Chapter 9 - Ethical aspects of ger. Nursing

What provisions for nursing service are part of the Omnibus Budget Reconciliation Act (OBRA) as it pertains to long-term care facilities? (Select all that apply.) a. Resident assessments b. Annual screenings c. Minimum staffing d. Ensuring resident rights e. Registered nurse educational requirements

ANS: A, B, C, D OBRA's service requirements include resident assessments and screenings, minimum staffing requirements, and ensuring resident rights. Educational requirements for nurses are not part of this mandate.

An older adult resident of a long-term care nursing facility frequently attempts to get out of bed and is at risk of sustaining an injury. The nurse's planned intervention to minimize the patient's risk for injury is guided by: a. the patient's right to self-determination and to be free to get out of bed. b. an understanding that non drug interventions must be tried before medications. c. the knowledge that application of a vest restraint requires a physician's order. d. the patient's cognitive ability to understand and follow directions.

ANS: B The drug use guidelines are based on the principles that certain problems can be handled with nondrug interventions and that such forms of treatment must be ruled out before drug therapy is initiated. The patient does have the right to self-determination, but the staff must ensure the patient's safety. Vest restraints do require an order, but environmental measures must be tried before chemical or physical restraints. The patient's cognitive abilities do not allow for unjustified physical or chemical restraints.

The nursing student learns about the Patient Self-Determination Act. What is a key provision of this act? a. It establishes new rights for patients in medical facilities. b. It requires facilities to educate patients on their rights. c. It allows families to be approached for organ donation. d. It spells out the procedures for creating an advance directive.

ANS: B The intent of this law is to ensure that patients are given information about the extent to which their rights are protected under state law. It does not establish new rights, is not related to organ donation, and does not specify procedures for advance directives.

The nurse recognizes that a nursing aide likely to abuse an older patient is one who has: a. ineffective verbal communication skills. b. little experience working with the older population. c. poor stress management skills. d. been a victim of abuse.

ANS: C It has been shown that the primary abusers of nursing facility residents are nurse aides and orderlies who have never received training in stress management.

The director of nursing at a long-term care facility is getting ready for the annual inspection. What information guides the director? a. Visits cannot be unannounced. b. The director must be off site during the inspection. c. Nurses must answer questions from the inspectors. d. Results will be shared only through the mail.

ANS: C Nurses present during inspections must answer questions posed by the inspectors. Visits can be unannounced. The director should be present during the survey. Results are shared during a conference, then a report is mailed later.

A nurse caring for older adult patients shows an understanding of the implementation of standards of care when: a. dialing the telephone when the patient wants to call his daughter. b. requesting the patient's favorite dessert on his birthday. c. closing the patient's door when he is praying. d. reminding the patient to call for assistance before getting out of bed.

ANS: D A standard of care is a guideline for nursing practice and establishes an expectation for the nurse to provide safe and appropriate care, such as reminding the patient to call for assistance before getting out of bed. Standards of care may be established on national or regional levels. Dialing the phone for the patient, closing the patient's door, and requesting a special dessert are not actions that conform to standards of care.

A graduate nurse learns about the provisions of the Health Insurance Portability and Accountability Act (HIPAA), which include which of the following? a. Requires employers to offer health care insurance b. Regulates the amount employers can charge for insurance c. Mandates that employers provide specific benefits d. Helps maintain coverage when a person changes jobs

ANS: D HIPAA has several provisions, one of which is that it helps people maintain health care insurance when they are changing jobs. The other statements are common misconceptions about HIPAA.

Artificial organs, genetic screening, ultrasound, and other innovations today save lives that once would have been given no hope. These advances have raised ethical questions related to which of the following issues? A) For whom and when technology should be used B) How procedures should be monitored and outcomes measured C) How judgments about patients' health status can be kept objective D) The limits of medical practice in diagnosing and treating disease

Ans: A Feedback: Although all the choices listed may be of concern, the greatest ethical conflict lies in deciding who can have access to a limited resource.

When advocating the rights of patients to receive health care regardless of ability to pay, a nurse is applying which of the following ethical principles? a. Holistics b. Justice c. Fidelity d. Autonomy

B Feedback: Justice argues that people should be treated equally regardless of their circumstances. Thus, medical treatments available to the rich should also be available to the poor. The other choices are not directly related to the situation.

