exam 3 212

While driving home from work, the nurse stops to help victims of a motor vehicle crash before an ambulance arrives. Which action ensures the nurse is functioning within the scope of the Good Samaritan laws? 1) Contacted 911 immediately upon arriving to the scene 2) Received victim's credit card information for payment 3) Stayed with the victim after emergency personnel arrived 4) Walked a block away from the site to get paper towels and water

1 Calling 911 ensures protection by Good Samaritan laws.

A healthcare provider prescribes a one-time ASAP dose of intravenous morphine sulfate of 25 mg for a client with a terminal illness. Which law should the nurse consult prior to responding to this healthcare provider's prescription? 1) Safe Harbor 2) Good Samaritan 3) Americans With Disabilities Act (ADA) 4) Health Insurance Portability and Accountability Act (HIPAA)

1 Safe harbor laws, found in the nurse practice act or other state laws, provide for exceptions to certain laws. They protect the nurse from being suspended, terminated, disciplined, or discriminated against for refusing to do (or not do) something the nurse believes would be harmful to a client. The nurse is aware that the medication dose would be harmful to the client and should consult this law before responding to the prescription.

. The staff development coordinator prepares the Nurse's Bill of Rights for new nursing orientation. What rights should the coordinator emphasize when reviewing this document? Select all that apply. 1) Fair compensation for work 2) Negotiate terms of employment 3) Freely and openly advocate for clients 4) Walk off a care area for unsafe conditions 5) Work in an environment that supports ethical practice

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The nurse notes that a patient with renal failure has an abnormal potassium level of 6.8; however, he fails to notify the physician and does not relate the value during hand-off communication. What does this scenario demonstrate? Select all that apply. 1) Failure to implement a plan of care 2) Failure to evaluate 3) Malpractice 4) Failure to assess and diagnose 5) Failure to follow a standard of care

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Which is an example of invasion of privacy by nurses? Select all that apply. 1) Searching a patient's belongings without permission 2) Reviewing the plan for patient care in the lunchroom 3) Discussing healthcare issues for an unconscious patient with his power of attorney 4) Releasing patient health information to local newspaper reporters 5) taking a photo of the patient and posting it on facebook

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What do negligence and malpractice have in common? Select all that apply. 1) Negligence and malpractice are unintentional torts. 2) Negligence and malpractice are felonies 3) Malpractice is the professional form of negligence. 4) Negligence and malpractice involve the intent to do harm to a patient. 5) Breach of duty must be present for negligence to occur

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the nurse gives a pt the wrong medication and documents that the correct medication was given. the next staff member recognizes the error and reports the nurse to the state board of nursing. which action can the state board of nursing take against the nurse in this situation? a. disciplinary action against the nurses license to practice b. criminal misdemeanor charges against the nurse c. medical malpractice lawsuit against the nurse d. employment release form the institution

1 The state board of nursing is empowered to initiate disciplinary action against the nurses license for professional misconduct

Upon initial assessment, the nurse notes bruises and scratches on the arms, legs, and trunk of an older client. With which state law is the nurse complying when the supervisor is notified regarding this patient as a potential victim of abuse? 1) Good Samaritan Law 2) Mandatory Reporting Law 3) Nurse Practice Act 4) Nursing Standards of Practice

2 under state mandatory reporting laws nurses must report to designated authorites suspected physical, sexual, emotional or verbal abuse or neglect by healthcare workers or family members. in general nurses who fail to report can be held criminally or civilly liable

The mother of a 4-year-old child with painful bruises and facial contusions explains that the mother's significant other pushed the child down the stairs in anger. What should the nurse do first? 1) Notify the nursing supervisor of the suspected physical abuse. 2) Complete a physical assessment of the child. 3) Obtain an order for pain medication. 4) Notify Child Protective Services of the suspected abuse.

2 The primary responsibility of the nurse in this situation is to evaluate the patient's physical condition and extent of his injuries in order for appropriate medical treatment to be provided

The nurse manager receives a note from a staff member's healthcare provider outlining physical limitations at work. Which information should the manager review to ensure the employee's and organization's rights are not violated? 1) Nursing scope of practice 2) Policy and procedure manual 3) Americans With Disabilities Act (ADA) 4) Health Insurance Portability and Accountability Act (HIPAA)

3 The Americans With Disabilities Act (ADA) provides protection against discrimination of individuals with disabilities. The ADA says that employers must provide reasonable accommodations within the work setting to allow employees with disabilities to perform their job.

