CHAPTER 9
14. The physician has prescribed Haldol 10 mg for a severely psychotic client. The client refuses the medication. Which nursing intervention is an appropriate response? A) Accept the client's decision B) Obtain a discharge order for noncompliance C) Tell the client that he is too sick to refuse D) Restrain the client and give the medication IM
Ans: A Feedback: Clients have the right to refuse medication even when they are psychotic. The client cannot be discharged just because he refuses to take his medications. In this situation, it is not appropriate for the nurse to tell the client that he is too sick to refuse. Restraints are not an appropriate means of getting the client to take the medication.
17. A nurse is questioning whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. What is the ethical principle that will best guide the decision on appropriate use of seclusion? A) Autonomy B) Beneficence C) Justice D) Veracity
Ans: A Feedback: Autonomy refers to the person's right to self-determination and independence. Beneficence refers to one's duty to benefit or to promote good for others. Justice refers to fairness, that is, treating all people fairly and equally without regard for social or economic status, race, sex, marital status, religion, ethnicity, or cultural beliefs. Veracity is the duty to be honest or truthful.
6. An adolescent on the unit is argumentative with staff and peers. The nurse tells the adolescent, "Arguing is not allowed. One more word and you will have to stay in your room the rest of the day." The nurse's directive is A) inappropriate; room restriction is not treatment in the least restrictive environment. B) inappropriate; the adolescent should be offered a sedative before room restriction. C) appropriate; room restriction is an effective behavior modification technique. D) appropriate; the adolescent should not have conflicts with others.
Ans: A Feedback: Clients have the right to treatment in the least restrictive environment appropriate to meet their needs. It means that a client does not have to be hospitalized if he or she can be treated in an outpatient setting or in a group home. It also means that the client must be free of restraint or seclusion unless it is necessary. Verbal and behavioral techniques should be instituted before physical measures such as sedation, restraint, or seclusion.
30. The staff on an inpatient psychiatric unit is very busy and fall behind on periodic assessment of a severely depressed client. During the rounds, the client is discovered to have completed a suicide attempt in the bathroom. Which type of lawsuit could the client's family file? A) Malpractice B) Breach of duty C) Assault D) Injury or damage
Ans: A Feedback: Clients or families can file malpractice lawsuits in any case of injury, loss, or death. Not all injury or harm to a client can be prevented, nor do all client injuries result from malpractice. The issues are whether or not the client's actions were predictable or foreseeable (and, therefore, preventable) and whether or not the nurse carried out appropriate assessment, interventions, and evaluation that met the standards of care. In the mental health setting, lawsuits most often are related to suicide and suicide attempts. Breach of duty and injury or damage are two of the four elements of malpractice. Assault involves causing a person to fear being touched in an injurious way without consent.
27. Which one of the following is the most common reason for ethical dilemmas being a challenge to nurses? A) Ethical dilemmas are often charged with emotion. B) There are no clear ethical codes established for guidance. C) A multitude of laws must be understood to make a clear decision. D) Clients are not familiar with the ethical code that nurses must follow.
Ans: A Feedback: Ethical dilemmas are often complicated and charged with emotion, making it difficult to arrive at fair or "right" decisions. ANA has established a Code of Ethics for Nurses. Few ethical decisions are guided strictly by legal precedent. Clients are not obligated to follow the professions' ethical principles.
4. Which of the following clients would most likely be mandated outpatient treatment? A) A client who is addicted to alcohol who has two DUI offenses B) A client with schizophrenia who lives in a single family home with siblings C) A client with bipolar disorder who has quit three jobs in the last 6 months D) A homeless client who has been arrested for petty theft of groceries from a convenience store.
Ans: A Feedback: Mandatory outpatient treatment is sometimes also called conditional release or outpatient commitment. Court-ordered outpatient treatment is most common among persons with severe and persistent metal illness who have had frequent and multiple contacts with mental health, social welfare, and criminal justice agencies. This supports the notion that clients are given several opportunities to voluntarily comply with outpatient treatment recommendations and that court-ordered treatment is considered when those attempts have been repeatedly unsuccessful.
7. The nurse on an addictive disorders unit receives a phone call inquiring about the status of a client. The caller is not on the client's allowed contact list. Which of the following is the appropriate response by the nurse to the caller? A) "I cannot confirm or deny the existence of any client here." B) "You will need to be placed on the client's contact list before I can discuss any information with you." C) "The person you are asking for is not a client here." D) "Hold 1 minute while I get the client for you."
