A psychiatric nurse documents in a client's chart:"Seems to have no regard for legal or ethical standards. A problem client who needs constant limit setting." Which response by the nurse manager reflects the potential liability related to this entry?

Correct Answer: C

Rationale: The correct answer is C: "Documenting this puts you at risk for defamation of character." This is because the nurse's statement could harm the client's reputation by implying they have no regard for legal or ethical standards. Defamation of character involves making false statements that harm someone's reputation. The nurse's documentation could be seen as libel if it's in writing. A: "Documenting this breaches the client's right to confidentiality." This is incorrect because the issue is not about breaching confidentiality but rather about potentially harming the client's reputation. B: "Documenting this puts you at risk for malpractice." This is incorrect because malpractice typically involves a failure to meet the standard of care, not necessarily defamation of character. D: "Documenting this breaches the client's right to informed consent." This is incorrect as informed consent relates to the client's understanding and agreement to treatment, not to the nurse's documentation of behavior.

Correct Answer: C

Rationale: The correct answer is C: The patient's verbal and nonverbal messages are incongruent. This is correct because the patient's statement "I enjoy spending time with you" does not align with their fidgeting, tapping foot, covering face, and looking under the chair - all signs of discomfort or unease. The incongruence between the verbal and nonverbal cues suggests a potential discrepancy between what the patient is saying and how they are truly feeling. A: The patient's behavior does not necessarily indicate positive feedback about the nurse's communication techniques. B: There is no indication of the nurse misinterpreting the patient's behavior based on cultural differences. D: There is no evidence to suggest that the patient is demonstrating psychotic behaviors based on the given information. In summary, the correct answer highlights the importance of recognizing and interpreting both verbal and nonverbal cues to gain a comprehensive understanding of a patient's communication.

Correct Answer: A

Rationale: The correct answer is A: The importance of using therapeutic communication was stressed by Nightingale. Florence Nightingale, considered the founder of modern nursing, emphasized the significance of therapeutic communication in nursing practice. Nightingale's focus was on creating an environment conducive to healing through effective communication with patients. Explanation: Nightingale's emphasis on therapeutic communication laid the foundation for psychiatric-mental health nursing. Incorrect Answers: B: The use of self-care to enhance the immune system was taught by Dorothea Dix. Dorothea Dix was a mental health advocate, not known for teaching self-care to enhance the immune system. C: The moral treatment of mental illness was a primary focus of deinstitutionalization. Deinstitutionalization aimed to shift care from mental hospitals to community-based settings, not primarily focusing on moral treatment. D: Peplau was the first nurse to stress the importance of therapeutic communication. While Peplau made significant contributions to psychiatric nursing, Night

Correct Answer: B

Rationale: The correct answer is B: Albert Bandura's social cognitive theory. Bandura's theory emphasizes observational learning, where individuals acquire new behaviors through watching others. In this scenario, the nurse is demonstrating behaviors for the patient to develop, aligning with Bandura's theory. This theory also emphasizes self-efficacy and the role of cognitive processes in behavior change, which are relevant in healthcare settings. Choice A (Erikson's model of psychosocial development) focuses on stages of psychosocial development across the lifespan, which is not directly related to the nurse's demonstration of behaviors. Choice C (Skinner's operant conditioning) emphasizes reinforcement and punishment to shape behavior, which is not the primary mechanism at play in the nurse's demonstration. Choice D (Freud's psychoanalytic model) emphasizes unconscious processes and early childhood experiences, which are not directly applicable to the nurse's intentional demonstration of behaviors.

Correct Answer: A

Rationale: Rationale for Correct Answer A: The statement "I need to be careful because the drug can make me sleepy" demonstrates understanding of a common side effect of imipramine, which is sedation. This shows that the patient comprehends the need to be cautious while taking the medication to prevent accidents or injuries due to drowsiness. Incorrect Choices: B: This statement is incorrect because imipramine can cause orthostatic hypotension, leading to dizziness when changing positions. C: This statement is incorrect because excess saliva is not a common side effect of imipramine. D: This statement is incorrect because imipramine can actually cause constipation rather than diarrhea, so avoiding fiber is not necessary.