Mental Health: Chapter 6

The nurse is caring for an angry patient on an involuntary emergency hold refusing antianxiety medication. Which is the best response by the nurse? "It is within your rights to refuse all medications." "If you do not take your medication, we will call security." "I see that you are angry. Your behavior is what brought you here and your uncooperative behavior is what can keep you here." "I understand you are angry about your admission. This medication can help you relax and we can sit and talk about what brought you here."

"I understand you are angry about your admission. This medication can help you relax and we can sit and talk about what brought you here."

A patient with suicidal ideation is being admitted and asks to wear her grandmother's scarf as a reminder of her. Which response by the nurse is most appropriate? "Be sure you tie the scarf very loosely." "It is a very nice scarf. Allow me tie it for you?" "It is your decision to wear the clothing you desire." "I understand; however, it is best for you not to wear the scarf. We will put it in a safe place."

"I understand; however, it is best for you not to wear the scarf. We will put it in a safe place."

The nurse is working in the local jail and cares for a number of prisoners with underlying mental illness. What is the focus of the nurse working in the justice system? Educating about the disease process Documenting for forensic evaluation Monitoring for compliance with treatment Providing resources for treatment after discharge

Monitoring for compliance with treatment

A patient with paranoid schizophrenia who lives with her mother states to the nurse that she has rigged her bedroom door at home with explosives. Which action is urgently indicated? Notify the psychiatrist and the police of the danger. Reassure the patient of her confidentiality on the unit. Administer a single dose of a psychotropic medication. Assure the patient of her right to refuse any visitor, including her mother.

Notify the psychiatrist and the police of the danger.

In order to protect themselves and others in the workplace, nurses may engage in which professional activity? Educate mental health patients about dangers of violence Inform all unit staff to take a mandatory self-defense course Participate in setting policies that create a safe environment Hold a meeting with patients' families to ask for support in maintaining a safe environment

Participate in setting policies that create a safe environment

Involuntary

Patient admitted without consent Considered a danger to self or others or cannot meet his or her basic needs Must be evaluated by a psychiatrist within a specified time frame (24-48 hours based on state law) Cannot be released unless deemed safe by an approved health care professional

Voluntary

Patient consents to be admitted and treated Patient has the right to demand and obtain release

Which legal tool is used when the mental health patient is unable to participate in the decision-making process regarding his or her own care? Patient's civil rights Patient's basic rights Patient's bill of rights Patient's psychiatric advance directives

Patient's psychiatric advance directives

The nurse must immediately report which situation to a higher authority? Patient's report of homicidal ideation. Patient's refusal of a psychotropic medication. Patient's demand for a psychiatric advance directive. Patient's use of the telephone to notify local police of desire to be discharged.

Patient's report of homicidal ideation.

Patients who are high risk for violent behavior toward self or others include:

Patients with suicidal or homicidal ideation Psychotic patients with magical thinking, where their irrational beliefs cause unpredictable behavior that may result in injury, even when the desire to inflict harm is absent Patients experiencing auditory hallucinations telling the patients to harm self or another Manic patients whose hyperactivity and impaired judgment may inadvertently result in harm

It is important to know that how the news is given to the patient about his or her involuntary commitment status is critical to the patient's immediate and delayed reaction. The information should be delivered in a

Professional, respectful, and compassionate manner. The nurse must remain hyper-vigilant in observing this population when the news of involuntary commitment is delivered. Patients may become aggressive and violent upon learning about their involuntary commitment and may put themselves and others at risk.

A severely (gravely) disabled individual is one who is unable to

Provide food, clothing, and shelter due to the mental illness.

Informed consent is required in order for the patient to receive

Psychotropic medications and medical procedure, such as ECT.

The Tarasoff court case involves which nursing duty? To protect others from harm To protect the patient's privacy To provide ethical care to patients To treat psychiatric patients with dignity and respect

To protect others from harm

The Supreme Court of California justices ruled that a staff member must

Use reasonable care to protect the intended victim of a violent patient.

