Psych - Chapter 9

A client with depression is found to have attempted suicide in the bathroom and sustains injury. There is no documentation that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against? A. Malpractice B. Battery C. Assault D. False imprisonment

ANS: A. Malpractice

A nurse is questioning another nurse about whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. Which is the ethical principle that will best guide the nurse's decision on appropriate use of seclusion? A. Autonomy B. Beneficence C. Justice D. Veracity

ANS: A. Autonomy

A client states to their parents, "I am going to hurt you if you come too close to me!" The parents called 911, and the client is now held involuntarily for a psychiatric evaluation. Which statement made by the nurse identifies the clients' rights that will be retained during this admission? Select all that apply. A. "We will not be discussing your admission with anyone other than health care personnel involved in your care." B. "You will be able to leave the facility whenever you feel that you are in control and your parents come and get you." C. "Your treatment plan will be reviewed regularly and changes will be made accordingly for the best outcomes." D. "If you don't want to take your medication, we are not able to force you to take it while you are here." E. "I understand that you want to write a letter to your parents and apologize but you cannot do this while hospitalized."

ANS: A. "We will not be discussing your admission with anyone other than health care personnel involved in your care." C. "Your treatment plan will be reviewed regularly and changes will be made accordingly for the best outcomes." D. "If you don't want to take your medication, we are not able to force you to take it while you are here."

The nurse is caring for several clients in the inpatient behavioral health unit. Which client(s) does the nurse identify will require someone to make decisions regarding their medical and psychiatric care in their best interest? Select all that apply. A. A client that is gravely disabled B. A client with severe intellectual developmental disorder C. A client that is nonadherent to their medication regimen D. A client that is unable to provide basic needs when resources exist E. A client that acts only on their own interests

ANS: A. A client that is gravely disabled B. A client with severe intellectual developmental disorder D. A client that is unable to provide basic needs when resources exist

The nurse is evaluating clients in the emergency department (ED) for pending mental-health admissions. Which client will be admitted for involuntary hospitalization? Select all that apply. A. A client who states they intend to commit suicide and is making a plan B. A client who does not bathe regularly or change clothes often C. A client who states they intend to harm others by a deliberate act D. A client who has diabetes who refuses to follow the prescribed diet E. A client who is unable to control rage and is assaulting others

ANS: A. A client who states they intend to commit suicide and is making a plan C. A client who states they intend to harm others by a deliberate act E. A client who is unable to control rage and is assaulting others

The nurse is considering the use of short-term restraints for a client. Which criteria will the nurse use to determine if the client meets the use of instituting the short-term use of restraint or seclusion? Select all that apply. A. The client is aggressive. B. The client requires punitive action for behavior. C. The client is imminently dangerous to the self or to others. D. The client is physically and emotionally self-controlled. E. All other means of calming the client have been unsuccessful.

ANS: A. The client is aggressive. C. The client is imminently dangerous to the self or to others. E. All other means of calming the client have been unsuccessful.

The nurse is working in a state psychiatric facility and encounters situations which require the evaluation of ethical dilemmas. Which dilemmas involve the ethical principle of fidelity? Select all that apply. A. The nurse is unable to agree with the policies or common practices of an agency. B. The nurse is faced with a decision to violate a policy that is harmful to the client. C. The nurse is certain that clients of different racial and ethnic backgrounds are treated the same as other clients. D. The nurse identifies a combative client must be secluded against their will to prevent harm to others. E. The client refuses to take medication and the nurse respects the client's right to refuse medication.

ANS: A. The nurse is unable to agree with the policies or common practices of an agency. B. The nurse is faced with a decision to violate a policy that is harmful to the client.

The nurse working in an addictive disorders' unit receives a phone call inquiring about the status of a client. The caller is not on the client's allowed contact list. Which is the appropriate response by the nurse to the caller? A. "I cannot confirm or deny the existence of any client here." B. "You will need to be placed on the client's contact list before I can discuss any information with you." C. "The person you are asking for is not a client here." D. "Hold one minute while I get the client for you."

ANS: A. "I cannot confirm or deny the existence of any client here."