Ans: A Feedback: The protection and privacy of personal health information is regulated by the federal government through the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Protected health information is any individually identifiable health information in oral, written, or electronic form. Mental health and substance abuse records have additional special protection under the privacy rules. Requesting placement on the contact list or getting the client verifies the client's presence to the caller. Denying the client's presence affirms the client's existence whether present not, which violates client privacy and confidentiality.
24. A client being served in a busy inpatient psychiatric unit becomes very noisy and combative. The other clients are complaining about the noise and are afraid that they will be hurt by the client. The nurse determines that the best course of action for all involved is to seclude the client until the client is able to regain control of his behavior. On which ethical principle did the nurse base this decision? A) Utilitarianism B) Deontology C) Nonmaleficence D) Veracity
Ans: A Feedback: Utilitarianism is a theory that bases decisions on the "greatest good for the greatest number." While the client may experience a temporary loss of freedom, all of the clients on the nursing unit and their visitors will benefit by not being at risk for harm from this client. Deontology is a theory that says decisions should be based on whether or not an action is morally right with no regard for the result or consequences. It may not be considered morally right to deny this client his freedom for any amount of time, irrespective of the consequences (harm to others). Nonmaleficence is the requirement to do no harm to others either intentionally or unintentionally. In this circumstance, it could be argued that secluding the client could be maleficence, but it also could be argued that the other clients' rights to not be harmed would be violated by not secluding this client until he is able to regain control of his behavior. Justice refers to fairness, that is, treating all people fairly and equally without regard for social or economic status, race, sex, marital status, religion, ethnicity, or cultural beliefs. It could be argued that the client was not treated fairly when he was secluded, but it also could be argued that the others were not treated fairly if the client was allowed to continue to freely engage in the disrupting behavior.
10. A client who had agreed to be hospitalized for depression problems has decided that now she wants to leave the hospital. The mental health staff caring for her realizes that at present she can legally A) be discharged if evaluated through administrative hearings. B) be retained in the hospital against her will. C) leave the hospital after giving written notice of her intent to do so. D) leave without discussing the situation with anyone.
Ans: C Feedback: Clients who are not dangerous to themselves or others can leave the hospital against medical advice. The other choices are not appropriate.
26. Which of the following dilemmas involve the ethical principle of fidelity? Select all that apply. A) When the nurse is unable to agree with the policies or common practices of an agency B) When the nurse is faced with a decision to violate a policy that is harmful to the client C) When the nurse is certain that clients of different racial and ethnic backgrounds are being treated the same as other clients D) When the nurse understands that a combative client must be secluded against their will to prevent harm to others E) When the client refuses to take medication and the nurse respects the client's right to refuse medication
Ans: A, B Feedback: When the nurse is unable to agree with the policies or common practices of an agency, the nurse is facing a dilemma about fidelity, which refers to the obligation to honor commitments and contracts. When the nurse is faced with a decision to violate a policy that is harmful to the client, the nurse is facing a dilemma about fidelity—that is, should the nurse be faithful to the employing agency or the individual client being cared for. When the nurse is certain that clients of different racial and ethnic backgrounds are being treated the same as other clients, the nurse is acting in accord with the ethical principle of justice. When the nurse understands that a combative client must be secluded against his or her will to prevent harm to others, the nurse is following the ethical principle of utilitarianism. When a client refuses to take medications and the nurse respects the client's right to refuse medication, the nurse is enacting the ethical principle of autonomy.
5. Under which conditions would it be in the client's best interest for the court to appoint a conservator, or legal guardian? Select all that apply. A) Gravely disabled B) Mentally incompetent C) Noncompliant D) Unable to provide basic needs when resources exist E) Act only on his or her own interests
Ans: A, B, D Feedback: The appointment of a conservator or legal guardian is a separate process from civil commitment. People who are gravely disabled; are found to be incompetent; cannot provide food, clothing, and shelter for themselves even when resources exist; and cannot act in their own best interests may require appointment of a conservator. In these cases, the court appoints a person to act as a legal guardian who assumes many responsibilities for the person.
