RN Client and Mental Health Team Member Safety Assessment

A nurse is leading a group session when a client begins cursing and running around the room shouting, Which of the following actions should the nurse take? a. Suggest the client go someplace quiet and compose themselves. b. Administer an anxiolytic to the client. c. Insist the client go to the seclusion room where monitoring can be done. d. Notify the entire treatment team to secure the area.

Answer: a. Rationale: Suggesting the client go someplace quiet and compose themselves indicates that the nurse will not tolerate their behavior. This is an example of a less restrictive alternative to restraints and will give the client a chance to change their behavior prior to returning to the group. The nurse should give the client an opportunity to calm themselves. Use of an anxiolytic might be appropriate after other de-escalation strategies have failed. Seclusion should only be considered if the client is being harmful to themselves or others, and after other de-escalation attempts have failed. Therefore, the nurse does not need to send the client to the seclusion room for monitoring. There is no indication that the scene needs to be secured. Therefore, the nurse does not need to notify the treatment team to secure the area.

A nurse overhears unit staff workers making jokes about a nursing student. This is an example of which of the following? a. incivility b. anger c. sexual harassment d. bullying

Answer: a. Rationale: This is an example of incivility. Incivility is an act or behavior that shows disrespect and lack of courtesy. Such acts, whether intended or unintended, are considered acts of aggression and can affect the well-being of the individual and negatively impact the work environment. This is not an example of anger. Anger is an emotional expression toward someone or something when feeling deliberately wronged. There is no indication that the jokes were of a sexual nature. Therefore, this is not an example of sexual harassment. Jokes at the expense of other team members is an example of incivility. However, if this action becomes repeated and focused on a specific group or individual, then it would be considered bullying.

A newly hired nurse confides in another nurse that despite trying to be hopeful, they feel very depressed. Which of the following actions should the nurse take? a. Suggest the newly hired nurse contact a mental health professional. b. Notify the employee assistance program about the newly hired nurse. c. Notify Risk Management. d. Suggest the newly hired nurse try yoga.

Answer: a. Rationale: When a fellow nurse or client confides that they are experiencing manifestations of burnout, depression, or another mental health concern, it is appropriate to encourage them to seek professional mental health care. It is important to give the newly hired nurse an opportunity to contact a mental health professional or employee assistance on their own. This is a drastic first step and will discourage transparency on the unit from other nurses who are feeling depressed. Suggesting yoga may be helpful. However, because the newly hired nurse is asking for help about a mental health concern, the nurse should recommend the newly hired nurse contact a mental health professional.

A nurse is discussing burnout among nurses with a colleague. Which of the following is a strategy to reduce burnout? a. Self-scheduling work shifts b. Keeping to oneself at work c. Working extra shifts during staff shortages d. Skipping shared governance meetings

Answer: a. rationale: Self-scheduling work shifts allows nurses to have more control over work-life balance and helps reduce burnout. Strategies for reducing burnout include engagement in shared governance, effective communication, supportive teams, supportive leadership, and consistent self-care. Isolation and avoiding engagement with team members is a contributing factor to burnout. Working extra shifts during staff shortages has been linked to an increased risk for burnout. Shared governances allow nurses to have input on policies and staffing decisions, which has been identified as a strategy to reduce burnout. Therefore, skipping shared governance meetings is not a strategy to reduce burnout.

A nurse on a mental health unit is discussing types of admissions with a newly licensed nurse. Which of the following statements should the nurse make? a. Most states require two providers to assess a client and confirm the need for an involuntary admission b. When a voluntarily admitted client requests discharge, the provider must legally do so within 8 hours of the request. c. Clients who are involuntarily admitted are not able to testify on their own behalf in a commitment hearing d. When a client is admitted involuntarily, they do not have to have a diagnosis of a mental illness.

