do not directly impact the use of mental health services. Choice D is incorrect as diverse cultural groups may actually contribute to a greater awareness and acceptance of mental health services within rural cultures.
A psychiatric-mental health nurse is providing care for a patient with a mental disorder. The patient is participating in the decision-making process. The nurse interprets this as which component of recovery?
- A. Self-direction
- B. Empowerment
- C. Person-centered
- D. Holistic
Correct Answer: A
Rationale: The correct answer is A: Self-direction. In the context of recovery, self-direction refers to the patient's ability to actively participate in decisions regarding their care and treatment. By involving the patient in the decision-making process, the nurse is promoting the patient's autonomy and self-determination, which are key components of recovery in mental health. This approach empowers the patient to take control of their own recovery journey and promotes a sense of ownership over their treatment plan.
Summary of other choices:
B: Empowerment - While empowerment is related to self-direction, it focuses more on giving the patient the tools and resources to make informed decisions rather than actively involving them in the decision-making process.
C: Person-centered - This choice emphasizes tailoring care to the individual's unique needs and preferences, which is important in recovery but not specifically related to the patient's active participation in decision-making.
D: Holistic - This choice pertains to considering all aspects of the patient's well-being, including physical,