Legal + Documenting PrepU
The nurse manager is using voluntary standards as a guideline for developing policies on the unit. What voluntary standards are available for the nurse to use? (Select all that apply.) -State nurse practice acts -Rules and regulations of nursing -American Nurses Association -Standards of Practice -Professional standards for certification of individual nurses in general practice -Process of certification
-American Nurses Association Standards of Practice -Professional standards for certification of individual nurses in general practice -Process of certification Explanation: Voluntary standards in nursing would include the American Nurses Association (ANA) Standards of Practice, the process of certification, and professional standards for certification of individual nurses in general practice. State nurse practice acts is not an example of voluntary standards in nursing. Rules and regulations of nursing are not examples of voluntary standards in nursing.
Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? -A client has asked a nurse if he can read the documentation that his physician wrote in his chart. -A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. -A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. -A client who resides in Indiana has required hospitalization during a vacation in Hawaii.
A client has asked a nurse if he can read the documentation that his physician wrote in his chart. Explanation: Among the provisions of HIPAA are clients' rights to see and read their medical records. Negotiation with an insurance provider, the necessity of a second opinion, and out-of-state care are aspects of care that fall within the specific auspices of HIPAA.
Which documentation tool will the nurse use to record the client's vital signs every 4 hours? A flow sheet Acuity charting forms Medication record 24-hour fluid balance record
A flow sheet Explanation: A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.
Which of the following is an example of certification? -A nurse who demonstrates advanced expertise in a content area of nursing through special testing. -A graduate of a nursing education program who passes NCLEX-RN. -An education program that meets standards of the National League for Nursing. -A hospital that meets the standards of the Joint Commission.
A nurse who demonstrates advanced expertise in a content area of nursing through special testing. Explanation: Certification is a voluntary process whereby a person who has met criteria established by a nongovernmental association is granted special recognition in a specified practice area. Licensure is granted by the state to a graduate of a nursing education program who passes NCLEX-RN. Accreditation is a voluntary process by which a nursing education program is recognized as having met certain standards by the National League for Nursing Accrediting Commission and/or the American Association of Colleges of Nursing. The Joint Commission can also accredit health care agencies.
A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? -Calling the client information desk to find out the room number of the family member -Finding the emergency medical technicians that transported the family members about the injuries -Asking the emergency department nurse for information on the family member -Accessing the electronic health record of the family member to find out extent of injury
Calling the client information desk to find out the room number of the family member Explanation: Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.
According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? Documentation Accreditation Psychomotor skills Clinical judgment
Documentation Explanation: Documentation is the primary source of evidence use to measure performance outcomes, according to the ANA. Accreditation, psychomotor skills, and clinical judgment are incorrect.
When the nurse informs a client's employer of his autoimmune deficiency disease, the nurse is committing the tort of: Breach of contract Assault Invasion of privacy Battery
Invasion of privacy Explanation: Nurses have access to information recorded in the medical record, information shared or observed through care or interactions with friends and family, and through access to the client's body. A loss of privacy occurs if others inappropriately use their access to a person.
An HIV-positive client discovers that his name is published in a research report on HIV care prepared by his nurse. He is hurt and files a lawsuit against her. Which offense has the nurse committed? Unintentional tort Invasion of privacy Defamation of client Negligence of duty
Invasion of privacy Explanation: The nurse has committed the tort of invasion of privacy. Personal names and identities are concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation, and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably.
A client informs the nurse that he wants to discontinue his treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation? -Let the client go after signing a document stating he is going against medical advice. -Restrain the client until his medical treatment is over. -Call the physician and get his discharge paper signed. -Warn the client that he may not be able to access health care again.
Let the client go after signing a document stating he is going against medical advice. Explanation: If a client wishes to go before his medical treatment is finished, he should sign a document indicating personal responsibility for leaving against medical advice. The nurse should not restrain the client, as it would make the nurse liable for legal action. The nurse may call the physician and get the discharge paper signed, but this is not appropriate. The nurse cannot warn the client that he will be denied health care in future, because it is his right to access the health care facility whenever he needs.
While caring for an infant, the nurse hears another child screaming in the next room. She rushes to the other room to check on the screaming child, forgetting to put the side rails up on the infant's crib. She returns to the room to find the infant has fallen out of the crib and sustained a head injury. Based on the nurse's action, which tort is the nurse liable for? Defamation Malpractice Assault Battery
Malpractice Explanation: The nurse did not ensure the safety of the infant by pulling up the side rails before leaving the infant unattended. Therefore, the nurse may be charged with malpractice because she had a duty that she breached; there was causation with harm to the infant. Assault occurs when a person threatens to touch a client without consent. Battery is carrying out the threat by touching the client without consent, whereas defamation occurs when a derogatory remark is made about another person.
A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse? Sedate the client. Get written consent. Obtain a medical order. Notify the family.
Obtain a medical order. Explanation: Nurses must obtain a medical order before each and every instance in which they use restraints. Due to the severity of the client illness requiring endotracheal intubation, the client may not be able to provide a written consent. The client does not need to be sedated unless medically necessary, and although it is appropriate to notify the family, this is not the priority.