A patient presents to the local behavioral health facility requesting admission for severe depression. What type of admission status will this patient fit? Voluntary Involuntary Short-term observation Long-term treatment

Voluntary

Psychiatric advance directives can be used to

plan for the possibility that someone may lose capacity to give or withhold informed consent to treatment during acute episodes of psychiatric illness.

A patient admitted on involuntary status is now calm, cooperative, alert, oriented, and is requesting to be discharged. What is the best response by the nurse? "You can sign out against medical advice when you are ready to leave." "You will not be able to leave because you are here on a court order." "You will be evaluated by a psychiatrist shortly and she will work with you to make a determination about your discharge." "Because you are here on an involuntary hold, it is mandatory that you stay here for at least 48 hours. You cannot be released before your time is up."

"You will be evaluated by a psychiatrist shortly and she will work with you to make a determination about your discharge."

Involuntary Outpatient Treatment

(e.g., addiction treatment, schizophrenia, bipolar disorder) Is court-ordered in order to avoid repeated admissions and discharges, such as for patients who discontinue their medications and ultimately display dangerous behaviors.

The severely disabled person (the conservatee) has a guardian, who is called

A conservator.

Which behavior would qualify for an emergency inpatient psychiatric evaluation? A young man is threatening to hurt himself. A woman is threatening to hurt her employer. An elderly man with anxiety refuses to take his medication. A young woman who is gainfully employed has not been caring for herself. A homeless man has been living on the street for two weeks with no money for housing.

A young man is threatening to hurt himself. A woman is threatening to hurt her employer. A young woman who is gainfully employed has not been caring for herself.

Match the term with the definition: Inability of mentally ill to provide for self despite means

Gravely disabled

A patient is receiving court-ordered psychotropic medications. A researcher insists that an experimental psychotropic be given to the patient. Which nursing action is indicated? Inform the researcher that the Psychotropic Consent form must be completed. Include the experimental medication with other court-ordered psychotropic medication. Encourage the patient to consent to the experimental medication or the patient will be discharged immediately.

Advise the researcher to obtain the patient's informed consent to participate in the research.

Protecting Patients from Unethical Providers

All mental health professions consider a sexual relationship with a patient unethical, and, in many states, this behavior is criminal, especially if it is within a few months of the therapeutic relationship. Some states have mandatory reporting laws for a second mental health professional who learns about such behavior.

The nurse receives orders from a new resident psychiatrist for a patient being held on an involuntary short-term commitment petition. Which order should the nurse question? Change diet to regular. Begin sertraline 25 mg po daily. Administer acetaminophen 325 mg po now for headache. Allow patient to be accompanied by staff to attend son's graduation.

Allow patient to be accompanied by staff to attend son's graduation.

In the Patient Bill of Rights, 42 US Code Section 9501 ensures that mental health patients receive the protection and services they need. These rights include the right to:

Appropriate treatment in the least restrictive setting. Participation in their plan of care and its periodic review. A reasonable explanation of the person's mental condition, the objectives of treatment, and the reasons such treatment is considered appropriate. NOT to receive a specific course of treatment if the patient declines unless: It is an emergency situation A court has ordered such treatment—where the nature of the patient's mental illness prevents the ability to make sound judgments; this is usually for psychotropic medication.

A patient has been admitted to the inpatient mental health facility after being placed on involuntary status for being gravely disabled. After the involuntary treatment period has expired, the patient is asked to remain in the facility voluntarily. What is the next course of action if the patient refuses to stay? Call the police and report the situation. Call the next of kin and report the situation. Ask the patient to sign out against medical advice. Keep the patient in the facility with close monitoring.

Ask the patient to sign out against medical advice.

A patient's out-of-control behavior necessitated emergency medication and seclusion. What are the nursing goals for this patient? Assist the patient to re-establish control. Monitor the other patients' reactions to the seclusion. Maintain the seclusion to keep other patients safe. Discontinue seclusion as soon as it is safely possible. Administering additional medications, despite patient refusal, to maintain therapeutic blood levels.