Answer: a. Rationale: An involuntary admission, or assisted inpatient treatment, is when a client is admitted without their request or consent. It is initiated when a client is exhibiting severe manifestations or is considered to be a danger to themselves or others. When a client is voluntarily admitted, they can ask to be discharged by submitting a request in writing. The provider must reassess the client within a timeframe dictated by state law to determine if the client is stable enough for discharge. In most states, the timeframe is 72 hr. Clients who are involuntarily admitted are provided legal counsel and have the right to be present and testify on their own behalf in these judicial hearings. When a client requests to be admitted for treatment, they must meet specific criteria, including having a diagnosis of a mental illness.

A nurse is caring for a client who is in physical restraints. The nurse should identify that which of the following complications can result from inadequate monitoring of the client? SATA a. Positional asphyxia b. Food aspiration c. Cardiac arrest d. Infection e. Somnolence

Answer: a., b., c. Rationale: Positional asphyxia is correct. A client who has been placed in physical restraints can assume positions in which they are unable to breathe. The nurse should continuously monitor the client who is in restraints to ensure the client's safety.Food aspiration is correct. A client who has been placed in physical restraints can have limited movement and ability to position themselves and are at risk for food aspiration. The nurse should continuously monitor the client who is in restraints to ensure the client's safety.Cardiac arrest is correct. A client who has been placed in physical restraints can experience increased physiological and psychological stress, which can place them at an increased risk for cardiac arrest. The nurse should continuously monitor the client who is in restraints to ensure the client's safety.Infection is incorrect. A client who has been placed in physical restraints does not have an increased risk for infection. Somnolence is incorrect. Somnolence is an expected outcome of chemical restraints and is not a risk associated with physical restraints.

A nurse is planning an in-service about client confidentiality for a group of newly hired nurses. Which of the following examples should the nurse include when discussing exceptions for maintaining client confidentiality? SATA a. A client tells a nurse that they intend to kill a coworker. b. A nurse is subpoenaed to testify in court about a client they cared for. c. An older adult client reports their caregiver allows them to eat one meal per day d. A client tells a nurse that they stole a watch from a friend's house e. A client tells a nurse that they plan to hang themselves when they are discharged.

Answer: a., b., c., e. Rationale: A client tells a nurse that they intend to kill a coworker is correct. The nurse should include the exception of duty to warn when discussing client confidentiality. If a client makes a threat to harm or kill someone else, the nurse must report this to the client's provider, who is legally obligated to notify the person of such intent. Duty to warn is a law in most states. A nurse is subpoenaed to testify in court about a client they cared for is correct. The nurse should include that a nurse may share confidential client information when legally obligated to do so via a court order. When a nurse's documentation is used in court, the nurses who cared for the client can testify in the case and share necessary information that would otherwise be considered confidential. An older adult client reports their caregiver allows them to eat one meal per day is correct. The nurse should include the exception of reporting client abuse. When a client reports or a nurse suspects abuse or neglect, the nurse is legally required to report this information to the appropriate agency. A client tells a nurse that they stole a watch from a friend's house is incorrect. The nurse should not include a client's report about stealing an item from a friend as an exception to maintaining client confidentiality. Crimes such as battery or murder are reportable. A client tells a nurse that they plan to hang themselves when they are discharged is correct. The nurse should include that an exception to maintaining client confidentiality is if a client expresses the intent to harm themselves. The nurse should notify the provider of this finding and initiate interventions to ensure the client's safety.

A nurse is discussing responsibilities in milieu therapy with a group of newly hired nurses. Which of the following should the nurse include? SATA a. Explain unit rules, including expectations and client rights b. Provide orientation, including a tour of the unit, rules, and expectations. c. Select activities based on preferences of available staff. d. Ensure that culturally sensitive- care is provided. e. Use a trauma-informed approach to client care.