To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for? Reinforcing data Response Recommendations Report
Recommendations Explanation: SBAR stands for Situation, Background, Assessment, and Recommendations
The health care provider prescribes orders for a client with newly diagnosed uncontrolled seizure activity. When reviewing the prescriptions, the nurse correctly identifies which prescription, if followed, puts him at risk for negligence charges? Neurologic assessments every 5 minutes Oxygen 2/L via nasal cannula Diazepam (Valium) 5 mg intravenously now Restrain all four extremities
Restrain all four extremities Explanation: The nurse is obligated to carry out health care provider's orders unless it is unclear or incorrect. The client with seizures must be protected from harm. Restraints restricts the client's movement and can cause harm. Diazepam, oxygen, and frequent neurologic assessments are correct interventions for a client with uncontrolled seizure activity.
A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged? Libel Slander Negligence Malpractice
Slander Explanation: The nurse can be charged with slander, which is a verbal attack on a person's character. Libel pertains to damaging written statements read by others. Both libel and slander are considered defamation of character - an intentional tort in which one party makes derogatory remarks about another that diminish the other party's reputation. Negligence and malpractice pertain to actions which are committed or omitted, thereby causing physical harm to a client.
A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology? Client engagement technology Data aggregation technology Telemedicine and mobile technology Population health management technology
Telemedicine and mobile technology Explanation: Telemedicine and mobile health technology facilitate client engagement, while helping providers deliver more cost-effective care. Telemedicine embraces applications and services that include two-way video communications, e-mail, and wireless phones. Mobile health features multiple technologies integrated into the increasingly wireless and mobile health care delivery system. Client engagement technology would include the concept of client portals (where clients can access an electronic medical record system and personal health information); online appointments scheduling; and personalized, condition-focused alerts/reminders in the form of e-mails, automated telephone calls, or text messages. Data aggregation is a process that involves data collection, analysis, use, reporting, and delivery of feedback throughout the organization. Organizations will use process and outcomes data to measure what they achieve for clients and population-based communities. Population health management technology performs data mining, risk stratification, and analysis. Searches can be conducted for disease trends, diagnoses, procedures, and missed appointments.
Which strategy could be implemented by the nurse in ensuring the protection of electronic data at healthcare agencies? -The nurses are expected to change their access number and password less frequently. -The nurse is being asked to remove screen saver for data that have been displayed for prolong periods. -The nurse gives unlimited access to the multidisciplinary team so that personnel from various departments could retrieve the data. -The nurse locks out client information, except to those who have been authorized through appropriate security measures.
The nurse locks out client information, except to those who have been authorized through appropriate security measures. Explanation: Locking out client information except to those who have been authorized through fingerprints or voice activation is correct, since this enhances confidentiality and protects electronic data in health agencies. Less frequently changing access numbers and passwords is incorrect, since this could allow staff who have left the agency to compromise the system. Removing automatic save and screen saver for data that have been displayed for prolong periods is incorrect, since this practice could allow unscrupulous individuals onto the system. Providing unlimited data access to the multidisciplinary team so personnel from various departments could retrieve the data is incorrect, because this could allow all staff access to information that does not impact their jobs.
A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal ECG waves, indicating arterial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which of the following describes the nurse's legal liability? Felony Defamation Tort Slander
Tort Explanation: A tort is a cause of action in which one person asserts that a physical, emotional, or financial injury was a consequence of another person's actions or failure to act. A tort implies that a person breached his duty to another person. In this case, the nurse had a duty that was breached. A felony is a serious criminal offense, such as murder. Defamation is an act in which untrue information harms a person's reputation. Slander is a character attack uttered orally in the presence of others.
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: have the right to copy their health records. need to obtain legal representation to update their health records. can be punished for violating guidelines. are required to obtain health record information through their insurance company.
have the right to copy their health records. Explanation: HIPAA affords clients the right to see and copy their health records, update their health records, and get a list of disclosures that a health care institution has made for the purposes of treatment, payment, and health care operations. Clients have the right to request a restriction on certain uses or disclosures and choose how to receive this health information. HIPAA includes punishments for anyone caught violating client privacy, but these punishments are not directed at the client because HIPAA was implemented to protect the privacy of an individual's health information.
While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects: invasion of privacy. defamation of character. professional negligence. false imprisonment.
invasion of privacy. Explanation: The nurse's action reflects an invasion of the client's privacy. Disclosing confidential information to an inappropriate third party subjects the nurse to liability for invasion of privacy, even if the information is true. Defamation of character includes false communication that results in injury to a person's reputation. Negligence is an act of omission or commission. Prevention of movement or unjustified retention of a person without consent may be false imprisonment.
Besides being an instrument of continuous client care, the client's health care record also serves as a(an): assessment tool. legal document. Kardex. incident report.
legal document. Explanation: The client record serves as a legal document of the client's health status and care received.