Assist the patient to re-establish control. Discontinue seclusion as soon as it is safely possible.

Documentation is important and crucial for the nurse as it relates to the legal status regarding a patient. Nurses should be utilizing specific

Behavioral, fair, and non-judgmental terms in documentation. Furthermore, the nurse must maintain accurate and documentation to support patients legal rights. Attorneys, patient advocates, and others rely heavily on documentation if court hearings or proceedings were to occur.

Which statement is true regarding the practice of bioethics? Ethical guidelines should override laws. Bioethics pertain to the health care team members. Nurses are allowed to befriend mental health patients after discharge. It is the study of morals and ethics as they relate to the specialty of mental health.

Bioethics pertain to the health care team members.

What is the purpose of an emergency hospitalization for a patient with a mental illness? To process patient requests for medication adjustment Helps patients who are unable to afford their psychiatric medications Cares for patients who are a danger to self or others and refuse voluntary treatment Assists patients who request to return to the hospital after being placed in a group home

Cares for patients who are a danger to self or others and refuse voluntary treatment

Match the term with the definition: Incarceration of person who pleads guilty by reason of insanity

Civil commitment

The patient's conservator speaks for the conservatee on matters affecting their mental health treatment; therefore, the nurse must obtain

Consent from conservators for decisions that are otherwise made by patients and to release medical information to anyone other than the patient or conservator.

Match the term with the definition: Person appointed to make decisions for gravely disabled

Conservator

Seclusion

Is considered a restraint and is defined as the process of isolating a person in a room and is physically prevented from leaving.

A conserved older adult is admitted to the acute hospital for an emergent surgical procedure. The patient appears alert and oriented and verbalizes understanding of the need for surgery. How is consent obtained for the necessary procedure? The patient may sign himself in for the emergency because he is alert, oriented, and understands need for surgery. The patient's doctor may sign him in hospital in case of an emergency. The patient's wife can sign in her husband in the case of an emergency. Conservator is contacted for consent.

Conservator is contacted for consent.

A patient who was found wandering in the community, disoriented, and not wearing proper clothing for the weather conditions was brought to the ED. She was also not carrying any identification. Once she is cleared medically, it is determined that she suffers from mental illness. Which type of legal procedure is most appropriate for this patient? Civil commitment Conservatorship Voluntary observation Mandated involuntary outpatient treatment

Conservatorship

Short-term Treatment

Danger to self Danger to others Gravely disabled The amount of time these individuals can be held for emergency treatment and short-term evaluation varies by state. Only designated persons, such as police officers or designated mental health professionals, can admit a person on an involuntary status. Family members can seek help through the court system to obtain involuntary petitions for those members suffering with mental illness.

A highly seductive patient reports the decision to stop the sexual relationship with the outpatient therapist and asks the nurse for a date after discharge. Which responses by the nurse would be appropriate? Decisively decline the date. Kindly explain that the nurse can only offer friendship to the patient. Tell the patient the date will depend on status upon discharge. Closely monitor the patient for sexual interactions with other patients on the unit. Initiate an investigation into the report of sexual activity between the outpatient therapist and the patient.

Decisively decline the date. Closely monitor the patient for sexual interactions with other patients on the unit. Initiate an investigation into the report of sexual activity between the outpatient therapist and the patient.

A patient in inpatient psychiatric treatment has a conservatee who is not one of her sons or daughter. The nurse receives a call from her son requesting his mother be moved to a different facility. Which is the priority action of the nurse? Notify the other children of the wishes of the son. Facilitate a meeting with the children and the conservator to discuss the change of facility. Do not discuss the care of Mrs. Smith with her son without the consent of the conservator. Organize a family meeting with Mrs. Smith's children to discuss the care plan for the patient.

Do not discuss the care of Mrs. Smith with her son without the consent of the conservator.

There are three criteria for the plea of insanity:

Does the individual charged with the crime understand the criminal charges? Is there an understanding of the legal process and the consequences of the charges? Can the individual advise an attorney and defend the charges?