28. The term "standards of care" refers to expectations of nursing performance. Standards of care are developed from which of the following? Select all that apply. A) Code of Ethics for Nurses with Interpretive Statements B) Licensure examinations C) State Nurse Practice Acts D) Agency job descriptions E) Professional nursing organizations
Ans: A, C, D, E Feedback: Standards of care are developed from professional standards, state nurse practice acts, federal agency regulations, agency policies and procedures, job descriptions, and civil and criminal laws.
2. Which of the following would be circumstances when a client could be subjected to involuntary hospitalization? Select all that apply. A) When a client states that he or she intends to commit suicide and is making plans to do so. B) When a client does not bathe regularly or change clothes often. C) When a client states that he or she intends to harm others by a deliberate act. D) When a client who has diabetes refuses to follow the prescribed diet. E) When a client is unable to control his or her rage and is assaulting everyone around him or her.
Ans: A, C, E Feedback: Health-care professionals respect the wishes of a client who does not wish to be hospitalized and treated unless clients are a danger to themselves or others (i.e., they are threatening or have attempted suicide or represent a danger to others). When a client states that he or she intends to commit suicide and is making plans to do so, the client is threatening suicide and could be subjected to involuntary hospitalization. When a client does not bathe regularly or change clothes often, the client is neglecting his or her hygiene, but it is unlikely that this could be construed as an imminent risk of harm to self. When a client states that he or she intends to harm others by a deliberate act, the client could be considered representing a danger to others. When a client who has diabetes refuses to follow the prescribed diet, the client is acting within his or her own right to comply with the recommendations of their health-care provider. When a client is unable to control his or her rage and is assaulting everyone around him or her, the client would be considered a danger to others.
20. Which of the following are criteria that must be adhered to when instituting the short-term use of restraint or seclusion? Select all that apply. A) The client is aggressive. B) The client is being punished. C) The client is imminently dangerous to himself or herself or to others. D) The client is physically and emotionally self-controlled. E) All other means of calming the client have been unsuccessful.
Ans: A, C, E Feedback: Short-term use of restraint or seclusion is permitted only when the client is imminently aggressive and dangerous to himself or herself or to others, and all other means of calming the client have been unsuccessful. The nurse must frequently contact the client and reassure the client that restraint is a restorative, not a punitive, procedure. If the client is physically and emotionally self-controlled, there is no reason for the client to be restrained or secluded.
18. A nurse is performing safety assessments on a client in mechanical restrains as required by policy. Which action by the nurse demonstrates the ethical principle of nonmaleficence? A) Explaining the behavioral requirements for release of restraint to the client B) Assuring that the restraints are not causing injury to the client C) Applying restraints based solely on assessment findings and not on attitude toward the client D) Releasing the client when stated behavioral control is achieved
Ans: B Feedback: Assuring that the restraints are not causing injury to the client is an example of nonmaleficence, or doing no harm. Explaining the behavioral requirements for release of restraint to the client is providing the client the autonomy to choose behaviors. Applying restraints based solely on assessment findings and not on attitude toward the client is displaying justice. Releasing the client when stated behavioral control is achieved is displaying veracity, or being honest and truthful.
29. A client underwent a procedure before the nurse verified the client's signature on the consent form. The client actually did not sign the form before the procedure. If the client is dissatisfied with the outcome of the procedure and files a suit against the health-care team, which kind of case can the client file? A) Negligence B) Malpractice C) Battery D) False Imprisonment
Ans: C Feedback: Battery involves harmful or unwarranted contact with a client. False imprisonment is defined as the unjustifiable detention of a client such as the inappropriate use of restraint or seclusion. Negligence is an unintentional tort that involves causing harm by failing to do what a reasonable and prudent person would do in similar circumstances. Clients or families can file malpractice lawsuits in any case of injury, loss, or death.
11. Two nurses are discussing the rights of hospitalized psychiatric clients. Which of the following statements is an error? A) Confidentiality allows for the disclosure of information under specific circumstances. B) If a committed client is also found to be incompetent, he loses his rights under the Patient's Bill of Rights. C) Privileged communication does not apply to medical records, and they can be used in court. D) Clients can never be held against their will.
