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: 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: 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: 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: 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.