Answer: a., b., d., e. Rationale: Explain unit rules, including expectations and client rights is correct. The nurse is responsible for providing client education that includes important features of the environment, expectations, and client rights. This cultivates a therapeutic milieu based on safety and recovery.Provide orientation, including a tour of the unit, rules, and expectations is correct. The nurse is responsible for providing orientation of the care unit, including treatments, expectations, and rules. This cultivates a therapeutic milieu that is focused on both safety and recovery.Select activities based on preferences of available staff is incorrect. The nurse should select activities that promote participation, recovery, and healing. Preferences of staff are not included in the foundation of client-centered care.Ensure that culturally-sensitive care is provided is correct. The nurse should ensure that culturally-sensitive care is provided. This cultivates a therapeutic milieu that is focused on both safety and recovery.Use a trauma-informed approach to client care is correct. The nurse should provide client-centered care that creates a welcoming, trauma-informed environment. This cultivates a therapeutic milieu that is focused on both safety and recovery.

A nurse is discussing privacy and confidentiality with a client. Which of the following is a U.S. congressional act that sets the standards for client privacy and confidentiality? a. No Surprises Act b. HIPAA c. Affordable Care Act of 2010 d. Nurse Practice Act

Answer: b. Rationale: The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy and confidentiality of a client's health information. The No Surprises Act requires providers to inform clients of the cost of treatment and whether the provider is covered by their insurance. The Affordable Care Act of 2010 made health care affordable for most Americans. It ensures that health care coverage for underinsured Americans, or those with pre-existing conditions, cannot be denied health care coverage. Nurse Practice acts vary from state to state and are not congressional acts.

A nurse on a mental health unit is caring for a client to return to their room to calm down. Which of the following de-escalation techniques is the nurse using? a. Seclusion b. Time out c. Restrains d. Distraction

Answer: b. Rationale: The nurse is using the de-escalation technique of time out. Time out involves giving the client time to regain control of their emotions, calm down, and end the behavior. Seclusion is a de-escalation technique that involves involuntary confinement in a locked location. There is no indication that the nurse is using seclusion. Restraints are used when other de-escalation techniques are unsuccessful. Restraints can be physical or chemical. Distraction is a de-escalation technique that involves redirecting the client's current thoughts by offering another activity.

A nurse is caring for a group of children who have experienced trauma. During group therapy, the children create drawings representing their family and community. Which of the following interprofessional team members is likely leading this group? a. Psychologist b. Art therapist c. Social worker d. Registered nurse

Answer: b. Rationale: An art therapist is likely leading this group. An art therapist uses different media, including painting, drawing, and pottery, to help clients explore their experiences and express their feelings. A psychologist is not usually trained in art therapy. Therefore, there is another interprofessional team member who is likely leading this group. A social worker is not usually trained in art therapy. Therefore, there is another interprofessional team member who is likely leading this group. A registered nurse is not trained to do therapy. Therefore, there is another interprofessional team member who is likely leading this group.

A nurse is discussing the purpose of ethics with a newly licensed nurse. Which of the following statements should the nurse make? a. Ethics describes a conflict between two or more actions where each action has a favorable and unfavorable consequence. b. Ethics involves reasoning about what one should do as a guide for what one actually does. c. Ethics provides a system of moral principles or standards for governing conduct d. Ethics explains the moral inquiry into issues raised by advances in medicine and the life sciences

Answer: c. Rationale: Ethics provides the nurse with a set of moral principles and standards, and is a basis for determining intentions, motives, and actions. A nurse's ethics is the basis from which conduct, including practices and decisions, is made.

A nurse is discussing false imprisonment with a group of newly hired staff members. Which of the following information should the nurse include? a. A client cannot claim false imprisonment if they were restrained by use of an injectable antipsychotic medication. b. Claims of false imprisonment can be made if a nurse verbally threatens to place a client in seclusion. c. Claims of false imprisonment are most often made in reference to the use of seclusion or restraints. d. A client cannot claim false imprisonment if they are involuntary admitted without being assessed by a provider.