The nurse is working with an adolescent client that is argumentative with staff and peers on the behavioral health unit. Which therapeutic response will be most beneficial for the client to decrease acting out behavior? A. "Let's go to a quiet area and talk about what is upsetting you." B. "I don't know what set you off today but you have to get along with others." C. "You have to take this medication to settle you down and stop your behavior." D. "If your behavior continues, we have no choice but to place you in seclusion."

ANS: A. "Let's go to a quiet area and talk about what is upsetting you."

The nurse is caring for a group of clients in the mental health clinic. Which client is most likely to be mandated for outpatient treatment? A. A client addicted to alcohol who has two driving under the influence offenses B. A client with schizophrenia living in a single-family home with siblings C. A client with bipolar disorder quit three jobs in the last 6 months D. A homeless client arrested for petty theft of groceries from a convenience store.

ANS: A. A client addicted to alcohol who has two driving under the influence offenses

The health care provider prescribes haloperidol 10 mg for a client with severe psychosis but the client refuses the medication. Which nursing action is appropriate? A. Accept the client's decision and continue to maintain safety. B. Obtain a discharge order for nonadherence to the medication regimen. C. Inform the client to refuse the medication means not getting any better. D. Restrain the client and give the medication intramuscularly.

ANS: A. Accept the client's decision and continue to maintain safety.

A client is struggling to make a decision about having an abortion since their spouse left them. The client has two children to care for and asks the nurse what they should do. Which action by the nurse is a priority? A. The nurse should examine their own values and beliefs first. B. The nurse should advise the client to make a decision without input from others. C. Encourage the client to talk with their religious leader about what to do. D. Refer the client to a facility that performs abortions on an outpatient basis.

ANS: A. The nurse should examine their own values and beliefs first.

A nurse is reviewing an electronic medical record to determine if a client's rights have been violated by another member of the health care team. Which finding will the nurse identify that would indicate a violation of the client rights? A. There is no documentation of benefits of treatment or treatment options. B. The client's belongings are searched at admission. C. Physical restraints were used to prevent harm to self and others. D. The client was placed on one-to-one continuous observation for threats of self harm.

ANS: A. There is no documentation of benefits of treatment or treatment options.

A client in a busy inpatient psychiatric unit is noisy and combative. The nurse determines that the best course of action for all involved is to seclude the client until they are able to regain control of his behavior. On which ethical principle did the nurse base this decision? A. Utilitarianism B. Deontology C. Nonmaleficence D. Veracity

ANS: A. Utilitarianism

A client with end-stage pancreatic cancer asks the nurse, "Am I going to die from this?" Which response by the nurse is demonstrative of veracity? A. "We all will die at some time, some earlier than others." B. "You have a terminal illness that will take your life at some point." C. "We will take care of you and try and keep you comfortable." D. "Why do you think you will die from this disease?"

ANS: B. "You have a terminal illness that will take your life at some point."

The nurse is working in a behavioral health unit with a variety of clients with mental health disorders. Which client does the nurse identify will require the nurse and the health care team to warn a third party? A. A client with paranoid schizophrenia states, "Those aliens are sending messages through my brain, and I have to protect myself." B. A client that states, "When I get out of here, I have a plan to kill that judge that sentenced me here. I am going to blow their house up." C. A client states to the nurse, "My spouse is so annoying, I just want to kill them sometimes." D. A client that states, "Sometimes I get so angry that I could just end everyone and be alone in the world."

ANS: B. A client that states, "When I get out of here, I have a plan to kill that judge that sentenced me here. I am going to blow their house up."

An adult client is put in restraints after all other attempts to reduce aggression have failed. Which action by the nurse is required now that restraints have been instituted? A. Review of the appropriateness of restraints every 8 hours B. A face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint C. A documented nursing assessment every 4 hours D. Constant one-on-one supervision during the first hour and then video monitoring

ANS: B. A face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint

A nurse is performing safety assessments on a client in mechanical restraints as required by policy. Which action by the nurse demonstrates the ethical principle of nonmaleficence? A. Explaining the behavioral requirements for release of restraint to the client B. Assuring that the restraints are not causing injury to the client C. Applying restraints based solely on assessment findings and not on attitude toward the client D. Releasing the client when stated behavioral control is achieved

ANS: B. Assuring that the restraints are not causing injury to the client

A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse? A. The client is entitled to have a relationship with anyone and the nurse should ignore the behavior. B. In order to protect the rights of the client, the nurse should report the behavior to the supervisor. C. The nurse should confront the nurse and tell them the behavior must immediately stop. D. Discuss this with the client and tell them they are being emotionally manipulated.

