Chapter 7 Legal Dimensions of Nursing Practice

A legal document that states a client's health-related wishes — such as a preference for pain management if the client becomes terminally ill — and also allows the client's adult child to direct the client's care, is:

an advance directive. Clients communicate their wishes to health care providers by verbally participating in health care decision making and by employing written documents called advance directives. A will is a legal document where one communicates wishes of how to dispose of personal effects and belongings upon one's death. The terms license and standard of care have no application in this scenario.

The nurse manager is using voluntary standards as a guideline for developing policies on the unit. What voluntary standards are available for the nurse to use? Select all that apply.

American Nurses Association Standards of Practice Professional standards for certification of individual nurses in general practice Process of certification

A client has been in the emergency department for 3 hours for treatment of a migraine headache. Care has been delayed due to a multiple fatality car accident. The client gets up to go to the bathroom unattended, faints, and suffers a subdural hematoma. The family threatens to sue for malpractice. Which element of malpractice will be the most difficult for the attorney to prove?

Causation Typically, causation is the most difficult component of malpractice to prove. Causation asks the question, "Did the nurse's actions directly cause the damages?" Duty is typically outlined in standards of care, breach of duty can be proved by documentation of the visit, and damages are clearly evident.

A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow?

Document the client's claims and the events surrounding the alleged incident. It is imperative for nurses to carefully and accurately document assessment findings and the nursing care that they provide, especially when legal action is anticipated. This thorough and accurate assessment should precede consultation with the legal department, the state board of nursing, and colleagues.

A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the mostappropriate action of the nurse?

Obtain a medical order. Nurses must obtain a medical order before each and every instance in which they use restraints. Due to the severity of the client illness requiring endotracheal intubation, the client may not be able to provide a written consent. The client does not need to be sedated unless medically necessary, and although it is appropriate to notify the family, this is not the priority.

A nurse is preparing a presentation for a group of staff nurses about the rules affecting nursing practice and the parties involved. When describing the role of different sources for the rules, which issue would the nurse identify as being addressed specifically by state legislation? Select all that apply.

Scope of practice Educational requirements of nurses State legislation is involved with issues such as scope of practice and educational requirements for nursing. Position statements related to medication administration and unprofessional conduct are issues addressed by the Board of Nursing. Clinical procedures are associated with rules established by the specific health care institution.

Which situation violates an element of informed consent?

The nurse says, "You have to sign this before we can do the surgery." The elements of informed consent are disclosure, comprehension, competence, and voluntariness. Telling the client that the surgery cannot be done until the form has been signed could be interpreted as coercion. The nurse's signature on the form indicates witness that the client or surrogate signed the paper. The nurse can answer questions about the surgery (within scope of practice) prior to the client signing the form. The client who is aware that there are no guarantees is informed.

A client newly diagnosed with congestive heart failure has a prescription for digoxin. The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care?

The nurse withholds the medication and notifies the health care practitioner. Nurses are responsible for following the standards of care for their particular work area. A reasonably prudent nurse would withhold the medication and notify the health care practitioner. All other options put the client's safety at risk and would not be done by a reasonably prudent nurse.

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

To protect the safety of the public Governing bodies, professional regulations, and laws are in place to protect the public by ensuring that nurses are accountable for safe, competent, and ethical nursing practice.

An alert, older adult has been deemed to be in imminent danger of harm to self and is being held on the mental health unit for 72 hours. The client begins to scream and demand they be discharged now. The nurse informs the client that if they do not stop screaming, they will be given a sedative and placed on restraints. Legally, the nurse may be charged with _ because of _.

assault, verbally threatening to administer a sedative Assault constitutes a behavior that threatens or attempts to cause bodily harm; the threat can be done verbally or through the use of gestures. The nurse may be charged with assault because of verbally threatening to administer a sedative. Battery involves physical contact that may or may not result in injury. There was no evidence of physical contact in the scenario. A person cannot be legally forced to remain in a health care facility against their will unless they have been committed to a psychiatric institution for treatment without their consent. An involuntary commitment can be ordered when a person has been deemed harmful to themselves or others. The client was not placed on restraints. Keeping the client hospitalized against their will while they are being held on a mental health hold due to presenting as an imminent danger to self or others meets the critera for involuntary commitment; not false imprisonment.

During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies?

Health care institution The health care institution determines the unit and institutional policies. These policies may vary from institution to institution. Such policies may include clinical procedures, policies specific to the institution, and personnel and employment policies. Unit and institutional-based policies are not derived from federal legislation, state legislation, or the board of nursing.

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged?

Slander The nurse can be charged with slander, which is a verbal attack on a person's character. Libel pertains to damaging written statements read by others. Both libel and slander are considered defamation of character-an intentional tort in which one party makes derogatory remarks about another that diminish the other party's reputation. To be found guilty of slander or libel, the statement must be proved false. Negligence and malpractice pertain to actions which are committed or omitted, thereby causing physical harm to a client.

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report?

To evaluate the quality of care provided and assess the potential risks for injury to the client An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. Incident reports determine how to prevent hazardous situations and serve as a reference in case of future litigation. Accurate and detailed documentation often helps to prove that the nurse acted reasonably or appropriately in the circumstances. It may not always serve as a method of determining the nurse's fault in the incident. The document does not evaluate the immediate care provided to the client but states the actions taken.

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

To improve quality of care The primary reason to fill out an incident report is to improve the quality of care. Incident reports are not designed to be a means for disciplinary action. Incident reports are designed to identify actual or potential risks that can be addressed to improve quality of care. Incident reports are not intended to initiate litigation or document everyday occurrences.

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally?

