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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.
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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.
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 situations qualify as abandonment on the part of a nurse?
- A. The nurse allows a patient with acute mania to refuse hospitalization without taking further action.
- B. The nurse terminates employment without referring a seriously mentally ill patient for aftercare.
- C. The nurse calls police to bring a suicidal patient to the hospital after a suicide attempt.
- D. The nurse refers a patient with persistent paranoid schizophrenia to community treatment.
- E. The nurse asks another nurse to provide a patient's care because of concerns about countertransference.
Correct Answer: A,B
Rationale: Failing to ensure continued care for acutely ill patients constitutes abandonment. Other actions provide for patient safety or self-awareness.
How does a psychiatric nurse best implement the ethical principle of autonomy?
- A. By intervening when a self-mutilating patient attempts to harm self.
- B. Staying with a patient who is demonstrating a high level of anxiety
- C. Suggesting that two patients who are fighting be restricted to the unit.
- D. Exploring alternative options with a patient, regarding medications.
Correct Answer: D
Rationale: Exploring options with the patient supports autonomy by enabling informed, self-determined decisions. Intervening with self-mutilation or staying with an anxious patient reflects beneficence and fidelity, while restricting fighting patients aligns with fidelity and justice.
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.