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The nurse is providing care to a male patient who is hospitalized with a diagnosis of schizophrenia. Which of the following would be appropriate for the nurse to include in the patient?s medical record?
- A. Patient states that he had a good night with no complaints.
- B. Complained of being unable to sleep because he heard voices throughout the night.
- C. Had a typical night without incidence of insomnia or nightmares.
- D. Acted crazily throughout the night; kept hearing voices and noises.
Correct Answer: B
Rationale: Documentation should be specific, objective, and reflect patient statements or symptoms, such as reporting inability to sleep due to hearing voices, which is relevant to schizophrenia. Terms like ?crazily? are unprofessional.
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A nursing instructor is preparing a class discussion on the topic of self-determinism. Which of the following would the instructor expect to include?
- A. Personal autonomy as a key value
- B. Choices based on pleasing others
- C. Activities reflect personal goals
- D. Right to refuse treatment
- E. Lack of empowerment
Correct Answer: A,C,D
Rationale: Self-determinism involves personal autonomy, activities reflecting personal goals, and the right to refuse treatment, emphasizing patient control over their healthcare decisions.
A patient receives a court order for commitment. Which of the following best exemplifies the concept of least restrictive environment?
- A. Involuntary commitment to an outpatient community mental health center
- B. Medication administration for sedation so the patient cannot get out of bed
- C. Placing the patient in a locked padded room in response to threats of self-harm
- D. Allowing the patient to make the decision about whether treatment is necessary
Correct Answer: A
Rationale: The least restrictive environment principle requires that treatment occur in the least confining setting possible, such as outpatient community mental health care, unless more restrictive measures are necessary for safety.
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: Documenting a patient?s subjective report of feeling better is factual and low-risk, whereas administering medication, describing behavior, or applying restraints carries higher legal risk if not properly justified or executed.
A patient is going to be discharged this afternoon from the mental health unit. The patient asks the nurse if a copy of his medical record could be sent to the psychologist he will be seeing on an outpatient basis. Which response by the nurse would be most appropriate?
- A. Sure, we?ll have that information sent out in today?s mail.
- B. You will need to sign written authorization for us before we can do this.
- C. I think it would just be best if you just told your psychologist everything he needs to know.
- D. How are you feeling about being discharged this afternoon?
Correct Answer: B
Rationale: HIPAA requires written patient authorization to release medical records to another provider, ensuring confidentiality and patient control over their health information.
After teaching a class about competency and how it is assessed, the nursing instructor determines the need for additional instruction when the class identifies which ability as being evaluated?
- A. Communication of choices
- B. Understanding of relevant information
- C. Appreciation for situation and consequences
- D. Discussion of what is right and wrong
Correct Answer: D
Rationale: Competency assessment evaluates the ability to communicate choices, understand relevant information, and appreciate the situation and consequences, not moral judgments about right and wrong.