Chapter 3

5. A nurse finds a mental health care directive in the medical record of a patient experiencing psychosis. The directive prohibits the prescription of specific medications. Considering the patient's impaired function, what is the nurse's primary responsibility regarding medication administration? a. Ensure that the directives are respected in treatment planning. b. Review the directive with the patient to ensure that it is current. c. Alert the prescribing psychiatrist of the directive. d. Discuss the revision of the directive with the patient's guardian or power of attorney.

ANS: A Advance directives for psychiatric care given by competent patients are considered binding and should be respected in planning treatment. The patient is not currently capable of making such decisions due to the psychosis. The decision cannot be rescinded if it was appropriately arrived at a time when the patient was cognitive. Alerting the current prescribing psychiatrist is appropriate, but it is not the primary nursing responsibility at this time.

6. A patient constantly disrupts activities on an inpatient unit. Which action would place the nurse at risk of being quality of assault? a. Threatening to rescind the patient's weekend pass b. Placing the patient in seclusion c. Refusing to medicate the patient as prescribed d. Pushing the patient out of the day room

ANS: A Assault is defined as an act that creates a reasonable apprehension of harmful or offensive contact to another without consent of the other. The nurse has threatened the patient thus risking the risk of assault. Battery is unwanted touching such as pushing. Negligence is failure to do what is reasonably prudent under the circumstances such as not providing prescribed medications. False imprisonment is associated with unwarranted seclusion.

4. To help preserve patients' rights to freedom from restraint and seclusion, the most important interventions that the nurse can use are based on which intervention? a. Therapeutic management of the patient's needs b. Reality-based communication to minimize cognitive disorientation c. Confidentiality of all documentation associated with the patient d. Effective use of ancillary personnel to monitor the patient

ANS: A Attention to the nurse-patient relationship, the therapeutic milieu, and principles of pharmacologic management can reduce the need for restrictive measures. The other options are important aspects of care but do not relate directly to the use of restraint and seclusion.

11. A crisis team led by a psychiatric nurse assesses a patient with a history of paranoid schizophrenia who is standing on the lawn shouting, "Don't come near me. People are poisoning my water." Which statement made to the police officer accurately identifies the patient's immediate needs? a. "We've identified that this patient requires immediate emergency care." b. "This patient will require a hearing to implement a long-term commitment." c. "Please arrange for a probable-cause hearing for this patient." d. "This patient meets the criteria for short-term observation and treatment.

ANS: A Individuals who are deemed to be dangerous to self, dangerous to others as is possible with this patient, or those who are gravely disabled can be detained involuntarily for evaluation and emergency treatment for a specified period of time (often for 72 hours). Long-term commitment might be unnecessary. A probable-cause hearing is needed only for short-term observation and treatment.

22. A nurse engaging in which behavior demonstrates a need for addition education regarding the release of patient information without expressed written consent? a. Providing the estimated date of discharge to the patient's employer b. Documenting the patient's daily behaviors during hospitalization c. Discussing the patient's history with other team members during care planning d. Documenting in the medical record the date and circumstances information was released to the court system

ANS: A Release of information to individuals or entities without patient authorization violates the patient's right to privacy. Documentation is a nursing responsibility and both the treatment care team and the court have the right to access such information.

21. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate to a patient diagnosed with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop. I don't want to take that medicine anymore. I hate the side effects." What action should the nurse take? a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Proceed with the injection but explain to the patient that there are medications that may help reduce the unpleasant side effects. c. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose." d. Notify other staff to report to the room for a show of force, and proceed with the injection, using restraint if necessary.

ANS: A The nurse, as an advocate and educator, should seek more information about the patient's decision and should not force the medication. Patients with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. It is not reasonable to promise a reduction in side effects without first discussing them, nor is it appropriate to pressure the patient into taking the medication. The medication cannot be given without the patient's informed consent.