Ans: B Feedback: Being committed and/or incompetent does not negate the Patient's Bill of Rights. However, if a guardian is appointed, the client loses the right to enter into legal contracts or agreements that require a signature. Confidentiality does allow for the disclosure of information under specific circumstances such as to another health-care provider who has a need to know or if the client specifically consents that information be shared with persons of his or her choice and also the duty to warn if the client threatens to harm others. Privileged communication relates to the privacy of what was discussed during therapy sessions and this can be documented in medical records. Clients may be held against their will if they are committed to a facility for psychiatric care until they no longer pose a danger to themselves or to anyone else.
1. A client made threats to harm his parents if they come too close to him. The parents called 911, and the client is now held involuntarily for a psychiatric evaluation. During this time of involuntary admission, the client retains all client rights except for which of the following? A) Confidentiality B) Right to freedom C) Periodic treatment review D) Choice of providers
Ans: B Feedback: Civil commitment or involuntary hospitalization curtails the client's right to freedom (the ability to leave the hospital when he or she wishes). All other client rights, however, remain intact.
15. Disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of A) beneficence. B) confidentiality. C) duty. D) veracity.
Ans: B Feedback: Confidentiality involves the disclosure of information only to authorized individuals. Beneficence is one's duty to benefit or to promote good for others. Duty is the existence of a legally recognized relationship. Veracity is the duty to be honest and truthful.
22. A malpractice lawsuit was filed after a nurse restrained the client for screaming at and attempting to strike anyone who was within striking distance. The nurse followed agency procedures that were consistent with Joint Commission Standards. For which reason is this malpractice lawsuit most likely to be unsuccessful? A) The nurse did not have a duty. B) The nurse did not breach duty. C) The client did not suffer some type of loss, damage, or injury. D) There was no evidence that a breach of duty was a direct cause of the loss, damage, or injury.
Ans: B Feedback: For a malpractice suit to be successful, the client or family needs to prove the following four elements: (1) Duty: a legally recognized relationship (i.e., physician to client, nurse to client) existed. The nurse had a duty to the client, meaning that the nurse was acting in the capacity of a nurse. (2) Breach of duty: the nurse (or physician) failed to conform to standards of care, thereby breaching or failing the existing duty. The nurse did not act as a reasonable, prudent nurse would have acted in similar circumstances. (3) Injury or damage: the client suffered some type of loss, damage, or injury. (4) Causation: the breach of duty was the direct cause of the loss, damage, or injury. In other words, the loss, damage, or injury would not have occurred if the nurse had acted in a reasonable, prudent manner. The nurse did have a duty to the client. The nurse did not breach this duty by the nursing actions. The client did experience loss of autonomy from being restrained. Since there was no breach of duty, there was no evidence that a breach of duty was a direct cause of the loss, damage, or injury.
19. An adult client is put in restraints after all other attempts to reduce aggression have failed. Which of the following is required now that restraints have been instituted? A) Review of the appropriateness of restraints every 8 hours B) A face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint. C) A documented nursing assessment every 4 hours D) Constant one-on-one supervision during the first hour and then video monitoring
Ans: B Feedback: For adult clients, use of restraint and seclusion requires a face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint or seclusion and every 8 hours thereafter, a physician's order every 4 hours, documented assessment by the nurse every 1 to 2 hours, and close supervision of the client. Staff must monitor a client in restraints continuously on a 1:1 basis for the duration of the restraint period. A client in seclusion is monitored 1:1 for the first hour and then may be monitored by audio and video equipment.
25. The nurse is attending an in-service training on safe take-down techniques for aggressive clients. Preparation for safe physical handling prepares the nurse to practice which ethical principle? A) Veracity B) Nonmaleficence C) Justice D) Autonomy
Ans: B Feedback: Nonmaleficence is the requirement to do no harm to others either intentionally or unintentionally. Safe take-down techniques are used to avoid unintentional harm to the client. Veracity is the duty to be honest or truthful. Justice refers to fairness, that is treating all people fairly and equally without regard for social or economic status, race, sex, marital status, religion, ethnicity, or cultural beliefs. Autonomy refers to the person's right to self-determination and independence.
16. A client who is depressed and suicidal is scheduled for electroconvulsive therapy (ECT), which requires consent. Legally, who should sign the consent for this treatment? A) A member of the treatment team B) The client C) The client's spouse D) The psychiatrist
Ans: B Feedback: The client has the right to sign (or refuse to sign) the consent. The other parties listed do not have the legal right to sign for the client unless they are the client's legal guardian.
