Chapter 9 Prep U

A nurse working on a psychiatric unit receives a telephone call from a client's employer. The employer asks for a copy of the client's latest laboratory work and psychological testing results so that client's medical records in employee health can be updated. Based on the nurse's knowledge of breach of confidentiality, which response would be appropriate?

Correct response: "I am unable to acknowledge whether or not your employee is a client on this unit." Explanation: A breach of confidentiality is the release of client information without the client's consent in the absence of legal compulsion or authorization to release information. Acknowledging that this employee is a client on the unit would be such a breach. Even if the nurse explains that he or she cannot give the information without the client's consent, the explanation lets the employer know that the client is receiving care in a psychiatric hospital.

The nurse is admitting a client to the hospital. The nurse gives the client information about patient rights while in the hospital. Which statement by the client indicates that more teaching is needed?

Correct response: "The doctor can copy my information and send it to my son." Explanation: Privacy refers to that part of an individual's personal life that is not governed by society's laws and government intrusion. Protecting an individual from intrusion is a responsibility of health care providers.

Student nurses are learning about the ethical treatment of clients. The nursing educator asks the students about the meaning of non-maleficence. Which response by the student nurse is best?

Correct response: "The nurse must pay attention to the client's advanced directives." Explanation: Non-maleficence is the duty to cause no harm, both individual and for all. The nurse must pay attention to the client's wishes and doing no harm. "The nurse encourages the client to stop smoking," "The client can do no harm to themselves" and "The nurse must follow all orders" are not examples of non-maleficence.

The nurse is working with a client who is manic and is in the partial hospitalization program, stabilized, and then given referrals for therapy and support groups. The significant other asks the nurse why the client was not admitted to the hospital? What is the best response from the nurse? Select all that apply.

Correct response: "The partial hospitalization program is the least restrictive environment appropriate to meet the client's needs." Explanation: Clients have the right to treatment in the least restrictive environment appropriate to meet their needs. An individual does not have to be hospitalized if he or she can be treated in an outpatient setting or in a group home. An individual cannot be restrained or locked in a room unless all other "less restrictive" interventions are tried first. The partial hospitalization program is the least restrictive environment appropriate to meet the client's needs. Incorrect responses include: "The partial hospitalization program is for client's who refuse treatment," "The partial hospitalization program is for client's who refuse medication," "The partial hospitalization program is for client's who refuse treatment without prior notification," and "The partial hospitalization program is for clients who don't want to be judged by the staff."

A nurse is caring for a voluntary client in the health care facility. The client doesn't show signs of suicidal ideation or pose harm to others. The client states, "I would really like to leave tonight and sleep in my own bed." Although the client wants discharge tonight, the health care provider recommends against it at this time. What is the most appropriate response of the nurse?

Correct response: "You will need to sign a written request for discharge." Explanation: Clients admitted to a health care facility have the right to leave, provided they do not pose a danger to themselves or others. A client who wishes to leave the health care facility can sign a written request for discharge. This provides evidence that the client wanted to leave and was not at risk to the self or others. It would be a breach of the client's confidentiality to inform the family members or the client's landlord of the discharge. Although the client is voluntary, the nurse cannot simply tell clients they are free to leave at their own will.

What is provided in the Code of Ethics for Nurses of the American Nurses Association (ANA)?

Correct response: A guideline for nurses regarding ethical conduct Explanation: The ANA's Code of Ethics for Nurses guides ethical decision-making.

A psychiatric-mental health nurse interested in joining a professional organization asks the psychiatric-mental health clinical nurse specialist about these organizations. Which organization would the clinical nurse specialist describe as the largest professional nursing organization focusing on mental health care?