Answer: c. Rationale: False imprisonment is the confinement of a client when there is no legal reason to do so. Most claims of false imprisonment result from the use of seclusion or restraints. Nurses can be accused of false imprisonment if they use any type of restraint for a client, including a chemical restraint that is unwarranted or inappropriate. Unwarranted or inappropriate use is based on adherence to legal criteria. Verbal threats to place a client in seclusion are an example of assault. False imprisonment is the unlawful physical confinement of a client and usually refers to the act of seclusion or restraints. Providers and nurses can be accused of false imprisonment if a client presents for treatment and is admitted involuntarily to a mental health unit without a provider determining the client meets specific legal criteria for such an admission.

A nurse is caring for a newly admitted client who expresses concern that their insurance will not cover their care. The nurse should identify that which of the following is a U.S. congressional act that requires provides to inform their clients of the costs for treatment and whether their insurance will cover it? a. HIPAA b. Affordable Care Act of 2010 c. No Surprises Act d. Nurse Practice Act

Answer: c. Rationale: In December 2021, Congress passed the No Surprises Act, which requires providers to inform clients of the cost of treatment and whether providers are covered by their insurance. The Health Insurance Portability and Accountability Act (HIPAA) entitles clients to privacy of their protected health information. The Affordable Care Act of 2010 extended health care coverage to uninsured Americans, preventing insurance companies from denying coverage due to pre-existing conditions. Nurse Practice acts vary from state to state and are not congressional acts.

A nurse is discussing the effects of workplace violence by clients and their family members on health care professionals with a peer. The nurse should identify that which of the following organizations provides oversight for nurses regarding workplace violence? a. American Hospital Association b. Department of Health and Human Services c. Occupational Safety and Health Administration d. The Joint Commission

Answer: c. Rationale: OSHA is the organization that is tasked with ensuring worker safety, including providing oversight for workplace violence. The American Hospital Association's mission is to advance the health of individuals and communities by representing the interest of hospitals. The Department of Health and Human Services is tasked with enhancing the health and well-being of all Americans. The Joint Commission evaluates health care organizations for quality, safe, and effective care.

A nurse on a pediatric mental health unit is discussing the importance of setting boundaries with another nurse. Which of the following statements by the nurse explains why setting boundaries is important? a. Setting boundaries will cause the children to try and leave the unit b. Children will automatically rebel against all boundaries set on the unit, so you must let them know the consequences c. Setting boundaries increases a child's sense of security through knowing the consequences of behaviors d. Children are not able to understand boundaries or consequences of their behavior

Answer: c. Rationale: Research indicates that setting boundaries increases a child's sense of security. Setting boundaries reduces any misunderstanding, establishes expected behaviors, and provides an understanding of consequences. Setting boundaries reduces any misunderstanding, establishes expected behaviors, and provides an understanding of consequences. This will assist the children to understand their goals for treatment and avoid the consequences of their behavior. All children do not automatically rebel when boundaries are set. Setting boundaries reduces any misunderstanding, establishes expected behaviors, and provides an understanding of consequences. This empowers children to avoid the consequences of their behavior. Care and treatment for children must be explained in a way that they understand. Best practice suggests that when a child understands boundaries and consequences of their behavior, they are more likely to avoid bad behaviors.

A nurse tells a client that they will return in 30 min with their medication. The nurse returns 30 min later with the client's medication. Which of the following ethical principles is the nurse demonstrating? a. Beneficence b. Autonomy c. Veracity d. Justice

Answer: c. Rationale: The nurse is demonstrating veracity. Veracity involves being truthful and honoring the verbal commitment made to a client. Beneficence involves acting in a manner that is "for the good" or in a way that benefits others. Autonomy involves allowing the client to make decisions about their care. Justice involves caring for all clients equally and with the same level of fairness.

