Chapter 9- Legal and Ethical Concerns
1. A 76-year-old Hispanic woman has been admitted to the hospital. There are no advance directives in the chart. Which of the following questions will best prepare the nurse to begin a dialogue with this client about advance directives? A) "With whom do you talk to about your health care decisions?" B) "I see that you have no advanced directives on your chart, could you tell me about that?" C) "Is there someone we should call to join us while we discuss your care?" D) "Tell me about your living arrangements; do you live alone or with others?"
Ans: A Nurses need to identify patterns of culturally influenced decision making in order to ask questions and obtain relevant information from clients of different cultures. Why there are no advance directives on the chart is not the place to start to open the conversation. Whether or not she lives with someone, inviting family to join reflects an emphasis on family caregiving consistent with the Hispanic culture.
12. An older adult with heart failure and mild dementia states the intent to refuse low sodium diet and diuretics, stating: "It's important to me to live free, without restrictions on what I eat." The family is supportive. Which action, by the nurse, should be done first? A) Assure that the client understands the consequences of this decision. B) Discuss this decision with the older adult's family to plan for the future. C) Document the client's wishes in the plan of care. D) Notify the primary health care provider of the client's wishes.
Ans: A All of these actions should be done; however, the primary concern is that the nurse assess the client's understanding of the consequences. During mild-to-moderate stages of dementia, assessment of decision-making ability is based on the person's ability to describe the importance or implications of the choice on his or her future health. Medical decision making is a complex process in which information is shared between clients and clinicians and among family and others who are affected by the outcomes.
13. A nurse in the long-term care facility plans a meeting to assist an older adult and family discuss end-of-life care options. Which of the following interventions is appropriate for the nurse to include in preparation for this event? (Select all that apply.) A) Assist the older adult to his or her wear hearing aid. B) Assure that the older adult is well rested. C) Obtain a private meeting room. D) Premedicate the older adult with Ativan (lorazepam). E) Schedule the meeting after a meal.
Ans: A, B, C An important role of nurses is to promote optimal decision-making capacity by identifying and addressing the factors that influence cognitive functioning and is within the realm of nursing responsibilities (such as wearing hearing aid and being rested). Benzodiazepines and overstimulation (such as after a meal) can interfere with the older adult's capacity
6. A 78-year-old was diagnosed with colorectal cancer 18 months ago and underwent a round of chemotherapy. The most recent computed tomographic scan, however, reveals that the cancer has metastasized to the lungs and liver. The older adult states, "I feel quite well and do not wish to undergo another round of chemotherapy. " The client's children are adamantly opposed to their parent's decision to forgo treatment and have appealed to the nurse. Which factor is the priority consideration for the nurse to determine the best course of action? A) The client's prognosis B) The client's autonomy C) The family's wishes D) The client's treatment options
Ans: B Autonomy is highly valued in Western societies, and personal autonomy supersedes family wishes and the medical facts about a client or client's situation.
5. A nurse manager of a nursing care facility reviews potential health and safety interventions and outcomes with the nursing staff. Which of the following interventions places emphasis on quality of life with the best possible health and safety outcomes? A) Telling the resident about his or her schedule for the day B) Allowing the resident with a history of falls to walk with the help of an assistant C) Discouraging the resident who states they are tired from participating in activities D) Advising the resident not to attend church because the resident is not Catholic
Ans: B Allowing the resident with a history of falls to walk with the help of an assistant places emphasis on quality of life with the best possible health and safety outcomes. Telling the resident about his or her schedule for the day does not address safety or autonomy. It is not quality of life to discourage the resident from participating in activities (even if tired). Advising the resident not to attend church because the resident is not Catholic is unethical.
7. The children of a resident of a nursing home have approached the nurse because they believe their parent is being manipulated by a person who also lives in the facility. Their parent has a diagnosis of early-stage Alzheimer disease and various comorbidities that affect mobility and function. How should the care team appraise the parent's decision-making capacity? A) Her decision-making ability is nullified by the presence of a dementia. B) Her decision-making capacity should be determined according to objective criteria. C) She should be asked to demonstrate sound decision making in minor matter before being allowed to make more important decisions. D) A surrogate should be appointed to make her decisions because she has been diagnosed with Alzheimer disease.
Ans: B The presence of dementia does not necessarily render a person incapable of all decision-making ability. Rather, this ability should be analyzed according to criteria of understanding, reasoning, choice, and expression.
3. An 87-year-old woman has a history of depression and hypothyroidism. She was recently diagnosed as having breast cancer. Her daughter tells her health care provider that her mother cannot participate in decision making about her care because she is too old. Which of the following statements is true about decision-making capacity? A) Determination of decision-making capacity is based on the older adult's diagnosis and chronologic age. B) The older adult has decision-making capacity if she understands most of the risks and benefits of medical treatment. C) The older adult needs to understand the issues involved in decision making and communicate about them. D) Decision-making capacity of older adults is always determined by a mental health judge.
Ans: C Decision making should not be determined by the diagnosis or the age of the older adult. The older adult needs to understand all of the risks and benefits of medical treatment. Decisionmaking capacity is determined by the health care practitioner or by the interdisciplinary team assigned to the client.
