Chapter 6 and 29

A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response. a. "Are you thinking of harming yourself?" b. "It will take time, but you will feel the same as before the attack." c. "Your friends will understand when you explain it was not your fault." d. "You will be able to find meaning from this experience as time goes on."

a. "Are you thinking of harming yourself?" The patient's words suggest hopelessness. Whenever hopelessness is present, so is suicide risk. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment.

Insurance will not pay for continued private hospitalization of a mentally ill patient. The family considers transferring the patient to a public hospital but expresses concern that the patient will not get any treatment if transferred. Select the nurse's most helpful reply. a. "By law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse." c. "You have a justifiable concern because the right to treatment extends only to provision of food, shelter, and safety." d. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable."

a. "By law, treatment must be provided. Hospitalization without treatment violates patients' rights." The right to medical and psychiatric treatment is conferred on all patients hospitalized in public mental hospitals under federal law.

A person in the community asks, "Why aren't people with mental illness kept in state institutions anymore?" Select the nurse's best response. a. "Less restrictive settings are available now to care for individuals with mental illness." b. "There are fewer persons with mental illness, so less hospital beds are needed." c. "Most people with mental illness are still in psychiatric institutions." d. "Psychiatric institutions violated patients' rights."

a. "Less restrictive settings are available now to care for individuals with mental illness." The community is a less restrictive alternative than hospitals for treatment of persons with mental illness. The distracters are incorrect and part of the stigma of mental illness.

Which scenarios describe completed rape? (Select all that apply.) a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. b. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient. e. A perpetrator grabs a potential victim, tears off most of her clothing, and fondles her breasts before she escapes.

a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient.

A nurse is concerned that an agency's policies are inadequate. Which understanding about the relationship between substandard institutional policies and individual nursing practice should guide nursing practice? a. Agency policies do not exempt an individual nurse of responsibility to practice according to professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. Faced with substandard policies, a nurse has a responsibility to inform the supervisor and discontinue patient care immediately. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

a. Agency policies do not exempt an individual nurse of responsibility to practice according to professional standards of nursing care. Nurses are professionally bound to uphold standards of practice regardless of lesser standards established by a health care agency or a state. Conversely, if the agency standards are higher than standards of practice, the agency standards must be upheld. The Courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded.

A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? (Select all that apply.) a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways. d. Invite the patient's family members to the examination room. e. Put an arm around the patient to demonstrate support and compassion.

a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways. Neutral, nonjudgmental care and emotional support are critical to crisis management for the rape victim. The rape victim should have privacy but not be left alone. The rape victim's anxiety may escalate when touched by a stranger, even when the stranger is a nurse. Some rape victims prefer not to have family involved. The patient's privacy may be compromised by family presence.

A patient in alcohol rehabilitation reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old before I was admitted." Select the nurse's most important action. a. Anonymously report the abuse by phone to the local child protection agency. b. Reply, "I'm glad you feel comfortable talking to me about it." c. File a written report with the agency's ethics committee. d. Respect nurse-patient relationship confidentiality.

a. Anonymously report the abuse by phone to the local child protection agency. Laws regarding child abuse reporting discovered by a professional during the suspected abuser's alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility.

An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? (Select all that apply.) a. Camera b. Body map c. DNA swabs d. Pulse oximeter e. Sphygmomanometer

a. Camera b. Body map c. DNA swabs Body maps, DNA swabs, and photographs are used to collect and preserve body fluids and other forensic evidence.

Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.) a. Coping mechanisms, the patient is using b. The patient's previous sexual experiences c. The patient's history of sexually transmitted diseases d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system

a. Coping mechanisms, the patient is using d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system The nurse assesses the victim's level of anxiety, coping mechanisms, available support systems, signs and symptoms of emotional trauma, and signs and symptoms of physical trauma. The history of STDs or previous sexual experiences has little relevance.

When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase, which symptoms should be included? (Select all that apply.) a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

a. Development of fears and phobias c. Feelings of numbness d. Flashbacks, dreams These reactions are common to the long-term phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes would not be expected.

Which action by a psychiatric nurse best applies the ethical principle of autonomy? a. Exploring alternative solutions with the patient, who then makes a choice. b. Suggesting that two patients who were fighting be restricted to the unit. c. Intervening when a self-mutilating patient attempts to harm self. d. Staying with a patient demonstrating a high level of anxiety.

a. Exploring alternative solutions with the patient, who then makes a choice. Autonomy is the right to self-determination, that is, to make one's own decisions. By exploring alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. The distracters demonstrate beneficence, fidelity, and justice.