"I cannot give you that information due to client confidentiality." Sharing a client's information without the client's consent is an invasion of privacy. The nurse should not give out the information even if the visitor provides proof of a relationship without the client's consent. It is inappropriate to call the client to ask for permission. The nurse claiming to be busy and offering to talk later does not address the issue but only delays it, perhaps leading the visitor to assume that the nurse will disclose information then.

Which are areas of potential liability for the nurse? Select all that apply.

-The nurse fails to document refusal by the client to ambulate following surgery. -The nurse documents that the client's blood pressure has increased from 118/72 to 188/98 mm Hg and decides to retake the blood pressure in an hour. Areas of potential liability would include failure to document refusal by the client to participate in the treatment regimen (such as ambulation after surgery) and failure to assess the client in a timely manner. Waiting an hour to reassess a significant elevation in blood pressure does not meet the standard of care. Reporting a client's adverse reaction to a medication, administering preoperative medication after the informed consent is signed, and documenting the client's response to education are nursing behaviors that meet the standard of care.

Which process evaluates and recognizes educational programs as having met certain standards?

Accreditation Accreditation is the process by which an educational program is evaluated and recognized as having met certain standards. Credentialing refers to ways in which professional competence is ensured and maintained. Licensure is the process by which a state determines that a candidate meets certain minimum requirements to practice in the profession—and grants that person the license to do so. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area.

A client informs the nurse about leaving the health care facility because the client is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?

Ask the client to sign a release without medical approval. If a client wants to leave the health care facility, the nurse should ask the client to sign a release stating that the client left without medical approval. The nurse cannot restrain the client because it amounts to false imprisonment. Calling the health care provider may be seen by the client as a delay tactic, although the nurse should follow facility protocol. Additional options would include having the client meet with the health care provider or client advocate if the client was willing to remain for care while those actions were initiated. Telling the client that the client may not be able to access the health care facility again is an inappropriate response because health care is a right and the client can access it whenever necessary.

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor?

Battery The UAP is engaging in battery, which is an assault that is carried out and includes willful, angry, and violent or negligent touching of another person's body or clothes or anything attached to (or held by) that other person. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Defamation of character is an intentional tort in which one party makes derogatory remarks about another that harm the other party's reputation.

A nurse working in a coronary care unit resuscitates a client who had expressed wishes not to be resuscitated. Which tort has the nurse committed?

Battery The nurse has committed battery by unlawfully carrying out a procedure that the client had refused. Battery is an assault and includes negligent touching of another person's body or clothes or anything attached to or held by that other person. Assault is the threat of touching another person without the person's consent. Defamation of character in spoken words is called slander. Libel is defamation of character in written words.

The nurse is providing care to a client who had orthopedic surgery. The nurse has medicated the client for pain. However, the client reports that the pain is unrelieved. The nurse takes no further action regarding assessment and intervention for the client's pain. The nurse does not notify the surgeon regarding the client's pain. The nurse's failure to take further action represents which element of liability in this case?

Breach of duty Breach of duty is the failure to assess, intervene, or notify the health care provider regarding the client's condition. It does not meet the expected standard of care. Duty refers to an obligation to use due care and is defined by the standard of care appropriate for the nurse-client relationship. Causation is when the failure to meet the standard of care caused injury. Damages are the harm or injury to the client.

A client is scheduled for a colonoscopy. The nurse realizes immediately after administering medications to induce conscious sedation that the client has not signed the informed consent. If the nurse has the client sign the informed consent at this point, which element of informed consent would be violated?

Competence The client under conscious sedation would not be considered competent to make a decision to undergo an invasive procedure such as a colonoscopy. Disclosure ensures that the following information has been given to the client: the nature of the treatment, possible alternative treatments, and potential risks and benefits of the treatment. Comprehension is met when the client demonstrates understanding by describing in the client's own words to what he is consenting. The client's consent must be given voluntarily.

The nurse is concerned about a potential malpractice or negligence lawsuit regarding a client who was cared for on the unit. What specific elements must be established to prove that malpractice or negligence has occurred in this client? Select all that apply.

Duty Breach of duty Causation Damages Elements of liability are duty, breach of duty, causation, and damages. Misrepresentation occurs in fraud. Breach of confidentiality is a type of invasion of privacy and a violation of HIPAA.

A nurse talks with family members about an AIDS client from the clinic where the nurse works. Which tort has the nurse committed?

Invasion of privacy Invasion of privacy involves a breach of keeping client information confidential. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Slander is oral defamation of character. Assault is a threat or attempt to make bodily contact with another person without that person's consent.

Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What is an example(s) of legal safeguards for the nurse? Select all that apply.

The nurse confirms informed consent was give by the client to perform a procedure. The nurse educates the client about what to expect during the hospital stay. The nurse documents all client care in a timely manner.

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an examination. She informs the physician and the nursing supervisor about this incident and also completes an incident report. Which action by the nurse indicates correct knowledge of handling an incident report?

The nurse documents a complete description of the happenings in the client's records. An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. It is kept separate from the medical record. The incident report is a legal document and making a copy of it is not advisable. It should not be placed in the client's records; however, the nurse can mention the incident in the client's records without mentioning the incident report.

After reporting to work for a night shift, the nurse learns that the unit is understaffed because two RNs called out sick. As a result, each nurse on the unit must provide care for four acute clients in addition to the nurse's regular clients. Which statement is true for this nurse when working in understaffed circumstances?

The nurse is legally held to the same standards of care as when staffing levels are normal. The claim of being overworked does not constitute a legal defense, and both the potential for liability and standards of care remain unchanged despite an increased client assignment. Although it is prudent to make all realistic attempts to fill the gaps in staffing, documenting these efforts does not change the nurse's legal position. A nurse has the right to refuse an unsafe client assignment but the nurse is not legally obliged to withhold care.