An adolescent in labor arrives at the hospital emergency department (ED) with her mother who states the family has no medical insurance or money to pay for the delivery. What is the first step that the ED staff should take? 1) Arrange for an ambulance to transport her to the nearest public hospital. 2) Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. 3) Examine her to determine whether her condition is stable or whether she requires immediate medical attention. 4) Inform her mother that she will need to transport her daughter to the nearest public hospital.

3 when a client comes to the ed requesting examination or tx for an emergency condition (including labor) hospital must provide stabilizing tx; the client cannot be transferred until she is stable

A patient sues the nurse for a fall that occurred because the bed's siderails were not in the upright position. The judgment is for the patient to receive $2 million; however, the nurse has an occurrence policy with double limit coverage of $3 million/$10 million that covered the time period when the incident occurred. What will the nurse's insurance pay to the patient? 1) Nothing 2) $4 million 3 2 million 4. 75% of the 2 million

3 An occurrence policy will cover those claims that occurred during the time the policy was in effect. However, the policy will pay up to $3 million per claim; because the amount awarded does not exceed this, the nurse is covered.

the nurse applies bilateral wrist restraints to a client threatening to leave the hospital against medical advice. what is the nurses action considered? a. assault and battery b. felony c. false imprisonment d. quasi intentional tort

3 False imprisonment involves an intentional or willful detention of a patient without consent or authority to do so. Restraining a patient without consent is another form of civil false imprisonment. Competent patients have a right to leave an institution, even if it is harmful to their health. Whenever possible, have the person sign a form stating that he is aware that he is leaving against medical advice.

The charge nurse assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) who has no experience caring for hemodialysis patients. The LPN fails to inform the charge nurse of not having experience with this type of patient. What should the actions of the charge nurse be considered? 1) Malpractice 2) Incompetence 3) Negligence 4) Abandonment

3 Negligence is the failure to use ordinary or reasonable care or the failure to act in a reasonable and prudent (careful) manner. It is negligent to assign a nurse to care for a patient without verifying the nurse has training, experience, and clinical competence in caring for such patients

a patient argues that a statement made in the medical record is incorrect and wants it corrected. Which regulation provides the patient with the right to have the documentation corrected? 1) Americans With Disabilities Act (ADA) 2) Patient Self-Determination Act (PSDA) 3) Health Insurance Portability and Accountability Act (HIPAA) 4) Health Care Quality Improvement Act (HCQIA)

3 The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule of 2004 provides comprehensive protection for the privacy of protected health information (confidentiality of patient records). In addition, patients have the right to see and copy their medical records and to reconcile incorrect

A patient asks the nurse to explain an advance directive. What should the nurse explain about this document? Select all that apply. 1) If the patient is unable to communicate, the family may make changes to the advance directive. 2) Once an advance directive is signed, no further care will be provided. 3) The patient may change the advance directive by telling the physician or by making changes in writing. 4) An advance directive will ensure the patient gets as much or as little care as desired. 5) An advance directive is overruled by the healthcare provider's prescriptions

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The nurse prepares information to document a client's care. What should the nurse do to ensure that the documentation is complete? 1) Review the medical record for new prescriptions. 2) Ask nursing assistive personnel for report on delegated tasks. 3) Use the mnemonic F-A-C-T-U-A-L as a reminder when charting. 4) Complete all documentation immediately before hand-off communication.

3 To ensure documentation is complete the nurse should use the mnemonic F-A-C-T-U-A-L as a reminder

The nurse receives a copy of a client's advance directive. What should the nurse do with this document? 1) Return it to the client. 2) Give it to the nursing supervisor. 3) Hand it to the healthcare provider. 4) Place it on the client's medical record.

4 the nurse should document in the clients medical record the presence or absence of advance directives

What do nursing codes of ethics support? 1) Patients can receive emergency treatment regardless of their ability to pay. 2) Nurses will educate patients about advance directives. 3) Nurses with HIV must disclose their condition to their employer. 4) Patients have the right to dignity, privacy, and safety.