A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. c. Reassure the victim that the outcome of the situation will be positive. d. Pose questions about the rape and help the patient explore why it happened.

a. Support the victim to separate issues of vulnerability from blame. Although the victim may have made choices that made her vulnerable, she is not to blame for the rape. Correcting this distortion in thinking allows the victim to begin to restore a sense of control. This is a positive response to victimization. The distracters do not permit the victim to begin to restore a sense of control or offer use of nontherapeutic communication techniques. In this interaction, the victim needs to talk about feelings rather than prevention.

A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? a. The acute phase reaction b. The long-term phase c. A delayed reaction d. The angry stage

a. The acute phase reaction The victim's response is typical of the acute phase and shows cognitive, affective, and behavioral disruptions. This response is immediate and does not include a display of behaviors suggestive of the long-term (reorganization) phase, anger, or a delayed reaction.

In order to release information to another health care facility or third party regarding a patient diagnosed with a mental illness, the nurse must obtain a. a signed consent by the patient for release of information stating specific information to be released. b. a verbal consent for information release from the patient and the patient's guardian or next of kin. c. permission from members of the health care team who participate in treatment planning. d. approval from the attending psychiatrist to authorize the release of information.

a. a signed consent by the patient for release of information stating specific information to be released. Nurses have an obligation to protect patients' privacy and confidentiality. Clinical information should not be released without the patient's signed consent for the release.

A nurse works at rape telephone hotline. Communication with potential victims should focus on a. explaining immediate steps victims should take. b. providing callers with a sympathetic listener. c. obtaining information for law enforcement. d. arranging counseling.

a. explaining immediate steps victims should take. The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Counseling is not the focus until immediate problems are resolved. The victim remains anonymous. The other distracters are inappropriate or incorrect because counselors are trained to be empathetic rather than sympathetic.

A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? a. "Does the victim have any kidney disease?" b. "Has the victim consumed any alcohol?" c. "What time was she given salty water?" d. "Did you witness the rape?"

b. "Has the victim consumed any alcohol?" Salty water is a slang/street name for GHB (γ-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1 to 12 hours, but the duration is less important than the potential for respiratory depression. Seeking evidence is less important than the victim's physiologic stability.

An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. a. "You are right. Federal law requires me to keep clinical information private." b. "I am obligated to share that information with the treatment team." c. "Those kinds of thoughts will make your hospitalization longer." d. "You should share this thought with your psychiatrist."

b. "I am obligated to share that information with the treatment team." Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should also know that the team has a duty to warn the father of the risk for harm.

A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge. I want to leave now." Select the nurse's best response. a. "I will get the forms for you right now and bring them to your room." b. "Since you signed your consent for treatment, you may leave if you desire." c. "I will get them for you, but let's talk about your decision to leave treatment." d. "I cannot give you those forms without your health care provider's permission."

c. "I will get them for you, but let's talk about your decision to leave treatment." A voluntarily admitted patient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient's wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. Facilitating discharge without consent is not in the patient's best interests before exploring the reason for the request.

A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? a. "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." c. "Do you have any male friends who have also been victims of sexual assault?" d. "Why do you think you became a victim of sexual assault?"

b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. "Why" questions represent probing, which is a nontherapeutic communication technique. The victim may or may not have friends who have had this experience, but it is important to talk about his feelings rather than theirs.

An aide in a psychiatric hospital says to the nurse, "We don't have time every day to help each patient complete a menu selection. Let's tell dietary to prepare popular choices and send them to our unit." Select the nurse's best response. a. "Thanks for the suggestion, but that idea may not work because so many patients take MAOI (monoamine oxidase inhibitor) antidepressants." b. "Thanks for the idea, but it's important to treat patients as individuals. Giving choices is one way we can respect patients' individuality." c. "Thank you for the suggestion, but the patients' bill of rights requires us to allow patients to select their own diet." d. "Thank you. That is a very good idea. It will make meal preparation easier for the dietary department."

b. "Thanks for the idea, but it's important to treat patients as individuals. Giving choices is one way we can respect patients' individuality." The nurse's response to the aide should recognize patients' rights to be treated with dignity and respect as well as promote autonomy. This response also shows respect for the aide and fulfills the nurse's obligation to provide supervision of unlicensed personnel. The incorrect responses have flawed rationale or do not respect patients as individuals.