Correct response: American Psychiatric Nurses Association Explanation: The American Psychiatric Nurses Association (APNA) and the International Society of Psychiatric Nursing (ISPN) are two organizations for psychiatric nurses that focus on mental health care. The APNA is the largest psychiatric-mental health nursing organization, with the primary mission of advancing psychiatric-mental health nursing practice; improving mental health care for culturally diverse individuals, families, groups, and communities; and shaping health policy for the delivery of mental health services. The ISPN consists of four specialist divisions: The Association of Child and Adolescent Psychiatric Nurses, International Society of Psychiatric Consultation Liaison Nurses, Society for Education and Research in Psychiatric-Mental Health Nursing, and Adult and Geropsychiatric-Mental Health Nurses. Although a large professional nursing organization, the American Nurses Association (ANA) focuses on addressing the emergent needs of nursing in general. The ANA supports psychiatric-mental health nursing practice through liaison activities and working closely with psychiatric-mental health nursing organizations.

A 22-year-old client diagnosed with schizophrenia is refusing antipsychotic medication. The client states, "I don't like the dopey way it makes me feel. I feel like I'm walking underwater when I take it." The nurse explains to the client, "Your schizophrenia is caused by a chemical imbalance in your brain, and this medication helps fix that chemical imbalance. You need to take it so your symptoms will get better." This conversation reflects a conflict between which two types of ethical principles?

Correct response: Autonomy and beneficence Explanation: Ethical conflicts can occur when the client is being guided by the principle of autonomy and the nurse by the principle of beneficence. According to the principle of autonomy, each person has the fundamental right of self-determination. According to the principle of beneficence, the health care provider uses knowledge of science, and incorporates the art of caring, to develop an environment in which individuals achieve their maximal health care potential. Justice involves a duty to treat all fairly. Paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the client. Veracity is the duty to tell the truth. Nonmaleficence is the duty to cause no harm.

A client was admitted for electroconvulsive therapy (ECT). The physician performing the procedure failed to obtain informed consent before the ECT was administered. The physician could be charged with what?

Correct response: Battery Explanation: All clients have the right to give informed consent before health care professionals perform interventions. Administration of treatments or procedures without a client's informed consent can result in legal action against the primary provider and the health care agency. In such lawsuits, clients will prevail, alleging battery (touching another without permission), if they can prove they did not consent to the procedure, providers did not give adequate information for a decision, or the treatment exceeded the scope of the consent.

A psychiatric mental health facility is undergoing a change from paper-based health records to electronic records. What action should the nurse prioritize in order to ensure client rights are protected?

Correct response: Being vigilant to identify any potential threats to client confidentiality Explanation: Electronic health records present potential threats to confidentiality that must be addressed. It would not be possible for a client to opt out of a documentation system. Teaching clients about the benefits of health records does not directly address client rights. Clients never lose the right to view their health records.

A client is being seen in the mental health clinic because of relapse. The client has been nonadherent with the medication regimen. The nurse reinforces the advantages of taking medications. The nurse is using which ethical principle?

Correct response: Beneficence Explanation: According to the principle of beneficence, the health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which people achieve their maximal health care potential. According to the principle of autonomy, each person has the fundamental right of self-determination. Justice is the duty to be treated fairly. Veracity is the duty to tell the truth.

A client with persistent depression is considering electroconvulsive therapy (ECT). The nurse has seen ECT be effective in other cases. When the client expresses fear and doubt about undergoing ECT, the nurse tries to talk the client into it, because the nurse truly believes it will help the client. Which two ethical concepts are in conflict?

Correct response: Beneficence and autonomy Explanation: Beneficence and autonomy are in conflict. Beneficence is practicing with the intent to do good; however, professionals define how to do good, which may override the wishes and self-determination of the client. Autonomy is the client's right to make decisions for himself or herself. Justice refers to fairness; that is, treating all people fairly and equally without regard for social and economic status, race, sex, marital status, religion, ethnicity and cultural beliefs. Fidelity is the nurse's faithfulness to duties, obligations, and promises.

A new nursing student correctly identifies which as most essential for guiding psychiatric-mental health nursing actions?