4 In the Patient Care Partnership, patients have the right to dignity, privacy, and safety. Although they are not laws, nursing codes of ethics specify ethical duties of the nurse to the patient as related to corresponding patient rights.

Which law does a hospital use to determine if a patient with no healthcare coverage who is seeking medical care should receive care or be transferred to another facility? 1) Health Care Quality Improvement Act (HCQIA) 2) Patient Self-Determination Act (PSDA) 3) Newborns' and Mothers' Health Protection Act (NMHPA) 4) Emergency Medical Treatment and Active Labor Act (EMTALA)

4 The intent of the Emergency Medical Treatment and Labor Act (EMTALA) is to ensure public access to emergency services regardless of ability to pay. The EMTALA prohibits "patient dumping," which is transferring indigent or uninsured patients from a private hospital to a public hospital without appropriate screening and stabilization. An exception is made if a hospital does not have the capability to stabilize a patient or if the patient requests a transfer.

The nurse manager learns of a staff nurse's behavior with a client. Which information suggests that nurse has committed a boundary violation? 1) Mentioned that a client's birthday was coming up 2) Observed talking with a client's spouse in the hallway 3) Asked the healthcare provider to change a client's pain medication 4) Switched an assignment so that the nurse can take care of the client

4 Providing excess attention to a client such as trading an assignment is a boundary violation

The nurse reviews an entry in a medical record before clicking the SAVE button. When performing this review, the nurse analyzes the content for completeness, clarity, accuracy, comprehensiveness, and which other criterion? 1) Concise 2) Category 3) Character 4) chronological

4 To ensure thorough documentation, the nurse can follow the 5 C's: Complete, Clear, Correct, Comprehensive, and Chronological.

n the situation presented, which nursing intervention constitutes false imprisonment? A. The client is combative and will not redirect, stating, No one can stop me from leaving. The nurse seeks the physicians order after the client is restrained. B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion. C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return. D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving.

ANS: B False imprisonment is the deliberate and unauthorized commitment of a person within fixed limits by the use of verbal or physical means. Seclusion should only be used in an emergency situation to prevent harm after least restrictive means have been unsuccessfully attempted.

The experience of being physically restrained can be traumatic. Which nursing intervention would best help the client deal with this experience? A. Administering a tranquilizing medication before applying the restraints B. Talking to the client at brief but regular intervals while the client is restrained C. Decreasing stimuli by leaving the client alone most of the time D. Checking on the client infrequently, in order to meet documentation requirements

ANS: B Restraints are never to be used as punishment or for the convenience of the staff. Connecting with the client by maintaining communication during the period of restraint will help the client recognize this intervention as a therapeutic treatment versus a punishment.

There is one bed available on an inpatient psychiatric unit. For which client should a nurse advocate emergency commitment? A. An individual who is persistently mentally ill and evicted from an apartment B. An individual treated in the emergency department (ED) for generalized anxiety disorder C. An individual who is delusional and has a plan to kill his wife D. An individual who rates mood 4/10 and is participating in a no-harm safety plan

ANS: C The criteria for involuntary emergency commitment include danger to self and/or others. Of the four clients considered, the client who is delusional and has a plan to kill his wife meets this criterion as a danger to others.

A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? A. The client is placed in seclusion. B. The client is placed in a geriatric chair with tray. C. The client is placed in soft Posey restraints. D. The client is monitored by an ankle bracelet.

ANS: D The least restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified.

13. Which assessment data should a school nurse recognize as signs of physical neglect? a. the child is often absent from school and seems apathetic and tired b. the child is very insecure and has poor self esteem c. the child has multiple bruises on various body parts d. the child has sophisticated knowledge of sexual behaviors

Ta he nurse should recognize that a child who is often absent from school and seems apathetic and tired might be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

which comment by the nurse would best support relationship building with a survivor of intimate partner abuse a. You are feeling violated because you thought you could trust your partner. b. im here for you. I want you to tell me about the bad things that happened to you. c. I was very worried about you. I knew you were living in a potentially violent situation. d.Abusers often target people who are passive. I will refer you to an assertiveness class.

a The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted.