The nurse is caring for a terminally ill older patient who has a living will that excludes pulmonary and cardiac resuscitation. The family expresses a concern that the patient may "change her mind." The nurse best reassures the family by stating: a. "The nursing staff will watch her very closely for any indication she has changed her mind." b. "We will discuss her wishes with her regularly." c. "She can change her mind about any provision in the document at any time." d. "Your mother was very clear about her wishes when she signed the document."

ANS: A AMD provisions appropriately provide that people can change their minds at any time and by any means. Nurses need to be alert to any indications from a patient. Based on the person's medical condition, subtle signs such as a gesture or a nod of the head may be easily overlooked. The patient may or may not be able to discuss her condition. Stating that the mother was very clear in her wishes does not take into account the fact that patients can change their minds any time.

The manager of a long-term care facility is evaluating patients' use of drugs. The resident on which of the following medications would be allowed to continue taking medications to control behavior? a. On anxiolytics; now able to participate in group activities b. Given a benzodiazepine at night; roommate now sleeps well c. Given sedatives; eats 100% of meals if resident is fed d. Taking an antipsychotic; no longer wanders at night .

ANS: A Drugs should not be used to control behavior. If used to manage health conditions, the patient should show improvement. The patient who is now able to participate in activities shows an increase in functional ability, so this medication is therapeutic for this patient. The other patients are given drugs to control behavior.

During the state inspection of a skilled nursing facility, a surveyor notes suspicion that a particular nurse may not be providing the proper standard of care. The nurse manager informs the nurse to expect: a. a review of the situation by the state board of nursing. b. termination of employment from the facility. c. mandatory remediation related to the suspect care issues. d. unannounced reevaluation of performance within the next 3 months.

ANS: A In such cases, the surveyor may forward the record showing the relevant findings to the appropriate state agency or board for review of the nurse's practice, requesting a determination of whether the nurse may have violated the state's nurse practice act. Regulations do not specify that the nurse be terminated, have remediation, or have an unannounced reevaluation.

The nurse manager in a long-term care facility reviews resident care plans at what interval? a. Quarterly b. Every 60 days c. Annually d. When changes occur

ANS: A The resident care plan is routinely reviewed quarterly.

11. An older adult patient has been approached to participate in a research study. The nurse best advocates for the patient's right of self-determination by: a. evaluating the patient's cognitive ability to understand the consequence of the study. b. determining what risks to the patient are involved. c. discussing the importance of the study with the patient and his family. d. encouraging the patient to discuss the decision with trusted family or friends.

ANS: A The right to self-determination has its basis in the doctrine of informed consent. Informed consent is the process by which competent individuals are provided with information that enables them to make a reasonable decision about any treatment or intervention that is to be performed on them. The other options do not address autonomy and self-determination.

A nurse new to geriatric nursing asks the nurse manager to clarify how to handle a patient's claim that she has been physically abused. The nurse manager responds most appropriately when stating: a. "I'll show you where you can find this state's reporting requirements." b. "As a nurse you are considered a 'mandated reporter' of elder abuse." c. "As long as you are reasonably sure abuse has occurred, report it." d. "You need to report any such claims directly to me."

ANS: A To be responsive to the legal obligation to report reasonably suspicious acts of abuse and because there is great variation among the states, nurses should determine the specific reporting requirements of their jurisdictions, including where reports and complaints are received and in what form they must be made. The statements that the nurse is a mandatory reporter and that abuse should be reported if suspected are true, but they do not help the nurse learn to handle the complaint. The manager may want to know about claims of abuse and it may be facility policy to report up the chain of command, but the nurse is responsible for filing the formal complaint.

To meet current guidelines regarding incontinence in a long-term care facility, what action by the director of nursing is best? a. Assess residents for the ability to participate in a bladder training program. b. Take all residents to the toilet every 2 hours and after meals. c. Ensure all residents wear incontinence briefs, which are changed routinely. d. Ask physicians and other providers to prescribe medications for bladder control.