A nurse is preparing a client who has schizophrenia for a magnetic resonance imaging (MRI) of their head to determine if they have a brain injury or a new onset of dementia. The nurse should identify that which of the following members of the interprofessional team likely prescribed the MRI? a. Licensed clinical social worker b. Psychologist c. Psychiatrist d. Occupational therapist

Answer: c. Rationale: The nurse should identify that a psychiatrist likely prescribed the MRI. Psychiatrists are medical doctors who can diagnose and prescribe medical procedures, tests, and medications.

A nurse on a mental health unit is discussing laws that guide the care of clients on the unit with a newly hired staff member. Which of the following statements by the staff member indicates an understanding? a. A claim of assault can only be substantiated if there is evidence of physical harm. b. False imprisonment only refers to seclusion of clients. c. Battery is the most common unintentional tort. d. A physical injury does not need to occur for a client to make a claim of battery.

Answer: d. Rationale: Battery is making contact with another person without their consent. The person does not need to be injured for battery to occur; the contact must simply be unwanted or offensive to the person. Assault can be a verbal threat made toward a person that causes that person to feel apprehension or fear of being touched. No physical harm needs to occur for a person to claim assault has occurred. False imprisonment refers to the use of seclusion or restraints and applies when a client is held unlawfully. This means that the use of seclusion or chemical or physical restraints is done inappropriately or without meeting legal criteria. Negligence is the most common unintentional tort. Medical malpractice is a type of negligence that is specific to health care providers.

A nurse is caring for a client who has schizophrenia and has recently been diagnosed with a terminal illness. The client's interprofessional team should recommend which of the following for the client? a. Urgent care b. Dementia care c. Experimental therapy d. Hospice care

Answer: d. Rationale: The interprofessional team should recommend hospice care for this client. Hospice care focuses on the care, comfort, and quality of life for a person who has a terminal illness and is approaching the end of life. Urgent care is for non-life threatening situations, such as an injury or illness, that need immediate attention. Therefore, the interdisciplinary team should not recommend urgent care for the client. There is no indication that the client has dementia. Therefore, the interprofessional team should not recommend dementia care for the client. A client who has a terminal illness should not be enrolled in clinical trials or experimental therapy. Therefore, the interprofessional team should not recommend experimental therapy for the client.

A nurse is sitting with a client who is extremely anxious until they fall asleep. The nurse should identify that this is an example of which of the following ethical principles? a. Justice b. Autonomy c. Nonmaleficence d. Beneficence

Answer: d. Rationale: The nurse should identify that this is an example of beneficence. Beneficence involves acting in a manner that is "for the good" or in a way that benefits others. Justice involves caring for all clients equally and with the same level of fairness. Autonomy involves allowing the client to make decisions about their care. Nonmaleficence involves advocating for treatment modalities that result in the least amount of harm while achieving a beneficial outcome.

A charge nurse on a mental health unit is discussing the concept of client competency with a group of newly licensed nurses. Which of the following information should the charge nurse include? a. A client can be deemed legally competent via confirmation by two mental health providers. b. A client is automatically deemed to be incompetent upon admission to the facility if they are experiencing psychosis. c. A client who is deemed incompetent will be unable to make decisions for themselves. d. A client is considered mentally competent until deemed incompetent by a judge in a legal hearing.

Answer: d. Rationale: The nurse should include that clients are considered to be competent until following a hearing and a decision by a judge. Competency is a legal term that must be determined in a court of law following a hearing and presentation of evidence. Health care providers cannot determine a client's competence. A client is considered to be legally competent unless deemed incompetent by a judge following a hearing, regardless of their diagnosis or condition. A client who is deemed incompetent will have a legal surrogate or representative that will make decisions on their behalf, as long as they are considered to lack competence in a court of law. Once a client is determined to be competent, all decision-making returns to the client.