Correct response: Code of Ethics for Nurses Explanation: Psychiatric-mental health nursing actions are guided by the Code of Ethics for Nurses.

A psychiatric nurse is assigned to perform observation of a client in restraints. The nurse knows that this client must be checked on how often?

Correct response: Constantly for the first hour. Explanation: A client in restraints must be observed 1:1 constantly for the first hour at which time the client must be assessed by a licensed independent practitioner.

A client is admitted to the behavioral health facility involuntarily. The client is scheduled to undergo electroconvulsive therapy. Which action does the nurse take before the procedure?

Correct response: Ensure the client has given informed consent. Explanation: Clients who are involuntarily committed have the right to treatment, as well as the right to refuse treatment. Additionally, those who are involuntarily committed do not lose the right to informed consent. The client should be provided information on the treatment and the client should provide informed consent. The other answer choices are incorrect and do not allow the client to maintain autonomy.

The inappropriate use of restraints or seclusion is considered which form of intentional tort?

Correct response: False imprisonment Explanation: False imprisonment is defined as the unjustified detention of a client, such as the inappropriate use of restraint or seclusion. Battery involves harmful or unwarranted contact with the client. Assault involves any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority. Causation occurs when a breach of duty was the direct cause of loss, damage, or injury.

An agitated client has been put in restraints against the client's will because of inadequate staffing. The nurse determines this as which form of malpractice?

Correct response: False imprisonment Explanation: False imprisonment is the intentional and unjustifiable detention of a person against his or her will. Detention can occur with the use of physical restraint, barriers, or threats of harm. Battery is unlawful touching of another without consent. Defamation involves injury to a person's reputation or character through oral (slander) or written (libel) communications to a third party. Assault is an act that puts another person in apprehension of being touched or of bodily harm without consent.

A client in a psychiatric facility has ideations about killing the client's spouse. This client requests to be discharged from the facility. Which represents the most appropriate action? The health care provider should:

Correct response: File for a civil commitment to detain. Explanation: Every client in a health care facility has a right to request to be discharged. If a client has suicidal ideations or is a danger to others, then the client should be under close supervision at all times. The health care provider should file a civil commitment to detain the client against the client's will until a hearing takes place to decide the matter. The caregivers may not understand the situation of the client and the danger that the client poses for the family. Thus, it would be inappropriate for the health care provider to ask the caregivers for consent.

When staff members physically control the client and move him or her to a seclusion room, what form of restraint is being implemented?

Correct response: Human Explanation: Human restraint is when staff members physically control the client and move him or her to a seclusion room. A mechanical restraint is a device, usually ankle or wrist restraints, fastened to a bed frame to curtail the client's physical aggression. Long- and short-term restraint refers to the time frame for the use of the restraint.

A client comes to the emergency department with severe depression and suicidal ideation. Staff members determine that the client does not have adequate insurance to cover inpatient psychiatric services at their facility, so they discharge the client with some prescriptions for medication. Which principle is being ignored by discharging this client?

Correct response: Justice Explanation: Justice is the duty to treat all clients fairly. It can become an ethical issue in mental health when a segment of the population does not have access to care, as in this case, in which access to inpatient care is warranted but denied.

While performing the admission assessment of a new client, the nurse observed that the client brought a bottle of over-the-counter pain medication to the hospital. The nurse failed to document this or remove the medication from the room. Subsequently, the client experienced a serious adverse drug reaction as a result of the interaction between this drug and one of the drugs that the client was prescribed in the hospital. This nurse may be guilty of what?

Correct response: Malpractice Explanation: The four elements of nursing malpractice are evident in this scenario. Assault is an act that puts another person in apprehension of being touched (or of bodily harm without consent), and failure of duty to warn surrounds a client's threat to harm another person. Incompetence, in the legal sense, surrounds a client's right to autonomy.

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what?

Correct response: Nonmaleficence Explanation: Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question.

A nurse is looking for information about the parameters of professional psychiatric-mental health nursing practice that provide the framework for nursing practice. The nurse would most likely seek out which source?