24. A patient's insurance will not pay for continuing hospitalization at a private facility, so the family considers transferring the patient to a public psychiatric hospital. They express concern that the patient will "never get any treatment." Select the nurse's most helpful reply to their concern. a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern, because the right to treatment extends only to provision of food, shelter, and safety." c. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse."

ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals under federal law. The remaining statements do not accurately describe that right.

1. Which interventions should the nurse apply to the care plan of a patient requiring involuntary secluded? (Select all that apply.) a. Seclusion instituted when all less restrictive interventions are ineffective in managing behavior b. Written medical order to be obtained within 2 hours of implementation of intervention c. Patient to be debriefed when seclusion is discontinued d. Patient to be offered bathroom privileges hourly e. Patient evaluation every 15 minutes

ANS: A, C, D The correct interventions include debriefing, resorting to seclusion as a last resort, and evaluations should be done every 15 minutes. A medical order must be secured within 1 hour.

18. A patient who is admitted involuntarily with a diagnosis of bipolar disorder, manic phase, refuses a prescribed dose of lithium. The nurse assembles a show of force and intimidates the patient into taking the medication. What is a likely an outcome of this action for the patient? a. A lessening of mania b. Grounds for a civil suit against the nurse for assault c. Grounds to sue the hospital for false imprisonment d. Improved nurse-patient relationship

ANS: B A nurse who forces a patient to accept treatment or take medication in a nonemergency situation against the patient's wishes can be found liable for assault (threatening) and battery (nonconsenting touching) in civil court, even if the nurse had the best interest of the patient in mind. Such action would not serve to improve the nurse-patient relationship. Diminished symptoms of mania are not likely to be related to a single dose of lithium. The scenario does not describe the conditions of false imprisonment. Actions taken in the best interest of the patient that violate the patient's rights are cause for civil action.

25. A patient diagnosed with paranoid schizophrenia believes that evil spirits are being stirred by a local minister and verbally threatens to bomb a local church. Considering the rights of this patient, what is the initial nursing responsibility? a. Obtaining the patient's permission to release this information to the police b. Recognizing and acting upon the duty to warn and protect c. Protecting the patient's right to confidentiality d. Reviewing the criteria associated with malpractice so as to avoid committing this tort

ANS: B It is the health care professional's duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not considered a violation of confidentiality or an example of malpractice and patient consent is not required.

16. A patient was restrained after assaulting a staff member. Which nursing measure has priority? a. Assess the patient for comfort needs every 15 minutes. b. Maintain constant supervision of the patient. c. Administer a sedating medication after applying the restraints. d. Distract the patient at frequent intervals while restraints are in use.

ANS: B Restrained patients must be constantly observed, with documentation of physical safety and comfort interventions occurring at 15-minute intervals. Medication may be administered, but this is not the priority action. Distraction is not an effective technique to use when a patient is in restraints, because minimal stimulation is preferred.

1. Considering the M'Naghten Rule, what information is most important for the nurse to document when caring for a patient who will soon be tried on murder charges? a. The patient's participation in treatment planning b. The patient's comments about commission of the crime c. Examples of behaviors that support psychiatric diagnoses d. The patient's perceptions of the need for hospitalization and treatment

ANS: B The M'Naghten Rule states that to be held legally accountable for his or her actions, a person with mental illness must be able to understand the nature and implications of the crime. Although each of the options refers to data that should be documented, the patient's comments about the crime would be of most importance to the trial.

2. When discussing the precedent established in Wyatt v. Stickney with nursing students, the nurse demonstrates an accurate understanding or the decision by focusing on what factor? a. Intellectualization of the client's condition b. About the client's rights to adequate treatment c. Minimizing the client's risk of being coerced into treatment d. Risks created by a request for immediate discharge from the facility

ANS: B Wyatt v. Stickney was a case in which the court ruled that patients had the right to adequate treatment while hospitalized. Intellectualizing is a defense mechanism. Right to refuse treatment and commitment issues were not the focus of Wyatt v. Stickney.