What is the legal significance of a nurses action when a nurse threatens a demanding client with restraints? A. The nurse can be charged with assault. B. The nurse can be charged with negligence. C. The nurse can be charged with malpractice. D. The nurse can be charged with beneficence.

a assault is an act that results in a persons genuine fear and apprehension that he or she will be touched without consent

An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment teams next action? A. State law determines how long a psychiatric facility can hold a client. B. Federal law determines if the client is competent. C. The clients family involvement will determine if discharge is possible. D. Hospital policies will determine treatment team actions.

a most states commonly cite that in an emergency a client who is dangerous to self or others may be involuntarily hospitalized

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurses coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworkers lack of involvement? A. Taking no action is still considered an action by the coworker. B. Taking no action releases the coworker from ethical responsibility. C. Taking no action is advised when potential adverse consequences are foreseen. D. Taking no action is acceptable, because the coworker is only a bystander.

a the coworkers lack of involvement can be interpreted as an action taken . the coworker is experiencing an ethical eilemma in which a decision needs o be made between two unfavorable alternatives. although the coworker may be struggling with ethical decision making, he or she has witnessed another nurse dispensing medication outside of the scope of practice; therefore , from a legal perspective, this should be reported

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? A. Refusing to give any information to the caller, citing rules of confidentiality B. Refusing to give any information to the caller by hanging up C. Affirming that the person has been seen at the facility but providing no further information D. Suggesting that the caller speak to the clients therapist

a the most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information and should not be disclosed by the nurse without prior consent

11. A patient tells the nurse, My husband lost his job. Hes abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me. What risk factor was most predictive for the husband to become abusive? a. hx of family violence b. loss of employment c. abuse of alcohol d. poverty

a An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

13. After treatment for a detached retina, a survivor of intimate partner abuse says, My partner only abuses me when I make mistakes. Ive considered leaving, but I was brought up to believe you stay together, no matter what happens. Which diagnosis should be the focus of the nurses initial actions? a. risk for injury related to physical abuse from partner b. social isolation related to lack of a community support system c. ineffective coping related to uneven distribution of power within a relationship d. deficient knowledge related to resources for escape from an abusive relationship

a Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patients safety.

5. The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who: a. have been abused b. are attention seeking c. have eating disorders d. are developmentally delayed

a Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options.

8. An 11-year-old says, My parents dont like me. They call me stupid and say they wish I were never born. It doesnt matter what they think because I already know Im dumb. Which nursing diagnosis applies to this child? a.Chronic low self-esteem related to negative feedback from parents b.Deficient knowledge related to interpersonal skills with parents c.Disturbed personal identity related to negative self-evaluation d.Complicated grieving related to poor academic performance

a The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the childs statements.

8. A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? a. i know that it was not my fault b. my boyfriend has trouble controlling his sexual urges c. if i dont put myself in a dating situation, i wont be at risk d. next time i will think twice about wearing a sexy dress

a The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self-worth.

which statement made by an emergency dept nurse indicates accurate knowledge of domestic violence a. power and control are central to the dynamic of domestic violence b. poor communication and social isolation are central to the dynamic of domestic violence c. erratic relationships and vulnerability are central to the dynamic of domestic violence d. emotional injury and learned helplessness are central to the dynamic of domestic violence

a The nurse accurately states that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

a kindergarten student is frequently violent toward other children. a school nurse notices bruises and burns on the childs face and arms. what other symptom should indicate to the nurse that the child might have been physically abused? a. the child shrinks at the approach of adults b. the child begs or steals food or money c. the child is frequently absent from school d. the child is delayed in physical and emotional development

a The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns might be a victim of abuse. Whether or not the adult intended to harm the child, maltreatment should be considered.

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? a. autonomy b. brneficence c. nonmaleficence d. justice

a The nurse should provide the information to support the clients autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent.

17. An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, My mother often wanders at night. Last night she fell down the stairs. Which nursing diagnosis has priority? a. risk for injury related to poor judgement, cognitive impairments, and inadequate supervision b. wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. chronic confusion related to degenerative changes in brain tissue as evidenced by night time wandering

a The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority.

19. An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult: a. expresses frustration verbally instead of physically b. explains the rationale for behaviors to the victim c. identifies three personal strengths d. agrees to seek counseling

a The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes.

