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A patient being treated in an alcohol rehabilitation unit reveals to the nurse, 'I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted.' Based on state and federal law, what action is the nurse expected to take?
- A. Anonymously report the abuse by telephone to the local child abuse hotline.
- B. Replying, 'I'm glad you feel comfortable talking to me about it.'
- C. Respecting the nurse-patient relationship of confidentiality.
- D. Filing a written report on the agency letterhead.
Correct Answer: A
Rationale: Federal law allows anonymous reporting of child abuse in treatment settings, balancing confidentiality and legal obligations.
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A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance?
- A. Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5)
- B. State's nurse practice act
- C. State and federal regulations that govern hospitals
- D. Summary of common practices of several local hospitals
- E. American Nurses Association Scope and Standards of Practice
Correct Answer: C,E
Rationale: Hospital regulations set minimum standards, and ANA standards elevate practice. DSM-5 and nurse practice acts are irrelevant, and local practices may not comply with best standards.
After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, 'Please document the administration of the medication I forgot to do. My password is alphal.' What action should the on-duty nurse take?
- A. Suggest the nurse return and document.
- B. Refer the matter to the charge nurse to resolve.
- C. Access the record and document the information.
- D. Report the request to the patient's health care provider.
Correct Answer: B
Rationale: Referring to the charge nurse ensures policy compliance and proper documentation without risking unauthorized access.
A nurse's neighbor asks, 'Why aren't people with mental illness kept in state institutions anymore?' What is the nurse's best response?
- A. Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent.'
- B. Less restrictive settings are now available to care for individuals with mental illness.'
- C. Our nation has fewer persons with mental illness; therefore, fewer hospital beds are needed.'
- D. Psychiatric institutions are no longer popular as a consequence of negative stories in the press.'
Correct Answer: B
Rationale: Community-based, less restrictive settings are preferred for mental health care, reducing institutionalization. The other options perpetuate stigma or are factually incorrect.
A patient diagnosed with mental illness asks a psychiatric technician, 'What's the matter with me?' The technician replies, 'Your wing nuts need tightening.' The nurse who overheard the exchange should take action based on what principle?
- A. Violation of the patient's right to be treated with dignity and respect
- B. The nurse's obligation to report caregiver negligence
- C. Preventing defamation of the patient's character
- D. Supervisory liability
Correct Answer: A
Rationale: The technician's response violates the patient's right to respectful treatment, constituting emotional abuse.
Which individual diagnosed with a mental illness may need emergency or involuntary hospitalization for mental illness?
- A. The patient who resumes using heroin while still taking methadone.
- B. The patient who reports hearing angels playing harps during thunderstorms.
- C. The patient who throws a heavy plate at a waiter at the direction of command hallucinations.
- D. The patient who does not show up for an outpatient appointment with the mental health nurse.
Correct Answer: C
Rationale: Throwing a plate due to hallucinations indicates danger to others, justifying involuntary hospitalization.