17. Which patient behavior should be considered when evaluating the need for an involuntary commitment for psychiatric treatment? a. Noncompliant with the treatment regimen b. Engaging in the selling and distribution of illegal drugs c. Verbalizing the threat to "eliminate anyone who comes near me" d. Living on the streets

ANS: C Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization since there is not direct threat of harm to self or to others.

9. A patient tells the nurse, "I still have suicidal thoughts, but don't tell anyone because I am supposed to be discharged today." Select the nurse's best course of action. a. Have the patient sign a "no suicide" contract. b. Respect the patient's request related to confidentiality. c. Inform the health care provider and other team members. d. Search the patient's belongings for potentially hazardous items.

ANS: C Patient right to confidentiality never includes keeping important clinical information secret, especially information related to patient safety. Patients should be informed that all relevant information will be shared with the health care team. None of the other options sufficiently address the safety issue presented by a patient who expresses suicidal thoughts.

3. A patient shouts, "I'm holding you responsible for mistreatment based on Rogers v. Orkin." The nurse should review past care related to what focus? a. Loss of privileges b. Inability to make phone calls c. Medication administration d. Involuntary hospitalization

ANS: C Rogers v. Orkin was a case in which the court ruled that nonviolent patients could not be forced to take medication. It did not have implications related to hospitalization or application of patient privileges.

13. An involuntarily admitted inpatient diagnosed with paranoid schizophrenia repeatedly calls the local mayor. The patient verbally abuses the person who answers the phone as well as the mayor. Select the most appropriate initial nursing intervention to help manage this behavior. a. Document the behavior and inform the patient that their phone privileges could be revoked. b. Include the patient in a social skills building group. c. Suspend the patient's phone privileges temporarily, and document the reason. d. Ask the patient advocate to review the limits of the patient's rights with the patient.

ANS: C The patient requires a consequence for unacceptable behavior. The nurse should document that the patient's calls violated the rights of others, thus providing a basis for temporary suspension of the right to make phone calls to the mayor's office. Allowing continued calls violates the rights of others. It might require several days for the advocate to meet with the patient. Social skill building is valuable but doesn't address the immediate behavior.

19. To reduce the risk of a lawsuit based on false imprisonment, mental health nurses must give the highest priority to which intervention? a. Educating patients about unit protocols b. Providing adequate treatment during hospitalization c. Selecting the least restrictive treatment environment that will be effective d. Ensuring that patients have probable-cause hearings within 24 hours of admission

ANS: C Treating a patient in the least restrictive environment that will be effective lessens the threat of the patient bringing civil suit for false imprisonment. In the least restrictive environment, the disruption to patient rights is minimized. Providing information about unit rules and providing adequate treatments are of less immediate importance than ensuring the least restrictive alternative. Probable-cause hearings are necessary only in certain cases.

2. A patient diagnosed with bipolar disorder is admitted involuntarily during a manic phase. Lithium 300 mg PO t.i.d. is prescribed. The patient refuses the morning dose. What are the nurse's best actions? (Select all that apply.) a. Get the prescription changed to an elixir, and administer it in juice. b. Assemble adequate help to force the patient to take the medication. c. Educate the patient about the importance of lithium in stabilizing the mood. d. Allow the patient to refuse the medication, and document the patient's comments. e. Inform the patient that unit privileges are contingent on taking prescribed medications.

ANS: C, D Patients have the right to refuse consent to treatment, including medication administration. The courts have ruled that neither voluntary nor involuntary patients can be forced to take psychotropic medication. Hiding the medication in food or fluids is not ethical. Assembling a show of force implies that forcible administration will occur. Making privileges contingent on medication ingestion is

10. Which nurse is at risk of being guilty of committing a legal tort? a. The primary nurse who does not complete the plan of care for a patient within 24 hours of the patient's admission. b. An advanced-practice nurse who recommends that a patient who is dangerous to self and others be involuntarily hospitalized. c. A nurse who suggests that a patient's admission status be changed from involuntary to voluntary after the patient's hallucinations subside. d. A nurse who gives a PRN dose of an antipsychotic drug to a patient to prevent violent acting out because the unit is short staffed.