A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? A. Allow the client to decline the medication and document. B. Tell the client that if the medication is refused, hospitalization will occur. C. Arrange with a relative to add medication to the clients morning orange juice. D. Call for help to hold the client down while the injection is administered.

a it is ethically and legally appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. the clients right to refuse tx should be upheld unless the refusal puts the client or others in harms way

16. Which of the following nursing diagnoses would be expected for an adult survivor of incest? Select all that apply. a. low self esteem b. powerlessness c. disturbed personal identity d. knowledge deficit e. noncompliance

a b An adult survivor of incest would most likely have low self-esteem and a sense of powerlessness. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders. Disturbed personal identity refers to an inability to distinguish between self and nonself and is seen in disorders such as autistic disorders, borderline personality disorders, dissociative disorders, and gender identity disorders.

3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, Why are you such a stupid kid? The wife says, I have difficulty disciplining the children. Its so frustrating. Which comments by the nurse will facilitate an interview with these parents? Select all that apply. a. Tell me how you discipline your children. b.How do you stop your baby from crying? c. Caring for four small children must be difficult. d. Do you or your husband ever spank your children? e.Calling children stupid injures their self-esteem.

a b c An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

1. A 10-year-old cares for siblings while the parents work because the family cannot afford a babysitter. This child says, My father doesnt like me. He calls me stupid all the time. The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources as priorities to stabilize the home situation? Select all that apply. a. parental sessions to teach childrearing practices b. anger management counseling for the father c. continuing home visits to give support d. a safety plan for the wife and children e. placing the children in foster care

a b c Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wifes admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan would not be a priority at this time.

15. When planning care for women in abusive relationships, which of the following information is important for the nurse to consider? Select all that apply. a. it often takes several attempts before a women leaves an abusive situation b. substance abuse is a common factor in abuse relationships c. until children reach school age, they are usually not affected by parental discord d. women in abusive relations usally feel isolated and unsupported e. economic factors rarely play a role in the decision to stay in abusive relationships

a b d When planning care for women who have been victims of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported. Children can be affected by domestic violence from infancy, and economic factors often play a role in the victims decision to stay.

2. A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? Select all that apply. a. keep a cell phone fully charged b. hide money with which to buy new clothes c. have the phone number for nearest shelter d. take enough toys to amuse the children for 2 days e. secure a supply of current medications for self and children f. assemble birth certificates, licenses, and social security cards g. determine a code word to signal children when it is time to leave

a c e f g The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department by police. The client threatens suicide. Which criteria would enable a physician to consider involuntary commitment? Select all that apply. A. Being dangerous to others B. Being homeless C. Being disruptive to the community D. Being gravely disabled and unable to meet basic needs E. Being suicidal

a d e The physician could consider involuntary commitment when a client is being dangerous to others, is gravely disabled, or is suicidal. If the client is determined to be mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator. A hospital administrator may give permission for involuntary commitment when time does not permit court intervention.

Which is an example of an intentional tort? A. A nurse fails to assess a clients obvious symptoms of neuroleptic malignant syndrome. B. A nurse physically places an irritating client in four-point restraints. C. A nurse makes a medication error and does not report the incident. D. A nurse gives patient information to an unauthorized person.

b a tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. a nurse who physically places an irritating client in restraints has touched the client without consent and has comitted an intentional tort. examples of unintentional torts are malpractice and negligence actions

Which situation exemplifies both assault and battery? A. The nurse becomes angry, calls the client offensive names, and withholds treatment. B. The nurse threatens to tie down the client and then does so against the clients wishes. C. The nurse hides the clients clothes and medicates the client to prevent elopement. D. The nurse restrains the client without just cause and communicates this to family.

b the nurse in this situation has committed both the acts of assault and battery. assault refers to an action that results in fear and apprehension that the person will be touched without consent. battery is the touching of another person without consent.

