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: 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,

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: 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.

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: 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.

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.