9. An 81-year-old adult suffered an ischemic stroke 6 days ago. The client has failed to regain consciousness since the event. The care team has approached the client's family to obtain their views on inserting a feeding tube. Which of the following documents will allow the family to make a decision on the parent's behalf? A) A do not resuscitate (DNR) order B) A living will C) A durable power of attorney for health care D) A will
Ans: C Feedback: A durable power of attorney for health care is an advance directive that takes effect whenever someone cannot, for any reason, provide informed consent for health care treatment decisions. A will, a DNR order, or a living will do not confer this authority on the client's family member.
15. A nurse plans discharge for an older woman from China who is living with her son. Which of the following should be included in this plan to indicate that the nurse understands cultural influences? A) Include all family members in discharge planning. B) Ensure that the discharge plan does not include any technologic aspects. C) Review the discharge plans with the client and her son. D) Speak only with the client.
Ans: C In the Chinese culture, each family has a recognized male head who has great authority and assumes all major responsibilities. Avoidance of technology is not part of this culture.
10. A series of transient ischemic attacks have caused an older adult to become dysphagic. Despite failing a swallowing assessment, the client is opposed to eating a minced and pureed diet and wishes to eat a regular diet. How should the care team respond to this request? A) Insert a feeding tube to provide nutrition while eliminating the risk of aspiration. B) Continue providing a minced and pureed diet to the client in order to ensure safety. C) Defer responsibility for feeding to the client's friends and family. D) Provide the client's requested diet after ensuring the client understands the risks.
Ans: D A common ethical dilemma is a client's or client's family's desire to continue an activity at risk. In general, an individual has the autonomy to choose this unless he or she is declared incompetent.
14. A nurse discusses the future with an older adult who has had surgery for a fractured hip and is also diagnosed as having depression. The client wavers between wanting to give up and going to rehabilitation. Which of the following questions should the nurse ask to assist the client toward values clarification? A) Which pain medication works best for you? B) How can we best assist you with your activities of daily living? C) Do you prefer to bath in the morning or in the evening? D) What goals do you have for the next year?
Ans: D In holistic nursing ethics, the process of values clarification can be used to guide nurses. Values clarification is an ongoing process in which an individual becomes increasingly aware of what is important and just—and why. The nurse can facilitate this process for clients by listing several health behaviors or values, such as health, happiness, independence, and good relationships, and ask clients to rank them or identify how they incorporate them into their lives why.
8. In which of the following situations would a living will provide clear direction to the care and treatment of the individual involved? A) Mr. Penny, age 81, has been diagnosed with bone cancer, is experiencing severe pain, and has been presented with treatment options. B) Ms. Jelic, age 78, has been brought to the emergency department after falling on an escalator. C) Mrs. Kerr, age 77, has been admitted to hospital with an electrolyte imbalance secondary to an accidental overdose of diuretics. D) Mr. Jimenez, age 84, has suffered a severe hemorrhagic stroke and is unconscious and unlikely to survive.
Ans: D Living wills are legal documents whose purpose is to allow people to specify the type of medical treatment they would want or not want if they become incapacitated as a result of terminal illness. A limitation of living will directives is that they apply only to situations in which the person is considered terminally ill, whereas advance directives apply to a broader range of circumstances.
2. A nurse discusses advance medical directives with a group of older adults at the senior citizens' center. Which of the following statements made by a member of the group indicates a need for further teaching about medical directives? A) "Advance directives address the person's right to refuse medical treatment." B) "It is helpful to see an attorney before completing a durable power of attorney." C) "Advance directives provide legal assurances that a person's preferences will be considered." D) "A durable power of attorney cannot be initiated before a person is incapacitated."
Ans: D Medical directives focus on the right to refuse treatment and address the person's desires for medical treatment in certain circumstances. The durable power of attorney for health care must be initiated when the person is competent, but it takes effect only when the person is incapacitated. Medical directives cannot guarantee that a medical intervention will be completed, but they give assurances that the person's preferences will be considered
4. An older woman of Filipino heritage has been having rectal bleeding for several months. Her physician has told the woman and her daughters that she has advanced colon cancer. Her daughters want to obtain hospice services but the client is reluctant and does not want to discuss what she feels is "beyond her control." Which of the following concerns is this client most likely experiencing? A) Entrenched optimism in health care providers B) Individual autonomy regarding end of life C) Impaired cognition secondary to cancer D) Cultural taboo to discuss death
Ans: D Some members of the Filipino culture believe in fatalism and resist any discussion about or planning for events beyond one's control such as illness or death, because it is viewed as tempting fate and will likely bring the potential event into reality.
11. An older adult client with urosepsis has become nonresponsive. The nurse is to identify the appropriate person to sign the consent forms for an invasive medical procedure. Which of the following actions by the nurse is appropriate? A) Find the older adult's family member to sign the consent. B) Inform the health care provider that no consent can be obtained. C) Move forward with guardianship as the client is incompetent. D) Review the chart for a health care power of attorney.
Ans: D The client, at this time, does not have the decision-making capacity to sign consents. Guardianship is a permanent option that is used only when a person has been declared incompetent. When the client does not have the decision-making capacity to sign consents, the durable power of attorney for health care should do so. If there is no power of attorney, the nurse needs to follow the institutional protocol for obtaining consent.