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?

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.

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.

Correct Answer: B

Rationale: The correct answer is B: Feelings. In the biopsychosocial model, the psychological domain focuses on the individual's emotions, thoughts, and behaviors. Assessing feelings allows the nurse to understand the patient's mental and emotional state, which is crucial in mental health care. Sleep patterns (A) fall under the biological domain, family functioning (C) falls under the social domain, and cultural groups (D) relate to the social and cultural aspects, not specifically the psychological domain. By assessing feelings, the nurse can gain insight into the patient's mental health and tailor interventions accordingly.

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.

Correct Answer: B

Rationale: The correct answer is B because when documenting administration of PRN medication, the nurse must include the reason for administration, dosage, route, and response every time it is given. This ensures comprehensive documentation for monitoring the patient's response to the medication and helps in evaluating the effectiveness of the treatment. Option A is incorrect because documenting the response is necessary each time, not just the first time. Option C is incorrect as it does not include documenting the response, which is crucial for assessing the medication's effectiveness. Option D is also incorrect as it excludes documenting the response, which is essential for evaluating the patient's progress.

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.

Correct Answer: C

Rationale: The correct answer is C: A domain of information. The multiaxial diagnostic system of the DSM-IV-TR includes five axes, each representing a different domain of information about an individual's mental health. Axis I is for clinical disorders, Axis II is for personality disorders and intellectual disabilities, Axis III is for general medical conditions, Axis IV is for psychosocial and environmental stressors, and Axis V is for global assessment of functioning. Therefore, each axis represents a distinct category or domain of information rather than an evidence-based research finding (A), an experimental design (B), or a laboratory test finding (D). The axes serve to provide a comprehensive and holistic assessment of an individual's mental health status.

Correct Answer: B

Rationale: The correct answer is B: Albert Bandura's social cognitive theory. The nurse is integrating this theory by demonstrating behaviors for the patient to develop through observational learning and modeling. Bandura's theory emphasizes that individuals learn by observing others and imitating their behaviors. The treatment team is likely using this approach to encourage the patient to adopt positive behaviors by showcasing them through the nurse's actions. Incorrect Choices: A: Erikson’s model of psychosocial development - This theory focuses on stages of psychosocial development and identity formation, not on observational learning or modeling. C: Skinner’s operant conditioning - This theory revolves around reinforcement and punishment to shape behavior, which is different from the observational learning emphasized in the scenario. D: Freud’s psychoanalytic model - This theory is based on unconscious processes and early childhood experiences, not on observational learning and modeling as seen in the nurse's behavior.

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,