Select the example of a tort. a. The plan of care for a patient is not completed within 24 hours of the patient's admission. b. A nurse gives a prn dose of an antipsychotic drug to an agitated patient because the unit is short-staffed. c. An advanced practice nurse recommends hospitalization for a patient who is dangerous to self and others. d. A patient's admission status changed from involuntary to voluntary after the patient's hallucinations subside.

b. A nurse gives a prn dose of an antipsychotic drug to an agitated patient because the unit is short-staffed. A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus, false imprisonment is a possible charge. The other options do not exemplify torts.

Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, "I'm getting out of here, and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. b. A patient has been irritating and attention seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you'll be put in seclusion." c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. The nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with homicidal ideation attempts to leave the facility. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

b. A patient has been irritating and attention seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you'll be put in seclusion." False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. If a patient is not competent (confused), then the nurse should act with beneficence. Patients admitted involuntarily should not be allowed to leave without permission of the treatment team.

After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? a. Decreased motor activity b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias

b. Confusion and disbelief Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase.

An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? a. The patient's vital signs b. Consent signed by the patient c. Supervision and credentials of the examiner d. Storage location of the patient's personal effects

b. Consent signed by the patient Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps.

Which action by a nurse constitutes a breach of a patient's right to privacy? a. Documenting the patient's daily behavior during hospitalization b. Releasing information to the patient's employer without consent c. Discussing the patient's history with other staff during care planning d. Asking family to share information about a patient's pre-hospitalization behavior

b. Releasing information to the patient's employer without consent Release of information without patient authorization violates the patient's right to privacy. The other options are acceptable nursing practices. See relationship to audience response question.

A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I shouldn't have been there alone. I knew it was a dangerous area." What is the patient's present coping strategy? a. Projection b. Self-blame c. Suppression d. Rationalization

b. Self-blame The patient's statements reflect self-blame, an unhealthy coping mechanism. The patient's statements do not reflect rationalization, suppression, or projection.

A nurse prepares to administer a scheduled intramuscular injection of an antipsychotic medication to an outpatient diagnosed with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best action. a. Assemble other staff for a show of force and proceed with the injection, using restraint if necessary. b. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." c. Proceed with the injection but explain to the patient that there are medications that will help reduce the unpleasant side effects. d. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose."

b. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." Patients diagnosed with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. The nurse, as an advocate and educator, should seek more information about the patient's decision and not force the medication.

A patient diagnosed with schizophrenia believes a local minister stirred evil spirits. The patient threatens to bomb a local church. The psychiatrist notifies the minister. Select the answer with the correct rationale. The psychiatrist a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient's confidentiality. d. avoided charges of malpractice.

b. demonstrated the duty to warn and protect. It is the health care professional's duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not a violation of confidentiality.

A nurse finds a psychiatric advance directive in the medical record of a patient currently experiencing psychosis. The directive was executed during a period when the patient was stable and competent. The nurse should a. review the directive with the patient to ensure it is current. b. ensure that the directive is respected in treatment planning. c. consider the directive only if there is a cardiac or respiratory arrest. d. encourage the patient to revise the directive in light of the current health problem.

b. ensure that the directive is respected in treatment planning. The nurse has an obligation to honor the right to self-determination. An advanced psychiatric directive supports that goal. Since the patient is currently psychotic, the terms of the directive now apply.

A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should (Select all that apply.) a. arrange for the victim to shower. b. explain that bathing destroys evidence. c. give the victim a basin of water and towels. d. offer the victim a shower after evidence is collected. e. explain that bathing facilities are not available in the emergency department.

b. explain that bathing destroys evidence. d. offer the victim a shower after evidence is collected. As uncomfortable as the victim may be, she should not bathe until the examination is completed. Collection of evidence is critical for prosecution of the attacker. Showering after the examination will provide comfort to the victim. The distracters will result in destruction of evidence or are untrue.

An unconscious teenager is treated in the emergency department. The teenager's friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on a. preserving rape evidence. b. maintaining physiological stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend.

b. maintaining physiological stability. Because the patient is unconscious, the risk for airway obstruction is present. The nurse's priority will focus on maintaining physiological stability. The distracters are of lower priority than preserving physiological functioning.

A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should a. say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information about physical and emotional reactions the person may experience. c. explain the need and importance of infectious disease and pregnancy tests. d. give verbal information about legal resources in the community.

b. provide written information about physical and emotional reactions the person may experience. All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to later. Patients may not be kept against their will or coerced into treatment. This constitutes false imprisonment.