Which client should a nurse identify as a potential candidate for involuntarily commitment? A. A client living under a bridge in a cardboard box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can

b the nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. the suicidal client who refuses treatments is a danger to self and requires emergency treatment

Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit managers policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit managers policy preserve? A. Justice B. Autonomy C. Veracity D. Beneficence

b the unit managers policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. the principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that healthcare workers must respect their devisions

14. An anorexic client states to a nurse, My father has recently moved back to town. Since that time the client has experienced insomnia, nightmares, and panic attacks that occur nightly. She has never married or dated and lives alone. What should the nurse suspect? a. possible major depressive disorder b. possible hx of childhood incest c. possible histrionic personality disorder d. possible history of childhood bulimia

b 14. An anorexic client states to a nurse, My father has recently moved back to town. Since that time the client has experienced insomnia, nightmares, and panic attacks that occur nightly. She has never married or dated and lives alone. What should the nurse suspect?

the nurse manager suspects that a staff nurse is taking narcotics from the care area. If reported, of what will this staff nurse be accused a. libel b. felony c. battery d. misdemeanor

b 2 Stealing drugs is a felony.

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

b Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

16. An older adult with Alzheimers disease lives with family in a rural area. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. multiple caregivers b. alzheimers disease c. living in a rural area d. being part of a busy family

b Older adults are at high risk for violence, particularly those with cognitive impairments. The other characteristics are not identified as placing an individual at high risk.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. self awareness enhances the nurses advocacy role b. strong negative feelings interfere with assessment and judgement c. strong positive feelings lead to healthy transference with the victim d. positive feelings promote the development of sympathy for patients

b Strong negative feelings cloud the nurses judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny feelings. Strong positive feelings lead to over-involvement with victims rather than healthy transference.

In response to a student's question regarding choosing a psychiatric specialty, a charge nurse states, "Mentally ill clients need special care. If I were in that position, I'd want a caring nurse also." From which ethical framework is the charge nurse operating? A. Kantianism B. Christian ethics C. Ethical egoism D. Utilitarianism

b The charge nurse is operating from a Christian ethics framework. A basic principle in Christian ethics is to do unto others as you would have them do unto you. Kantianism states that decisions should be based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made with a focus on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual.

14. A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, Ive considered leaving, but I made a vow and I must keep it no matter what happens. Which outcome should be met before discharge? The patient will: a. facilitate counseling for the abuser b. name two community resourses for help c. demonstrate insight into the abusive relationship d. reexamine cultural beliefs about marital commitment

b The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abusers counseling may require weeks or months.

18. An older woman diagnosed with Alzheimers disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, It takes all my energy to care for my mother. Shes awake all night. I never get any sleep. Which nursing intervention has priority? a. teach the caregiver about the effects of sundowners syndrome b. secure additional resources for the mothers evening and night care c. support the caregiver to grieve the loss of the mothers cognitive abilities d. teach the family how to give physical care more effectively and efficiently

b The patients caregivers were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

In which circumstance might the nurse defer obtaining informed consent for care and treatment of a patient? a. the pt is confused and cannot understand or sign the consent form b. the pt is brought to the ED in cardiac arrest; no family is present c. the surgeon requests that the pt be sent to the surgical suite before you get the consent signed d. an unconscious pt is admitted to your unit, he is alone

b Written consent is not necessary in an emergency if experts agree that there was an immediate threat to life or health

During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework? A. I would want to be treated in a caring manner if I were mentally ill. B. This job will pay the bills, and the workload is light enough for me. C. I will be happy caring for the mentally ill. Working in Med/Surg kills my back. D. It is my duty in life to be a psychiatric nurse. It is the right thing to do.

b the applicants comment reflects an ethical egoism framework. this framework promotes the idea that decisions are based on what is good for the individual and may not take the needs of others into account

4. A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? a. discourage the client from discussing the event, as this may lead to further emotional trauma b. remain nonjudgemental and actively listen to the clients description of the event c. meet the clients self care needs by assisting with showering and perineal care d. provide cues, based on police information, to encourage further description of the event

b\ The most appropriate nursing action is to remain nonjudgmental and actively listen to the clients description of the event. It is important to also communicate to the victim that he or she is safe and that it is not his or her fault. Nonjudgmental listening provides an avenue for client catharsis needed in order to begin the process of healing.