Correct response: Standards of Practice Explanation: The ANA and the psychiatric nursing organizations collaborate in defining the boundaries of psychiatric-mental health nursing and informing society about the parameters of practice. The standards are authoritative statements that describe the responsibilities for which the practitioners are accountable. The six standards of practice include competencies for which Psychiatric-Mental Health Registered Nurse (PMH-RN) and Advanced Practice Psychiatric-Mental Health Registered Nurses (PMH-APRN) are accountable and define the parameters of psychiatric-mental health nursing practice. Ten standards of professional performance for psychiatric-mental health nurses define and inform society about the professional role of psychiatric-mental health nurses. The Code of Ethics for Nurses presents ethical values, obligations, duties and professional ideals, establishes an ethical standard, and confirms nursing's commitment to society. The State Board of Nursing is considered the legal agency for the practice of nursing.

The interdisciplinary team is discussing the best approach to planning the care for a client with complex psychiatric-mental health needs. When determining which tasks can be performed by the psychiatric-mental health registered nurse (PMH-RN) and which must be performed by the psychiatric-mental health advanced practice registered nurse (PMH-APRN), the team should prioritize guidelines from what source?

Correct response: The American Nurses Association Standards of Practice Explanation: The American Nurses Association standards outline the scope of practice for PMH-RNs and PMH-APRNs. These standards override institutional policies and local norms. There is no World Health Organization Guidelines for Nursing Practice.

A client with a psychiatric illness has become extremely aggressive and the nurse decides that the client needs to be restrained. Which action would be considered human restraint?

Correct response: The nurse and a group of paramedics hold the client. Explanation: Restraint is the direct application of physical force to restrict the client's freedom of movement. The nurse and a group of paramedics holding the client is an example of human restraint. The nurse does not apply force while telling the client to calm down. Sedating the client is an example of chemical restraint. Applying a wrist cuff to control the aggression of the client indicates the use of mechanical restraints.

Professional regulations and laws that govern nursing practice are in place for what reason?

Correct response: To protect the safety of the public. Explanation: Governing bodies, professional regulations, and laws are in place to protect the public by ensuring that nurses are accountable for safe, competent, and ethical nursing practice. The other options do not describe accurately the role and responsibility of the governing bodies and the regulations and laws of nursing.

The client is brought to the hospital in a coma. The nurse understands that when a person is incapacitated, the document used to dictate the patient's written instructions for health care is called:

Correct response: advance directive Explanation: Advance care directives are written instructions for health care when individuals are incapacitated. Informed consent, durable power of attorney, and patient rights are not instructions for health care when individuals are incapacitated. A durable power of attorney means that the advance care directives stays in effect if you become incapacitated and unable to handle matters on your own. Informed consent is the permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits. Patient rights are those basic rule of conduct between patients and medical caregivers as well as the institutions and people that support them.

A client with depression tells the nurse, "I want to stop taking my antidepressant medication because I don't like taking medications." The nurse discusses the benefits of adhering to the medication plan and strongly urges the client to use the medication. The nurse interprets the client's statement as reflecting which ethical principle?

Correct response: autonomy Explanation: Autonomy reflects the fundamental right of all persons for self-determination, to make independently make choices. Autonomy is reflected by the client's statement to stop taking the medication. The nurse's urging the client to continue to use the medication because of the medication's benefits reflects the principle of beneficence, that is, the nurse is using scientific knowledge and incorporating that knowledge to promote the client's maximum health potential. In this case, the medication would help to control the client's depressive symptoms. Justice reflects the duty to treat all fairly; paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the client.

The client has not been on speaking terms with the client's parents for several years. The parents have expressed a desire to reunite with the client. At first, the client agreed to a family meeting, and then decided not to meet with the parents. The nurse has encouraged the client to attend the family meeting knowing that the family's support would be valuable. What ethical principles are in conflict in this situation?