ANS: A Urinary incontinence is a common problem that can lead to several complications. The extent to which residents participate in bladder training programs is an area of focus for facility inspectors. Some residents may need routine toileting, wearing briefs, and medications, but they should all be assessed for the ability to participate in bladder training.

The adult child of a long-term care facility resident receives a phone call from the director of nursing stating that her parent has 30 days to move out of the home. Under what conditions can a facility require a resident to move? (Select all that apply.) a. Nonpayment for services received b. Needs exceeding what the facility can provide c. Stay is no longer required based on the resident's medical condition d. Facility is going out of business e. Frequent disruptive behavior during the night

ANS: A, B, C, D A facility can require a resident to leave in four situations: nonpayment for services, needs that exceed what the facility can provide, the patient's medical condition no longer warrants long-term care, or the facility is going out of business. Being disruptive is not a cause for expelling a resident.

To best address the patient's right to self-determination, which of the follow questions does the nurse ask at the time the patient is admitted to a nursing facility? (Select all that apply.) a. "Do you understand what a living will and durable power of attorney are?" b. "If you have already prepared an advance care directive, can you provide it now?" c. "Are you prepared to discuss your end-of-life choices with the nursing staff?" d. "Have you discussed your end-of-life choices with your family or designated surrogate?" e. "Would you like help with preparing a living will or a durable power of attorney?"

ANS: A, B, D, E All the correct options address the patient's right to make an informed decision regarding health care issues by using various advance directives. The patient does not need to discuss end-of-life choices with the staff in order to exercise the right to self-determination.

An alert but disoriented older patient lives with family members. The home health nurse, being aware of the role of patient advocate, recognizes the obligation to report possible patient abuse based on: a. a family member stating, "It's hard being a caregiver." b. assessment showing bruises in the genital area. c. observation of mild changes in orientation. d. patient's report of always being hungry.

ANS: B Even when a patient exhibits disorientation, any report of mistreatment or neglect is to be considered reasonably suspicious and so should be reported. Bruises in the genital area raise suspicions of abuse. The family stating caregiving is hard does not mean they don't have enough support to cope. Mild changes in orientation may be expected in a disoriented patient. The patient who is always hungry should be followed up with a nutrition assessment, and this may or may not be a sign of abuse.

The director of nursing at a certified long-term care facility overhauls the nursing assistant training program to include which features? (Select all that apply.) a. 12 hours of classroom content b. Training in infection control measures c. Instruction on resident rights d. 6 hours of quarterly in-service education e. Education on safety measures

ANS: B, C, D, E Requirements for a nursing assistant's education includes training in infection control and interpersonal skills, instruction on resident rights and safety procedures, and 6 hours of education through in-services quarterly. Nursing assistants must have classroom training before working with residents, but the amount of time is not specified.

The nurse is caring for an unresponsive patient who has terminal cancer with a Do Not Resuscitate order in effect. A family member tells the nurse, "I'll sue you and every other nurse here if you don't do everything possible to keep her alive." The nurse understands that protection from legal prosecution in this situation is provided by: a. legal immunity granted when acting according to the patient's expressed wishes. b. the legal view that the duty to put into effect the patient's wishes falls to the physician. c. knowledge of and compliance with facility policies and procedures regarding end-of-life care. d. implementing interventions that preserve the patient's right to self-determination.

ANS: C In this case, immunity applies only to the physician and not to the nurse because the physician is given the legal duty to put into effect the patient's wishes. Consequently, the nurse must rely on effective communication with the physician, patient, and family, and on the quality of the facility's policies and procedures, to be sure that his or her actions are consistent with the legally required steps.

An 87-year-old patient is unsure of the purpose of a living will. The nurse describes its purpose best when stating: a. "It's a legal document that Social Services can help you create." b. "It designates a family member to make decisions if you become incompetent." c. "It provides a written description of your wishes in the event you become terminally ill." d. "It assures you won't be subjected to treatments you don't want."

ANS: C Living wills are intended to provide written expressions of a patient's wishes regarding the use of medical treatments in the event of a terminal illness or condition.

A nurse responsible for the care of older adult patients shows the best understanding of the nursing standards of practice when basing nursing care on the: a. physician's medical orders. b. stated requests of the individual patient. c. care that a responsible geriatric nurse would provide. d. implementation of the nursing process.