A patient in the mental health facility has been charged with a crime. The psychiatrist must evaluate the patient to determine competency to stand trial and the individual indicates that a plea will be entered as not guilty by reason of insanity. Which criteria are used to determine the plea of insanity? SATA Can the individual afford an attorney? Does the individual understand English? Does the individual understand the criminal charges? Does the individual understand the consequences of the charges? Can the individual advise the attorney and defend the charges?

Does the individual understand the criminal charges? Does the individual understand the consequences of the charges? Can the individual advise the attorney and defend the charges?

Continued Inpatient Treatment

During the emergency evaluation period, if it is determined further hospitalization is needed for continued inpatient treatment, a certification hearing takes place. A probable cause statement is written, indicating that the person is a danger to self or others or is gravely disabled. Probable cause means that known facts would lead an ordinary person to believe that the person detained is mentally disabled and is a danger to self or others or is gravely disabled. The probable cause statement is filed with the court and a hearing is held to determine whether just cause exists to keep the person for treatment against his or her will longer than the initial emergency hold period (24-48 hours).

When the patient is involuntarily committed, the nurse may use this time to

Explain the legal process in simple and direct terms. It is always important to allow the patient the opportunity to express emotion and ask questions during this time.

Which nursing action is indicated when an angry patient threatens to hurt his psychiatrist? Place the patient in seclusion. Initiate an investigation into the patient's past behavior and file the necessary report. Administer an antipsychotic to the patient to address paranoid delusions. Explore the patient's potential for violence and warn the psychiatrist of potential danger.

Explore the patient's potential for violence and warn the psychiatrist of potential danger.

The nurse is reviewing discharge paperwork with the patient when the patient states, "I am eager to have vengeance upon my neighbor for triggering this admission." Which nursing intervention is indicated? Discharge the patient as ordered. Medicate the patient to stabilize his mood. Remind the patient of coping skills learned during hospitalization. Explore the potential for violence and confer with the psychiatrist about the need to delay discharge.

Explore the potential for violence and confer with the psychiatrist about the need to delay discharge.

A patient on a 24-hour emergency psychiatric hold is believed to need further treatment. In order to keep the patient in the facility, what legal action is required? Informed consent Notification of a family member Filing of a probable cause statement Appointment of a conservator for the patient

Filing of a probable cause statement

A patient is undergoing court-ordered ECT as a treatment for severe depression. The patient is refusing psychotropic medication. What should the nurse do? Hide the medication in the patient's food. Honor the patient's refusal and document it. Briefly restrain the patient to administer the medication. Inform the patient that the court has mandated the medication.

Honor the patient's refusal and document it.

In which situation may the nurse legally administer a psychotropic medication, despite the patient's refusal? If the patient is under a legal hold. If the medication is medically beneficial to the patient. If the patient is an imminent danger to self or another person. If the patient shows medical proof that the medication is not required.

If the patient is an imminent danger to self or another person.

Electroconvulsive Therapy (ECT)

Informed consent must be obtained from the patient for ECT, necessitating information about the risks, benefits, and alternatives. The administration of ECT can be voluntary or involuntarily, but strict guidelines must be followed and informed consent must be met. The number of treatments and rationale for ECT is governed by specific laws.

Match the term with the definition: Prevents recurrent admissions for those in drug therapy

Involuntary outpatient commitment

Restraint

Is a broad term used to characterize any form of limiting a person's movement or access to his or her own body. The limits can be the result of physical holds, bed rails, lap trays, restraint devices, or medications.

Long-term Treatment

Is reserved for persons who need extended psychiatric care but refuse to seek such help voluntarily. These hospitalizations can last from about 90 days or longer. Those who undergo extended involuntary hospitalization are admitted through medical certification, judicial review, or administrative action. Individuals are usually brought before a hearing officer, which is a major part of the system of checks and balances that decreases the possibility of someone being unnecessarily forced into treatment. Some patients may also be court-mandated to undergo extended involuntary long-term outpatient care to improve compliance.