Two hospitalized patients fight whenever they are together. During a team meeting, a nurse asserts that safety is of paramount importance, so treatment plans should call for both patients to be secluded to keep them from injuring each other. This assertion a. reinforces the autonomy of the two patients. b. violates the civil rights of both patients. c. represents the intentional tort of battery. d. correctly places emphasis on safety.

b. violates the civil rights of both patients. Patients have a right to treatment in the least restrictive setting. Safety is important, but less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion violates the patient's autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment.

A patient experiencing psychosis asks a psychiatric technician, "What's the matter with me?" The technician replies, "Nothing is wrong with you. You just need to use some self-control." The nurse who overheard the exchange should take action based on a. the technician's unauthorized disclosure of confidential clinical information. b. violation of the patient's right to be treated with dignity and respect. c. the nurse's obligation to report caregiver negligence. d. the patient's right to social interaction.

b. violation of the patient's right to be treated with dignity and respect. Patients have the right to be treated with dignity and respect. The technician's comment disregards the seriousness of the patient's illness. The Code of Ethics for Nurses requires intervention. Patient emotional abuse has been demonstrated, not negligence. An interaction with the technician is not an aspect of social interaction. The technician did not disclose clinical information.

A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful and the victim is now in recovery? a. "I have a rash on my buttocks. It itches all the time." b. "Now I know what I did that triggered the attack on me." c. "I'm sleeping better although I still have an occasional nightmare." d. "I have lost 8 pounds since the attack, but I needed to lose some weight."

c. "I'm sleeping better although I still have an occasional nightmare." Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victim's sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing.

In which situations would a nurse have the duty to intervene and report? (Select all that apply.) a. A peer has difficulty writing measurable outcomes. b. A health care provider gives a telephone order for medication. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member violates relationship boundaries with a patient. e. A patient refuses medication prescribed by a licensed health care provider.

c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member violates relationship boundaries with a patient. Both keyed answers are events that jeopardize patient safety. The distracters describe situations that may be resolved with education or that are acceptable practices.

Which actions violate the civil rights of a psychiatric patient? The nurse (Select all that apply) a. performs mouth checks after overhearing a patient say, "I've been spitting out my medication." b. begins suicide precautions before a patient is assessed by the health care provider. c. opens and reads a letter a patient left at the nurse's station to be mailed. d. places a patient's expensive watch in the hospital business office safe. e. restrains a patient who uses profanity when speaking to the nurse.

c. opens and reads a letter a patient left at the nurse's station to be mailed. e. restrains a patient who uses profanity when speaking to the nurse. The patient has the right to send and receive mail without interference. Restraint is not indicated because a patient uses profanity; there are other less restrictive ways to deal with this behavior. The other options are examples of good nursing judgment and do not violate the patient's civil rights.

After leaving work, a nurse realizes documentation of administration of a prn medication was omitted. This off-duty nurse phones the nurse on duty and says, "Please document administration of the medication for me. My password is alpha1." The nurse receiving the call should a. fulfill the request promptly. b. document the caller's password. c. refer the matter to the charge nurse to resolve. d. report the request to the patient's health care provider.

c. refer the matter to the charge nurse to resolve. Fraudulent documentation may be grounds for discipline by the state board of nursing. Referring the matter to the charge nurse will allow observance of hospital policy while ensuring that documentation occurs. Notifying the health care provider would be unnecessary when the charge nurse can resolve the problem. Nurses should not provide passwords to others.

Which individual diagnosed with a mental illness may need involuntary hospitalization? An individual a. who has a panic attack after her child gets lost in a shopping mall. b. with visions of demons emerging from cemetery plots throughout the community. c. who takes 38 acetaminophen tablets after the person's stock portfolio becomes worthless. d. diagnosed with major depression who stops taking prescribed antidepressant medication.

c. who takes 38 acetaminophen tablets after the person's stock portfolio becomes worthless. Involuntary hospitalization protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary hospitalization also protects other individuals in society. An overdose of acetaminophen indicates dangerousness to self. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

A new antidepressant is prescribed for an elderly patient diagnosed with major depressive disorder, but the dose is more than the usual geriatric dose. The nurse should a. consult a reliable drug reference. b. teach the patient about possible side effects and adverse effects. c. withhold the medication and confer with the health care provider. d. encourage the patient to increase oral fluids to reduce drug concentration.

c. withhold the medication and confer with the health care provider. The dose of antidepressants for elderly patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse's duty is to practice according to professional standards as well as intervene and protect the patient.

1. The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. a. "Your plan is not adequate. You could still be raped or sexually assaulted." b. "I am glad you have this excellent safety plan. Would others like to comment?" c. "It's better to walk with someone or call security when you enter or leave a building." d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that." Almost half of female victims have been raped by an acquaintance. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion.