ANS: C Nursing standards of practice are measured according to the expected level of professional practice of those in similar roles and clinical fields. Nursing care is not judged against the physician's orders, stated requests of the patient, or implementation of the nursing process

The nurse caring for an older patient who resides in an assisted living facility is asked to obtain and witness the patient's signature on a living will document. The nurse responds most appropriately when stating: a. "I will, because such a document is so valuable to the patient's plan of care." b. "I'll ask the patient's family if they agree that the patient should sign the document." c. "First I need to discuss the purpose of this document with the patient." d. "I'm sorry but I cannot ethically do that."

ANS: D It is not permissible for the nurse to secure the patient's signature or to witness the patient's signature on a living will document. Generally speaking, an employee or owner of a facility in which the patient resides cannot witness this document.

A pt has been found by nursing staff wandering in and out of other patients' rooms during the night. The nurse views the patient's PRN antipsychotic medication order as: a. an appropriate intervention to help assure his safety. b. an option to be used only when all other non drug interventions prove ineffective. c. inappropriate unless the physician is notified and approves its use. d. not an option because it should not be used to manage behaviors of this type.

ANS: D Reasons for the use of antipsychotic drugs do not include behaviors such as restlessness, insomnia, yelling or screaming, inability to manage the resident, or wandering. The staff must provide nondrug alternatives to help calm the patient.

Which of the following is the best example of the ethical principle of beneficence? A) The nurses at City Hospital answer patients' call buttons "with all deliberate speed" B) The nursing supervisor fires an incompetent part-time nursing assistant, leaving a less than full complement of staff C) At a nursing home, the staff closes residents' doors before the body of a deceased resident is wheeled out D) The charge nurse documents all reported incidents at the end of the shift

Ans: A Feedback: Beneficence means to do good for patients. Of the examples given, A is the best demonstration of this principle.

Which of the following statements that nurses on a hospital unit made about ethical decision making is most accurate? A) "Instead of making ethical decisions in isolation we should enlist the help of people like ethics committees and clergy." B) "We should ensure that contributors to our ethical decision making have direct experience with the types of hands-on care we provide." C) "Decisions that we make involve complex realities so we have to avoid specific philosophies of ethics." D) "The need for confidentiality means that we shouldn't be discussing particular ethical issues with anyone other than patients themselves."

Ans: A Feedback: Ethical decision making should include individuals apart from the situation, including ethics committees, lawyers, and clergy, many of whom will not have direct health-care experience. Specific philosophies of ethics can provide a useful framework for decision making.

Nurse H is providing care in the hospital for a 71-year-old male patient who is in the late stages of cancer and who has painful bone metastases. The client is non-responsive but groans and grimaces intermittently. Nurse H is drawing up a breakthrough dose of morphine for the patient, but Nurse R cautions that, "sure, that will address his pain, but it could depress his respiratory drive and actually kill him at this stage." Which of the following ethical principles is Nurse R prioritizing? A) Nonmaleficence B) Justice C) Beneficence D) Fidelity

Ans: A Feedback: Nurse R's emphasis on preventing harm to the patient, even during an act that may be motivated by altruism, is characteristic of the principle of nonmaleficence.

Patient R is seriously injured in an automobile accident, and his chances of survival are slim. During his diagnostic workup, lab tests reveal that he is HIV positive. The health care professional who decides to withhold the test results from R is violating the ethical principle of: A) Veracity B) Nonmaleficence C) Beneficence D) Autonomy

Ans: A Feedback: This principle is central to all nurse-patient interactions because the quality of this relationship depends on trust and integrity. Veracity is truthfulness; withholding information violates it.

Which of the following phenomena have contributed to recent increases in the number and complexity of ethical dilemmas for gerontological nurses? Select all that apply. A) The scope of practice goes beyond simply following doctors' orders. B) Nurses' levels of responsibility are higher than in past years. C) Medical technology has made significant advances. D) The Internet has made patients and their families more informed about health. E) Deaths from heart disease are declining while deaths from cancer are increasing. F) Conflicts between cost effectiveness and quality of care

Ans: A, B, C, F Feedback: The increasing scope and responsibility that nurses bring to practice contribute to ethical dilemmas, while advances in medical technology and fiscal constraints bring a new series of issues to care. Increasingly informed patients and changes in causes of death do not directly increase the number of ethical dilemmas faced by nurses.