ANS: D A tort is a civil wrong demonstrated by a person who violates the legal rights of another. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify a tort since considering the situations described, no patient right has been violated.

23. An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my parents, but you can't tell them." Select the nurse's initial response. a. "You're right. Federal law requires me to keep information private." b. "Those kinds of threats will make your hospitalization last much longer." c. "You really should share this thought with your psychiatrist." d. "I am required to talk to the treatment team about your threats."

ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances, because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the patient's parents of the risk for harm. Considering this information, none of the other options is accurate.

20. How many violations of Medicare and Medicaid guidelines are evident in this documentation? Patient assaulted nurse in hall at 1730. Staff provided verbal intervention, but patient continued to strike out. Patient placed in seclusion at 1745. Observation instituted at hourly intervals. Order received from physician at 1930. Patient sleeping soundly at 2100. Patient released from seclusion at 2230 and returned to own room. a. Two b. Three c. Four d. Five

ANS: D Constant observation of a secluded individual is necessary, with attention given at frequent intervals for safety and comfort interventions. No mention is made of providing fluids or bathroom privileges. Seclusion requires a written order posted within 1 hour. Seclusion must be terminated when patient behavior permits. If the patient is calm enough to sleep, the need for seclusion should be re-evaluated.

8. A cognitively impaired psychiatric patient has been a court appointed guardian. What the nurse is appropriate in seeking the opinion of the guardian regarding what matter? a. The patient's need for a winter coat b. Accompanying the patient on an outing off of facility grounds c. Addressing the patient's financial issues d. TA change in needed treatment

ANS: D Guardians make decisions on behalf of the patient related to their well-being. Being consulted about treatment planning is an appropriate area for a guardian's input. None of the other options are directly associated with the role of a guardian. D

12. Which individual would be the most likely candidate to require at court appointed guardian? a. A patient diagnosed with panic attacks b. A patient who frequently refuses medication c. A patient with frequent admissions for drug abuse d. A patient diagnosed with chronic, paranoid schizophrenia

ANS: D Guardians or conservators are appointed by the courts to manage the affairs of mentally ill individuals found to be incompetent and unable to manage their own affairs appropriately. A patient diagnosed with chronic, paranoid schizophrenia would be in need of a conservator or guardian, whereas the other individuals would more likely be judged competent since their diagnoses are not necessarily chronic in nature or as likely to impair rational thinking.

14. A nurse in a community mental health center receives a call asking for information about a patient. Under which condition can the nurse release information to the caller? a. The caller is related to the patient. b. The psychiatrist approves the request. c. The caller is a mental health professional. d. The patient has given written consent for release of information.

ANS: D Patient information is privileged. Information cannot be released without consent signed by the patient. None of the other conditions meet that criteria.

7. A patient tells the nurse, "When I get out, I'm going to get even with a lot of people." With respect to the nurse's duty to warn, what priority action should the nurse take? a. Discuss the consequences of such actions with the client. b. Notify local law enforcement officials of the threat. c. Warn close relatives and significant other as required by law. d. Document and discuss the threat with the clinical team.

ANS: D The Tarasoff ruling specifies that a specific threat to a readily identifiable person or persons must be made. In this situation, the threat is nonspecific. The prudent action is to document and discuss with the clinical team to determine the need for providing a warning to third parties and to notify the police. While discussing the consequences of acting on the threat is not inappropriate, it is not the priority intervention required.

15. A patient backs into a corner of the room and shouts at the nurse, "Stay away from me." What is the nurse's best initial nursing intervention in this situation? a. Obtain an order for seclusion. b. Administer a PRN antipsychotic drug. c. Call for assistance to physically restrain the patient. d. Talk to the patient in a calm, nonthreatening manner.

ANS: D Verbal intervention provides the least restrictive alternative in this situation. Verbal intervention might halt escalation and prevent the need for medication or the use of restraint or seclusion. Seclusion, restraint, and medication usage are all more restrictive than verbal intervention.