A nurse encourages each client in a group session to speak and be heard. The nurse should identify that this is an example of which of the following ethical principles? a. Beneficence b. Autonomy c. Nonmaleficence d. Justice

Answer: d. The nurse should identify that this is an example of justice. Justice involves caring for all clients equally and with the same level of fairness. Beneficence involves acting in a manner that is "for the good" or in a way that benefits others. Autonomy involves allowing the client to make decisions about their care. Nonmaleficence involves advocating for treatment modalities that result in the least amount of harm while achieving a beneficial outcome.

A nurse is caring for a client who is agitated and requires chemical restraints. Which of the following types of medications should the nurse expect the provider to prescribe? a. Antidepressant b. Sedative c. Steroid d. NDMA inhibitor

Answer: b. Rationale: The nurse should expect the provider to prescribe a sedative. Sedatives are frequently used to calm clients who are agitated. They act fast and are usually well tolerated. It takes several weeks to see the effects of an antidepressant. Therefore, the nurse should not expect the provider to prescribe an antidepressant. Steroids can stimulate agitation. Therefore, the nurse should not expect the provider to prescribe a steroid. NMDA inhibitors are indicated for clients who have dementia. There is no indication that this client has dementia; therefore, the nurse should not expect the provider to prescribe an NMDA inhibitor.

A nurse in the emergency department is caring for a client who experienced abuse by an intimate partner and is scared to return home. To which of the following interprofessional team members should the nurse refer the client? a. Occupational therapist b. Social worker c. Substance use counselor d. Pharmacist

Answer: b. Rationale: The nurse should refer the client to a social worker. Social workers provide client support and advocacy related to living situations. Occupational therapists work with clients to provide skill assessments and rehabilitation, such as those related to work or school. Therefore, the nurse should not refer the client to an occupational therapist. Substance use counselors specialize in treatment of individuals who have a substance use history. Therefore, the nurse should not refer the client to a substance use counselor. Pharmacists assist clients with questions related to medications. Therefore, the nurse should not refer the client to a pharmacist.

A nurse is beginning a debrief with staff about a behavioral emergency that resulted in physically restraining a client. The nurse should identify that which of the following is the purpose of debriefing? a. To determine what to say to the client about the incident. b. To determine which members did not perform well. c. To carefully document the entire incident. d. To improve the quality of future responses.

Answer: d. Rationale: The purpose of debriefing is to review what happened and determine what should be done to improve the quality of future responses. Debriefing provides staff and clients with the opportunity to discuss how the situation evolved, their feelings, and to promote recovery for the client. Best practice suggests that both clients and staff participate in the debriefing because it improves collaboration and promotes recovery for the client. The focus of debriefing should be on improving, not blaming. It is important to identify what needs improving, including staff education and skills. Documentation is an important component of nursing care and should adequately reflect what occurred and the client's response. However, it is not the purpose of debriefing.

A nurse is discussing what to do about feelings of burnout with a group of nurses. Which of the following is the best strategy the nurse should implement? a. Suggest that nurses who are experiencing burnout get treatment or quit their position. b. Reduce meetings for shared governance. c. Request an increase in pay. d. Meet with other nurses to create a plan to support each other.

Answer: d. Rationale: Having a supportive team helps prevent burnout and has been identified as the most effective strategy for reducing burnout. Other strategies that help to prevent burnout include shared governance, supportive leadership, a good professional identity, and consistent self-care.

A nurse is caring for several children who experienced trauma. One of the children goes to group therapy wearing a cape and pretending to be a superhero. The nurse should identify that which of the following interprofessional team members should lead the group session? a. Drama therapist b. Art therapist c. Occupational therapist d. Social worker

Answer: a. Rationale: A drama therapist encourages clients to act out feelings that may be difficult for them to express in words. Therefore, the nurse should identify that a drama therapist should lead the group session. An art therapist encourages clients to express their feelings through paintings and drawings. An occupational therapist provides skill assessment and rehabilitation for clients. A social worker provides social support, such as housing, financial assistance, and insurance. Some licensed social workers assist with creating treatment goals for clients.