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In which situations does a nurse have a duty to intervene and report?
- A. A peer is unable to write behavioral outcomes.
- B. A health care provider consults the Physicians' Desk Reference.
- C. A peer tries to provide patient care in an alcohol-impaired state.
- D. A team member has violated the boundaries of a vulnerable patient.
- E. A patient refuses a medication prescribed by a licensed health care provider.
Correct Answer: C,D
Rationale: Impaired care and boundary violations jeopardize safety, requiring intervention. Other situations are less critical or acceptable.
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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 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. A nurse rushes after the patient and convinces the patient to return to the unit.
- D. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team uses established protocols to prevent the patient from leaving.
Correct Answer: B
Rationale: Threatening seclusion without justification creates fear of confinement, constituting false imprisonment. The other scenarios involve justified actions for patient safety or incompetence.
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.
Which scenario is an example of a tort?
- A. The primary nurse completes the plan of care for a patient but takes a full 24 hours after the admission to do so.
- B. An advanced practice nurse recommends that a patient who has a history of danger to self and others be voluntarily hospitalized when reporting audio hallucinations.
- C. A patient's admission status is changed from involuntary to voluntary after the patient's hallucinations subside after medication is started.
- D. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent any possible violence because the unit is short staffed.
Correct Answer: D
Rationale: Giving unnecessary medication for staff convenience is a tort, akin to false imprisonment, violating patient rights. The other scenarios do not involve rights violations.
The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will 'never get any treatment.' Which reply by the nurse would be most helpful?
- A. Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights.'
- B. That's a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety.'
- C. 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.'
- D. All patients in public hospitals have the right to choose both a primary therapist and a primary nurse.'
Correct Answer: A
Rationale: The 1964 Hospitalization of Mentally Ill Act ensures treatment rights in public hospitals, reassuring the family.
A patient diagnosed with schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. What principle governs the proper action in this situation?
- A. Need for authorization
- B. Duty to warn and protect
- C. Patient right to confidentiality
- D. Patient's right to self-actualization
Correct Answer: B
Rationale: The duty to warn protects potential victims, overriding confidentiality when threats are made.