Correct response: autonomy and beneficence Explanation: According to the principle of autonomy, each person has the fundamental right of self-determination. According to the principle of beneficence, the health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which individuals achieve their maximal health care potential. The client has the right to decide whether to go to a family meeting or not, and the nurse urges the client to go to the meeting because the nurse knows that the family will be a great support to the client. The ethical principles that are not in conflict in this situation are justice and beneficence, non-maleficence and autonomy, and veracity and fidelity.

The nurse is teaching a client about the importance of adhering to a medication regimen. The client does not believe that it is important. The nurse is communicating which ethical principle?

Correct response: beneficence Explanation: According to the principle of beneficence, the health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which individuals achieve their maximum health care potential. Justice is the duty to treat all fairly, distributing the risk and benefits equally. Veracity is the duty to tell the truth. Paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the client.

The nurse is caring for a client after having various diagnostic tests. The client discusses a proxy being in attendance for the health care provider's diagnosis. The nurse requests a copy for the file, and allows the proxy to be in attendance with what type of document?

Correct response: durable power of attorney Explanation: A durable power of attorney for health care appoints a proxy, usually a relative or trusted friend, to make health care decisions on an individual's behalf. The living will, patient rights, and informed consent are not included in the durable power of attorney. A living will is a written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive. Patient rights are those basic rule of conduct between patients and medical caregivers as well as the institutions and people that support them. Informed consent is the permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.

Which ethical principles become an issue in mental health when a segment of a population does not have access to health care?

Correct response: justice Explanation: Justice is the duty to treat all fairly, distributing the risk and benefits equally. Justice becomes an issue in mental health when a segment of a population does not have access to health care. Basic good should be distributed so the least advantaged members of society benefit. Nonmaleficence, fidelity, and veracity are not being used in this situation.

The nursing instructor is talking to a class of nursing students about the American's with Disabilities Act, and persons having various disabilities that have the right to education in the least restrictive environment. The nursing instructor asks the students, "what is the reason for the least restrictive environment?" Which example should the student nurse choose?

Correct response: unique needs Explanation: Least restrictive environment means the individual cannot be restricted to an institution when he or she can be successfully treated according to the client's needs, and stay in the community. Budget factors, placement options, and availability of space are not factors related to The American's with Disabilities Act.

The nurse manager is reviewing ethical principles at a staff meeting. The manager asks, "What examples can you provide where the nurse must consider the principle of nonmaleficence?" Which response(s) by the staff nurse are most appropriate? Select all that apply.

Correct response: ✓ "Giving the client an injection for a sexually transmitted infection (STIs)" ✓ "Assisting with the client's bone marrow transplant" ✓ "Performing chest compressions for a client with no pulse" Explanation: Nonmaleficence is the requirement to do no harm to others either intentionally or unintentionally. Sometimes an action would do both good and harm; in these cases, the utilitarian theory of doing the greatest good for the greatest number may guide the nurse in deciding which course of action follows the principle of nonmaleficence. Examples include "Performing chest compressions for a client with no pulse" even though doing chest compressions may facilitate broken ribs; "Assisting with the client's bone marrow transplant" even though doing this may cause pain; and "Giving an injection for sexually transmitted infections" even though the injection may cause pain. Teaching the client about medications and encouraging the client to quit smoking are not examples of actions where the nurse must consider nonmaleficence.

The nursing instructor is discussing the Individuals with Disabilities Education Act and various disabilities that have the right to education in the least restrictive environment. The instructor asks whom this applies to, clients with which problems? Which examples should the student nurse choose? Select all that apply.

Correct response: ✓ autism ✓ traumatic brain injury ✓ orthopedic impairment Explanation: The right to be treated in the least restrictive environment means that an individual cannot be restricted to an institution when he or she can be successfully treated in the community. Disabilities include autism, orthopedic impairments, and traumatic brain injuries. Flu, and pneumonia are not among the problems included in the Individuals with Disabilities Education Act.