Nurse T promised an 81-year-old female client that he would liaise with the physiotherapy team and ensure that her rehabilitation would commence soon, since it was apparent that she was being overlooked. Due to a busy shift during which another patient declined rapidly, the nurse did not follow up. Which ethical principle has Nurse T most clearly violated? A) Beneficence B) Fidelity C) Veracity D) Justice

Ans: B Feedback: Central to the principle of fidelity is respecting words and duties to patients, such as following up when promised. The nurse's actions are less indicative of deficits in beneficence, veracity (since he did not overtly lie to the patient), or justice.

A patient with a terminal illness confides in his nurse that he plans to commit suicide. The nurse struggles with whether to report his intent. In the "Code of Ethics for Nurses" of the American Nurses Association, the nurse reads the following statement: "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient." In this case, the nurse perceives the greatest ethical conflict between: A) Advocacy and protection B) Safety and patient rights C) Health and terminal illness D) The patient and the nurse

Ans: B Feedback: In this case, the right of the patient (patient rights) to confidentiality and the nurse's commitment to sustaining his life (safety) are in direct conflict.

Which of the following factors most contributes to the fact that society is experiencing an increased burden for entitlement programs for the elderly? A) The rights of older citizens to receive health services unavailable to other age groups B) The increasing ratio of dependent elderly to productive workers C) Growing public attention to policy and reimbursement decisions that are not in the best interest of elders D) The widening scope and increased accountability of gerontological nurses

Ans: B Feedback: The impact of entitlement programs and services for older adults was felt less severely when only a small portion of the population was old; but with growing numbers of people spending more time in old age and the ratio of dependent individuals to productive workers increasing, society is beginning to feel burdened.

The ethics committee of a hospital has decided that it is unethical to prioritize patients who possess more comprehensive insurance plans than those with minimal or no insurance. Which of the following principles most clearly underlies this decision? A) Beneficence B) Justice C) Fidelity D) Veracity

Ans: B Feedback: The principle of justice includes treating individuals fairly and giving patients the service they need, emphasizing service based on need rather than the ability to pay. This perspective is not central to the principles of beneficence, fidelity, or veracity.

The ethics committee of a hospital has decided that it is unethical to prioritize patients who possess more comprehensive insurance plans than those with minimal or no insurance. Which of the following principles most clearly underlies this decision? A)Beneficence B) Justice C) Fidelity D) Veracity

Ans: B Feedback: The principle of justice includes treating individuals fairly and giving patients the service they need, emphasizing service based on need rather than the ability to pay. This perspective is not central to the principles of beneficence, fidelity, or veracity.

In which of the following cases is the ethical conflict between cost containment and quality care most obvious? A) The termination of an incompetent aide who is the sole support of his family B) The conversion of a community playground into a senior citizen center C) An insurance company that denies reimbursement for dialysis of patients older than age 70 D) The decision to remove the feeding tube from a comatose patient

Ans: C Feedback: Although all choices involve ethical dilemmas, the most direct opposition between cost containment and quality care arises in the denial of expensive treatments to elderly patients.

19. Which of the following is the best way for nurses to minimize their struggles in making ethical decisions? A) Take no action unless an advance directive, will, and other legally binding documents are in effect B) Act on the recommendations of a patient's healthcare provider, friends, and family members C) Consult the guidelines of the American Nurses Association and the institution's ethics committee D) Maintain nursing's traditional focus on following physicians' orders and providing care and comfort for the patient

Ans: C Feedback: Although legal documents and the views of family members should be taken into account, a nurse may be called on to make ethical decisions without them or occasionally in opposition to them. Retreating into a "care-only' mode does not resolve ethical dilemmas. The best choice among those listed is to seek guidance from professional organizations and committees charged with establishing ethical guidelines for institutions.

