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An adolescent hospitalized after a violent physical outburst tells the nurse, 'I'm going to kill my father, but I know you can't tell anyone.' What is the nurse's best response?
- A. You're right. Federal law requires me to keep that information private.'
- B. Those kinds of thoughts will make your hospitalization even longer.'
- C. You really should share these kinds of thoughts with your psychiatrist.'
- D. I am required to share information like this with your treatment team.'
Correct Answer: D
Rationale: Threats of harm must be shared with the treatment team to ensure safety, overriding confidentiality.
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Two hospitalized patients resort to physical fighting when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. Which does this assertion indicate about the nurse who presented it?
- A. Reveals that the nurse has a strong sense of justice.
- B. Values the reinforcement of the autonomy of the two patients.
- C. Has a poor understanding of the civil rights of the two patients.
- D. Doesn't understand the actions that constitute the intentional tort of battery.
Correct Answer: C
Rationale: The nurse's suggestion of seclusion ignores the right to the least restrictive treatment, indicating a poor understanding of civil rights. Seclusion removes autonomy, is motivated by beneficence, not justice, and risks false imprisonment, not battery.
A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care?
- A. Health care provider
- B. Profession
- C. Hospital
- D. Patient
Correct Answer: D
Rationale: The primary duty of care is owed to the patient, despite accountability to others.
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.
A voluntarily hospitalized patient tells the nurse, 'Get me the forms I need to sign so I can leave this place now.' What is the nurse's best initial response?
- A. I can't give you those forms without your health care provider's knowledge.'
- B. I will get them for you, but let's talk about your decision to leave treatment.'
- C. Since you signed your consent for treatment, you may leave if you desire.'
- D. I'll get the forms for you right now and bring them to your room.'
Correct Answer: B
Rationale: Discussing the decision respects patient rights while advocating for their best interests. Immediate discharge without exploration may neglect underlying issues.
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 and more cooperative. Participated actively in group. No evidence of psychotic thinking.
- C. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others
- D. Wears four layers of clothing. States, 'I need protection from dangerous bacteria trying to penetrate my skin.'
Correct Answer: D
Rationale: Specific observations and direct quotes provide clear, objective documentation, unlike vague or subjective options.