The nursing staff is discussing the concept of competency. Which information about competency should a nurse recognize as true? A. Competency is determined with a clients compliance with treatment. B. Refusal of medication can initiate an incompetency hearing leading to forced medications. C. A competent client has the ability to make reasonable judgments and decisions. D. Competency is a medical determination made by the clients physician.

c a competent individuals cognition is not impaired to an extent that would interfere with decision making

A client is concerned that information given to the nurse remains confidential. Which is the nurses best response? A. Your information is confidential. It will be kept just between you and me. B. I will share the information with staff members only with your approval. C. If the information impacts your care, I will need to share it with the treatment team. D. You can make the decision whether your physician needs this information or not.

c basic to the psychiatric clients hospitalization is his or her right to confidentiality and privacy. when admitted to an inpatient psychiatric facility, a client gives implied consent for information to be shared with health care workers specifically involved in the clients care

A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? A. The client is paranoid. B. The client is 87 years old. C. The client incorrectly reports his or her spouses name, the date, and the time of day. D. The client relies on his or her spouse to interpret the information.

c the nurse should question the validity of informed consent when the client incorrectly reports the spouses name, date, and time of day. this indicates that this client is disoriented and may not be competent to make informed choices

Which situation contradicts the ethical principle of veracity? A. A nurse provides a client with outpatient resources to benefit recovery. B. A nurse refuses to give information to a physician who is not responsible for the clients care. C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. D. A nurse treats all of the clients equally regardless of illness severity.

c the nurse who tricks a client into seclusion has violated the ethical principle of veracity. the principle of veracity refers to ones duty to always be truthful and not intentionally deceive or mislead clients

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the clients wishes? A. When the client makes inappropriate sexual innuendos to a staff member B. When the client constantly demands inappropriate attention from the nurse C. When the client physically attacks another client after being confronted in group therapy D. When the client refuses to bathe or perform hygienic activities

c the nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. this client poses a significant risk to safety and is incapable of making rational choices. the clients refusal to accept tx can be challenged because the client is endangering the safety of others

The nurse receives a document from an attorney that states a former client is suing for injuries obtained when receiving care. What should the nurse do first? a. call a lawyer b. contact the client c. notify the organization d. contact the insurance company

c If served with a complaint, the nurse must immediately notify the employer.

20. Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. support group b. a mental health center c. a womens shelter d. vocational counseling

c Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

6. What is a nurses legal responsibility if child abuse or neglect is suspected? a. discuss the findings with the childs parent and health care provider b. document the observation and suspicion in the medical record c. report the suspicion according to state regulations d. continue the assessment

c Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts.

2. An 11-year-old reluctantly tells the nurse, My parents dont like me. They said they wish I was never born. Which type of abuse is likely? a. sexual b. physical c. emotional d. economic

c Examples of emotional abuse include having an adult demean a childs worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

7. Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has: a. complaints of abdominal pain b. bruises on extremeties c. repeated middle ear infections c. bruises on extremeties d. diarrhea

c Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence.

15. An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. psychological b. financial c. physical d. sexual

c Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurses observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

10. When questioned about bruises, a woman states, It was an accident. My husband just had a bad day at work. Hes being so gentle now and even brought me flowers. Hes going to get a new job, so it wont happen again. This client is in which phase of the cycle of battering? a. phase I: the tension building phase b. phase II: the acute battering incident phase c. phase III the honeymoon phase d. phase IV the resolution and reorganization phase

c The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

12. An adult tells the nurse, My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. Ive considered leaving but havent been able to bring myself to actually do it. Which phase in the cycle of violence prevents this adult from leaving? a. tension building b. acute battering c. honeymoon d. stabilization

c The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage.

7. A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, The beatings have been getting worse, and Im afraid that next time he might kill me. Which is the appropriate nursing reply? a. leopards dont change their spots and neither will he b. there are things you can do to prevent him from losing control c. lets talk about your options so that you dont have to go home d. why dont we call the police so that they can confront your husband with his behavior

c The most appropriate reply by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions independently without the nurse being the rescuer. Imposing judgments and giving advice is nontherapeutic.

A nursing instructor is presenting content on the provisions of the Nurse Practice Act as it relates to their state. Which student statement indicates a need for further instruction? A. The Nurse Practice Act provides a list of definitions of important terms, including the definition of nursing. B. The Nurse Practice Act lists education requirements for licensure and reciprocity. C. The Nurse Practice Act contains detailed statements that describe the scope of practice for registered nurses (RNs). D. The Nurse Practice Act lists the general authority and powers of the state board of nursing.

c The nurse practice act contains broad, not detailed, statements that describe the scope of practice for various levels of nursing (APN, RN, LPN), not just for the RN. This student statement indicates a need for further instruction.