A nurse is providing education on the psychiatric involuntary commitment process. Which is true of involuntary commitment? SATA It is time-limited. It is determined by state law. It is for an indefinite time period. The person must be a threat to self or others. Anyone can place another under commitment. The court system is not involved in the process.

It is time-limited. It is determined by state law. The person must be a threat to self or others

Why are laws needed to govern the care of patients with mental illness? Patients with mental illness are always incapable of making decisions. Laws are established for the protection of the patient and the public. Patients with mental illness are automatically entered into the court system. Any patient diagnosed with a mental illness must be appointed a legal guardian.

Laws are established for the protection of the patient and the public.

Health Insurance Portability and Accountability Act (HIPAA)

Legally protects the psychiatric patient's confidentiality, which includes the patient's right to receive treatment and to have medical records kept private and not disclosed to anyone.

Different factors that restrict sufficient mental health service access as described extensively by Lamb and Weinberger (1998) include:

Long-term treatment facility closures (state hospitals) A limit of established and advanced community treatment resources Lack of empathy from police officers and the general population Harsh civil commitment standard development

The nurse is caring for a patient with suicidal ideations who has a plan with a high level of lethality. The patient's inpatient psychiatric managed care benefits have expired. Which is the best action by the nurse? Discharge the patient to outpatient care. The nurse must discharge the patient due to insurance regulations. Send the patient to a medical surgical unit where different benefits apply. Maintain the patient on inpatient psychiatric care with a high level of suicide observation.

Maintain the patient on inpatient psychiatric care with a high level of suicide observation.

Research or Experimental Treatment

Regardless of their legal hold status, patients have the right to refuse participation in research or experimental treatments. Due to their vulnerability, potentially impaired judgment, and difficulty in advocating for themselves, psychiatric patients are a specially protected population in the area of research. It is most important to note that the research is voluntary and that it clearly reflects autonomy on the participants' part. Mental health patients have the right to voice grievances and recommend changes in policies or services offered by the facility, without fear of punishment or reprisal.

Most mental health inpatients retain their civil rights, such as:

Right to vote, manage finances Enter into contractual relationships Seek the advice of an attorney Religious freedom Exercise Participate in recreational activities Have social interactions and relationships

Tarasoff v. Regents of the University of California (1976) was a legal case that addressed the

Rights of the public to be protected from harm from a patient with mental illness.

Patients have the right to:

Send and receive unopened mail Participate in recreation and exercise Wear one's own clothes, although staff may remove items for safety reasons. Highly seductive clothing is generally not permitted. Receive visitors, usually under staff supervision to monitor patient's reaction to the visitor, which may change over the course of a conversation, and also prevent transfer of a substance or object, which may present a danger. The patient has a right to know the reason why the access to a certain visitor is curtailed. Keep and use personal possessions unless they constitute a danger risk. Have access to a telephone. Sometimes, telephone privileges must be curtailed if patients make repeated calls to emergency services or law enforcement (common when a patient on a legal hold wishes to leave).

Protecting Hospital Staff from Violent Patients

Staff are encouraged to promote safety in institutional and community settings. Nurses must protect themselves and others by participating in setting policies that create a safe environment. To prevent situations from escalating, culminating in danger to patients, visitors and staff, good judgment is used to assess the potential for violence. When a patient is discharged following a short-term stay, the psychiatric mental health nurse must also be aware of the potential for violence in the community. The nurse's assessment of the patient's potential for violence must be documented, and acted on, if there is concern regarding the discharge of a patient who is discussing or exhibiting potentially violent behavior. Observations and concerns must be communicated to the medical staff when discharge decisions are being considered.

All states permit some form of legal advance directive (AD) for health care, which can be used in conjunction with at least some forms of psychiatric treatment. Typically, these instruments authorize a

Surrogate decision-maker with Durable Power of Attorney for health care to act in accordance with an incapacitated patient's previously expressed wishes, known values, or to act in the patient's best interest if the patient's preferences are unknown.