12. When is a nurse legally obligated to breach confidentiality? A) At any time a client is threatening B) If threats are made to an identifiable third party C) Whenever the client becomes aggressive D) When the client violates the nurse's boundaries
Ans: B Feedback: The duty to warn a third party exists when a client threatens harm to that identifiable third party; the client's confidentiality is overridden. Answer choices A, C, and D are not situations in which confidentiality may be breached. Decisions about the duty to warn third parties usually are made by psychiatrists or by qualified mental health therapists in outpatient settings. It is not permissible for a nurse to breach confidentiality at any time a client is threatening, or becomes aggressive or violates the nurse's boundaries.
3. A client who has depression is admitted to treatment on a voluntary basis. While in the hospital, the client makes several comments about wanting to "end it all." The client decides one day to leave against medical advice. Which of the following would be the most appropriate action by the nursing staff? A) Calling security and asking them to detain the client B) Allowing the client to leave with community resources for follow-up care C) Contacting the psychiatrist for initiation of commitment proceedings D) Contacting the client's family to request they convince the client to stay
Ans: C Feedback: If a voluntary client who is dangerous to himself or herself or to others signs a request for discharge, the psychiatrist may file for a civil commitment to detain the client against his or her will until a hearing can take place to decide the matter.
13. A client was brought to the emergency department by police after neighbors complained that he was loud and disruptive. The client is paranoid and upset and states, "No one can be trusted." Which of the criteria for involuntary admission does this client meet? A) Dangerous to self. B) Dangerous to others. C) Gravely disabled. D) He does not meet any of the necessary criteria.
Ans: D Feedback: Having a mental illness alone is not sufficient for an involuntary commitment. In this situation, the client is not a danger to himself or others and is not gravely disabled.
8. Which of the following client situations most urgently requires the nurse to break confidentiality and warn a third party? A) An abused woman states, "I have dreams that he is dead." B) A mother states, "Sometimes I feel like killing my kids!" C) A paranoid woman states, "I'll get them before they get me." D) A jealous man states, "I am getting my gun and going to shoot my wife's lover!"
Ans: D Feedback: Mental health clinicians have a duty to warn identifiable third parties of threats made by clients, even if these threats were discussed during therapy sessions otherwise protected by privilege. The clinician must base his or her decision to warn others on the following: Is the client dangerous to others? Is the danger the result of serious mental illness? Is the danger serious? Are the means to carry out the threat available? Is the danger targeted at identifiable victims? Is the victim accessible?
9. A 22-year-old client has been manipulative of staff and disruptive in the milieu. Although she is not dangerous to herself or others, she has created problems on the unit and clearly is not making progress. The nurses offer prescribed medication, but she consistently refuses "any drugs." The staff realizes that legally this client can A) be coerced to accept treatment. B) be committed by her family to receive needed treatment. C) have her family sign permission for treatment. D) continue to refuse treatment.
Ans: D Feedback: The client maintains the right to refuse treatment even if it is needed when she is not dangerous to herself or others. If a client able to give consent, she cannot be coerced into doing so, have her family sign permission for her, or be committed by the family to receive treatment unless she is a danger to herself or others.
21. Placing a client in restraints before using other methods of intervention violates which of the client's rights? A) Receive confidential and respectful care B) Provide informed consent C) Refuse treatment D) Receive treatment in the least restrictive environment
Ans: D Feedback: The least restrictive environment means that the client must be free of restraint or seclusion unless it is necessary. Less restrictive treatments must be tried and found to be ineffective before more restrictive measures can be used. It is not necessary for the client to provide informed consent for restraints to be used when appropriate. A client may not refuse restraints if they are to be used when appropriate.
23. Ensuring that the client has informed consent before agreeing to a treatment regimen displays which of the following ethical principles? A) Fidelity B) Nonmaleficence C) Justice D) Autonomy
Ans: D Feedback: The nurse respects the client's autonomy through client's rights, informed consent, and encouraging the client to make choices about his or her health care. The nurse has a duty to take actions that promote the client's health (beneficence) and that do not harm the client (nonmaleficence). The nurse must treat all clients fairly (justice), be truthful and honest (veracity), and honor all duties and commitments to clients and families (fidelity).