A nurse manager who provides leadership in a long-term care facility prioritizes the need for residents to have current and relevant immunizations, stating, "it's inconvenient and costly, but it provides protection not only to the person getting the vaccine but to all those that they're in contact with." Which of the following ethical philosophies most likely underlies the nurse's statement? A) Nonmaleficence B) Absolutism C) Utilitarianism D) Relativism

Ans: C Feedback: The nurse's emphasis on providing a perceived good to a maximum number of individuals is typical of a utilitarian outlook

A nurse manager who provides leadership in a long-term care facility prioritizes the need for residents to have current and relevant immunizations, stating, "it's inconvenient and costly, but it provides protection not only to the person getting the vaccine but to all those that they're in contact with." Which of the following ethical philosophies most likely underlies the nurse's statement? A) Nonmaleficence B) Absolutism C) Utilitarianism D) Relativism

Ans: C Feedback: The nurse's emphasis on providing a perceived good to a maximum number of individuals is typical of a utilitarian outlook.

Nurse G is a practicing alcoholic, but continues in the job without seeking treatment. Nurse G is most in violation of which provision of the American Nurses Association "Code of Ethics for Nurses"? A) The nurse practices with respect for the inherent dignity of every individual B) The nurse is responsible and accountable for determining the appropriate delegation of tasks C) The nurse owes the same duties to self as to others, including the responsibility to preserve integrity D) The nurse participates in maintaining conditions of employment conducive to the provision of quality care

Ans: C Feedback: A nurse who is a practicing alcoholic is attempting to perform with his or her integrity compromised. Nurse G is violating duties to self and to patients.

Despite the wishes of her family and the recommendations of the care team, a 70-year-old client with a diagnosis of congestive heart failure, but who is otherwise healthy, wants to have a no-code order in place. Which of the following statements by the care team most clearly prioritizes the patient's autonomy? A) "If this is what is best for everyone then we need to go ahead with the order." B) "Provided it can be demonstrated that she has a potentially poor prognosis, we should certainly consider doing this." C) "It's best that social work get involved at this point to reconcile the family's and the patient's wishes." D) "If that's what she wants, then ultimately we're obliged to respect her wishes."

Ans: D

Which of the following statements most accurately captures an aspect of the use of ethics committees in the ethical decision-making process? A) It is important that lawyers be excluded from ethics committees. B) Ethics committees should originate within academic and religious contexts rather than health care organizations themselves. C) Multiple ethics committees are often necessary in order to gain a holistic and balanced perspective on issues. D) Evaluation by ethics committees of decisions that have been made can lead to the development of policies and better decision making in the future.

Ans: D Feedback: The outcomes of ethical decision making should be assessed, a process that can result in the development of improved policies and procedures. Lawyers are valid members of ethics committees and while they should draw from various professions and perspectives, ethics committees can justifiably exist in health care contexts. It is not necessary to have multiple, coexisting ethics committees, but rather to ensure that any given committee have a variety of perspectives and backgrounds.

Which of the following actions is viewed as ethically acceptable under the philosophy of relativism? A) An older adult's children propose that she split her life savings between them before she needs care. B) A lottery winner donates money to a hospital only if the hospital's new wing is named after him. C) A millionaire finds a wallet in her physician's waiting room and keeps the money inside. D) A poor man steals medicine and diabetic supplies from a pharmacy to help his ill child.

Ans: D Feedback: The act of stealing is ethically wrong in some philosophies, but condoned under the philosophy of relativism, or situational ethics, because of the circumstances—in this case, need. Choice A exemplifies utilitarianism; B and C, egoism.

Mrs. J's insurance company reimburses for a maximum of four physical therapy sessions annually. At age 62, Mrs. J is recovering slowly from hip surgery, and her nurse believes that additional sessions would enhance Mrs. J's self-care capacity. Mrs. J cannot afford to pay for additional sessions. Which of the following is the nurse's major ethical concern? A) Do I increase financial risks for health care institutions by insisting that nonreimbursed therapy be provided? B) Is the insurance company reimbursing in a manner that threatens my patient's well-being? C) Have meta-analyses shown that additional therapy sessions are cost-effective? D) Am I in compliance with the integrity requirement of the "Code of Ethics for Nurses" of the American Nurses Association?

B Feedback: The nurse's first priority is quality care for the patient. If an insurance company is reimbursing in a manner that threatens a patient's well-being, the nurse faces a difficult ethical conflict.