Forensic mental health services consist of

The evaluation and possible civil commitment of individuals charged with or convicted of crimes. Patients need to meet commitment standards or they will be released. A psychiatrist performs a forensic evaluation to determine their competency to stand trial. The outcome, not guilty by reason of insanity or guilty but mentally ill, will determine where the individual is treated.

A general rule for nurses to follow is that the more intrusive or risky the procedure,

The higher the likelihood that informed consent must be obtained

What are the criteria needed to plead guilty by reason of insanity? Select all that apply. The individual has a diagnosis of schizophrenia. The inability of the individual to understand the charges filed against him or her. The individual has a diagnosed mental illness and was on drugs at the time of the crime. The individual does not have the mental capacity to advise an attorney and defend the charges. The individual does not have the mental ability to understand legal processes and the consequences of the charges.

The inability of the individual to understand the charges filed against him or her. The individual does not have the mental capacity to advise an attorney and defend the charges. The individual does not have the mental ability to understand legal processes and the consequences of the charges.

Steps must be taken to protect the potential recipient of harm, and others in the environment, if a nurse is aware of a patient's intention to cause harm to self or others.

The nurse must communicate this information immediately to other professionals and law enforcement.

The nurse is evaluating a patient's chart for evidence that supports the need for a long-term involuntary commitment of an inpatient psychiatric patient. Which evidence supports the need for a court petition? SATA The patient attends group therapy. The patient is compliant with medications. The patient sometimes responds to unseen stimuli. The patient continues to require 1:1 care due to suicidality on day 10 of inpatient care. The patient ranks his depression as a 10 on a scale of 1-10 with 10 being the worse and is actively suicidal. The patient has threatened to harm people at her place of employment if she leaves the hospital and has verbalized a working plan.

The patient continues to require 1:1 care due to suicidality on day 10 of inpatient care. The patient ranks his depression as a 10 on a scale of 1-10 with 10 being the worse and is actively suicidal. The patient has threatened to harm people at her place of employment if she leaves the hospital and has verbalized a working plan.

A patient who was originally admitted involuntarily for suicidal ideation has since signed in voluntarily with the approval of her psychiatrist. Which patient right should guide the nurse's delivery of care? SATA The patient has the right to participate in the plan of care. The patient has the right to refuse any treatment modality. The patient has the right to choose which staff members provide care. If the patient declines to participate in treatment, she must be discharged. The patient has the right to receive an explanation of her mental condition.

The patient has the right to participate in the plan of care. The patient has the right to refuse any treatment modality. The patient has the right to receive an explanation of her mental condition.

Which mental health patient rights are important for the nurse to maintain? The patient has the right to receive visitors. To participate in recreation and exercise. To send and receive unopened mail. To refuse a court-ordered treatment. To call emergency medical services to free the patient from a legal hold.

The patient has the right to receive visitors. To participate in recreation and exercise. To send and receive unopened mail.

Which situation would indicate a patient might need long-term involuntary outpatient treatment? The patient cannot afford medication for anxiety. The patient takes his antidepressant sporadically. The patient is in a court-mandated drug treatment program. The patient calls to reschedule her appointment at the clinic. The patient had 3 admissions within 2 months due to psychiatric treatment noncompliance. The patient requires a long-term injectable antipsychotic to manage his condition and has demonstrated noncompliance in the past.

The patient is in a court-mandated drug treatment program. The patient had 3 admissions within 2 months due to psychiatric treatment noncompliance. The patient requires a long-term injectable antipsychotic to manage his condition and has demonstrated noncompliance in the past

What legally qualifies a person to be placed in conservatorship? The person is homeless. The person cannot afford medication. The person is gravely disabled because of a mental illness. The person has had at least 3 hospitalizations within 1 year because of mental illness.

The person is gravely disabled because of a mental illness.

However, if the mental health patient, while hospitalized, lacks mental capacity or competence,

They will not be able to exercise his or her civil rights.