A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. a. "Rape can happen anywhere." b. "Blaming yourself increases your anxiety and discomfort." c. "You are right. You should not have been alone on the street at night." d. "You feel as though this would not have happened if you had not been alone."

d. "You feel as though this would not have happened if you had not been alone." A reflective communication technique is most helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victim's perceived role and interfere with further discussion.

A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for a. coma. b. seizures. c. hypotonia. d. respiratory depression.

d. respiratory depression. Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma.

In a team meeting a nurse says, "I'm concerned about whether we are behaving ethically by using restraint to prevent one patient from self-mutilation, while the care plan for another self-mutilating patient requires one-on-one supervision." Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice

d. Justice The nurse is concerned about justice, that is, fair distribution of care, which includes treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one's own decisions. Fidelity is the observance of loyalty and commitment to the patient.

A newly admitted acutely psychotic patient is a private patient of the medical director and a private-pay patient. To whom does the psychiatric nurse assigned to the patient owe the duty of care? a. Medical director b. Hospital c. Profession d. Patient

d. Patient Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient. This duty reflects both legal and ethical standards of nursing practice.

A patient experiencing psychosis became aggressive, struck another patient, and required seclusion. Select the best documentation. a. Patient struck another patient who attempted to leave day room to go to bathroom. Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these two patients away from each other for 24 hours. b. Seclusion ordered by physician at 1415 after command hallucinations told the patient to hit another patient. Careful monitoring of patient maintained during period of seclusion. c. Seclusion ordered by MD for aggressive behavior. Begun at 1415. Maintained for 2 hours without incident. Outcome: Patient calmer and apologized for outburst. d. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me," and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430.

d. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me," and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430. Documentation must be specific and detail the key aspects of care. It should demonstrate implementation of the least restrictive alternative. Justification for why a patient was secluded should be recorded, along with interventions attempted in an effort to avoid seclusion. Documentation should include a description of behavior and verbalizations, interventions tried and their outcomes, and the name of the health care provider ordering the use of seclusion.

A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

d. Severe Acute anxiety results from the personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level.

The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate.

d. The patient agrees to a follow-up appointment with a rape victim advocate. Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department.

Which documentation of a patient's behavior best demonstrates a nurse's observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer; more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Frequently increased volume on television, causing conflict with others. d. Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin."

d. Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin." The documentation states specific observations of the patient's appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways.

What is the legal significance of a nurse's action when a patient verbally refuses medication and the nurse gives the medication over the patient's objection? The nurse a. has been negligent. b. committed malpractice. c. fulfilled the standard of care. d. can be charged with battery.

d. can be charged with battery. Battery is an intentional tort in which one individual violates the rights of another through touching without consent. Forcing a patient to take medication after the medication was refused constitutes battery. The charge of battery can be brought against the nurse. The medication may not necessarily harm the patient; harm is a component of malpractice.

A family member of a patient with delusions of persecution asks the nurse, "Are there any circumstances under which the treatment team is justified in violating a patient's right to confidentiality?" The nurse should reply that confidentiality may be breached a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person.

d. if the patient threatens the life of another person. The duty to warn a person whose life has been threatened by a psychiatric patient overrides the patient's right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations.

Before a victim of sexual assault is discharged from the emergency department, the nurse should a. notify the victim's family to provide emotional support. b. offer to stay with the patient until stability is regained. c. advise the patient to try not to think about the assault. d. provide referral information verbally and in writing.

d. provide referral information verbally and in writing. Immediately after the assault, rape victims are often disorganized and unable to think well or remember instructions. Written information acknowledges this fact and provides a solution. The distracters violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The patient who a. is noncompliant with the treatment regimen. b. fraudulently files for bankruptcy. c. sold and distributed illegal drugs. d. threatens to harm self and others.

d. threatens to harm self and others. Involuntary hospitalization protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

Which individual diagnosed with mental illness may need emergency or involuntary admission? The individual who a. resumes using heroin while still taking naltrexone (ReVia). b. reports hearing angels playing harps during thunderstorms. c. does not keep an outpatient appointment with the mental health nurse. d. throws a heavy plate at a waiter at the direction of command hallucinations.

d. throws a heavy plate at a waiter at the direction of command hallucinations. Throwing a heavy plate is likely to harm the waiter and is evidence of dangerousness to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness. See related audience response question.

chapter 6

legal and ethical considerations

Chapter 29

sexual assault