9. A nursing student asks an emergency department nurse, Why does a rapist use a weapon during the act of rape? Which nursing reply is most accurate? a. a weapons is used to increase the victimizers security b. a weapon is used to inflict physical harm c. a weapon is used to terrorize and subdue the victim d. a weapon is used to mirror learned family behavior patterns

c The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

12. A client who has been raped is crying, pacing, and cursing her attacker in an emergency department. Which behavioral defense should a nurse recognize? a. controlled response pattern b. compounded rape reaction c. expressed response pattern d. silent rape reaction

c The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the clients feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

5. In the emergency department, a raped client appears calm and exhibits a blunt affect. The client answers a nurses questions in a monotone using single words. How should the nurse interpret this clients responses? a. the client may be lying about the incident b. the client may be experiencing a silent rape reaction c. the client may be demonstrating a controlled response pattern d. the client may be having a compounded rape reaction

c This client is most likely demonstrating a controlled response pattern. In a controlled response pattern, the clients feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension.

A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the clients approved call list. What law has the nurse broken? A. The National Alliance for the Mentally Ill Act B. The Tarasoff Ruling C. The Health Insurance Portability and Accountability Act D. The Good Samaritan Law

c the nurse has violated by HIPAA by revealing that the client had been admitted to the psychiatric unit. the nurse should not have provided any information without proper consent from the client

Which is an accurate description of a common law? A. A common law would be invoked to deal with a nurse who, without justification, threatens a client with restraints. B. A common law would be invoked to deal with a nurse who touches a client without the clients consent. C. A common law would be invoked to deal with a hospital employee who steals drugs, hospital equipment, or both. D. A common law would be invoked to deal with a nurses refusal to provide care for a specific client

d Common laws apply to a body of principles that evolve from court decisions resolving various controversies. Common law may vary from state to state. Assault (threats) and battery (touch) are governed by civil law. Stealing is governed by criminal law.

An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? A. Verbally redirect the client, and then limit one-on-one interaction. B. Involve the hospitals security division as soon as possible. C. Notify the client that documenting personal staff information is against hospital policy. D. Continue professional attempts to establish a positive working relationship with the client.

d the most appropriate nursing action is to continue professional attempt to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed.

Which statement should a nurse identify as correct regarding a clients right to refuse treatment? A. Clients can refuse pharmacological but not psychological treatment. B. Clients can refuse any treatment at any time. C. Clients can refuse only electroconvulsive therapy (ECT). D. Professionals can override treatment refusal if the client is actively suicidal or homicidal.

d the nurse should understand that health care professionals can override tx refusal when a client is actively suicidal or homicidal.

10. A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, My partner beat me, but it was because I did not do the laundry. What is the nurses next action? a. call the police b. arrange for hospitalization c. call the adult protective agency d. document injuries with a body map

d Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

9. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurses priority assessment? a. interpersonal relationships b. work responsibilities c. socialization skills d. physical injuries

d The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

12. An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation? a. autonomy b. beneficence c. nonmaleficence d. justice

d The nurse should determine that the ethical principle of justice has been violated by the physicians actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.

Which teaching should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? A. Have ready access to a gun and learn how to use it B. Research lawyers who can aid in divorce proceedings C. File charges of assault and battery D. Have ready access to the number of a safe house for battered women

d The nurse should provide information about safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear for their lives.

2. A woman describes a history of physical and emotional abuse in intimate relationships. Which additional factor should a nurse suspect? a. the woman may be exhibiting a controlled response pattern b. the woman may have a hx of childhood neglect c. the women may be exhibiting codependent characteristics d. the woman might be a victim of incest

d The nurse should suspect that this client might be a victim of incest. Women in abusive relationships often grew up in abusive homes.

6. A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, Why doesnt she just leave him? Which is the nursing supervisors most appropriate reply? A. These clients dont know life any other way, and change is not an option until they have improved insight. B. These clients have limited skills and few vocational abilities to be able to make it on their own. C. These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation. D. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness.

d The nursing supervisor is accurate when stating that clients in severely abusive relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner for some of the following reasons: for the children, financial reasons, fear of retaliation, lack of a support network, religious reasons, and/or hopelessness.