ANS: B. In order to protect the rights of the client, the nurse should report the behavior to the supervisor.

A nurse in the emergency department is planning for a client with mental illness to be placed in an inpatient hospitalization. Which is a criterion assessed by the nurse is condition of this type of admission? A. Nonadherence with medication administration at home B. Presents a clear danger to self or others C. Develops new symptoms of the illness D. Has no support systems in the community

ANS: B. Presents a clear danger to self or others

A malpractice lawsuit was filed after a nurse restrained a client for screaming at and attempting to strike anyone who was within striking distance. The nurse followed agency procedures that were consistent with Joint Commission Standards. For which reason is this malpractice lawsuit most likely to be unsuccessful? A. The nurse did not have a duty. B. The nurse did not breach duty. C. The client did not suffer some type of loss, damage, or injury. D. There was no evidence that a breach of duty was a direct cause of the loss, damage, or injury.

ANS: B. The nurse did not breach duty.

A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client? A. The nurse pushes the client, and the client falls to the floor and sustains a nosebleed. B. The nurse goes to the client's room and applies restraints, then forces the medication in the client's mouth. C. The nurse throws the medication in the trash and documents the client refuses the medication. D. The nurse informs the client that the behavior will not be tolerated and will be addressed by the psychiatrist.

ANS: B. The nurse goes to the client's room and applies restraints, then forces the medication in the client's mouth.

The nurse is working on the behavioral health unit caring for several clients. Which client situation indicates that the client is being falsely imprisoned? A. A client is confused, combative, and insists they will not be stopped from leaving. The nurse restrains the client and then seeks the order. B. When the client exhibits attention seeking behaviors, the nurse informs the client they will have to stay in their room or be restrained. C. A client with psychosis attempts to leave the unit, and the nurse escorts the client back to the unit. D. An involuntarily admitted client is brought back to the unit by security when locking themselves in the bathroom.

ANS: B. When the client exhibits attention seeking behaviors, the nurse informs the client they will have to stay in their room or be restrained.

A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and killing themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice? A. Call security and ask them to detain the client from leaving B. Allow the client to leave with a referral to community resources for follow-up care C. Contact the psychiatrist for initiation of commitment proceedings D. Contact the client's family to request they convince the client to stay

ANS: C. Contact the psychiatrist for initiation of commitment proceedings

The nurse is working in the Emergency Department and caring for several clients. Which client situation will require the nurse to break confidentiality and warn a third party? A. An abused client states, "I have dreams that they are dead." B. A client states, "Sometimes I feel like killing my kids!" C. A paranoid client states, "I'll get them before they get me." D. A jealous client states, "I am getting my gun and going to shoot my spouse's lover!"

ANS: D. A jealous client states, "I am getting my gun and going to shoot my spouse's lover!"

A nurse is assigned to administer oral medications to a client. Which actions will the nurse take if a client refuses to take prescribed oral medications? A. Inform the client that the nurse will get reprimanded for not administering the medication. B. Inform the client that refusal is not permitted and it is required that the client take the medication. C. Document the client's refusal on the medication administration record without comment. D. Ask the client's reason for refusing and report it to the health care provider.

ANS: D. Ask the client's reason for refusing and report it to the health care provider.

The client is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Ensuring that the client has provided informed consent for a treatment regimen displays which ethical principle? A. Fidelity B. Nonmaleficence C. Justice D. Autonomy

ANS: D. Autonomy

A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate? A. Inform the client that without the medications, their mental status will not improve. B. Prepare discharge paperwork since the client is refusing assistance. C. Inform the client that a family member will be called to see if they can help. D. Set clear boundaries for behavior and allow the refusal of medication

ANS: D. Set clear boundaries for behavior and allow the refusal of medication

The client feels that their rights have been violated when being placed in restraints after an incident involving a physical altercation with another client. Which action by the nurse is violating the client's rights? A. The right to receive confidential and respectful care B. The right to provide informed consent C. The right to be treated in a timely manner D. The right to receive treatment in the least restrictive environment

ANS: D. The right to receive treatment in the least restrictive environment