Legal and Ethical Basis for Practice

MULTIPLE CHOICE

1. A psychiatric nurse best implements the ethical principle of autonomy when he or she:
a. intervenes when a self-mutilating patient attempts to harm self.
b. stays with a patient who is demonstrating a high level of anxiety.
c. suggests that two patients who are fighting be restricted to the unit.
d. explores alternative solutions with a patient, who then makes a choice.
ANS: D
Autonomy is the right to self-determination, that is, to make one’s own decisions. When the nurse explores alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. Staying with a highly anxious patient or intervening with a self-mutilating patient demonstrates beneficence and fidelity. Suggesting that two fighting patients be restricted to the unit demonstrates the principles of fidelity and justice.

DIF: Cognitive Level: Application (Applying) REF: Page: 80 | Pages: 82-84
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

2. Which action by a psychiatric nurse best supports a patient’s right to be treated with dignity and respect?
a. Consistently addressing a patient by title and surname.
b. Strongly encouraging a patient to participate in the unit milieu.
c. Discussing a patient’s condition with another health care provider in the elevator.
d. Informing a treatment team that a patient is too drowsy to participate in care planning.
ANS: A
A simple way of showing respect is to address the patient by title and surname rather than assuming that the patient would wish to be called by his or her first name. Discussing a patient’s condition with a health care provider in the elevator violates confidentiality. Informing a treatment team that the patient is too drowsy to participate in care planning violates patient autonomy. Encouraging a patient to participate in the unit milieu exemplifies beneficence and fidelity.

DIF: Cognitive Level: Application (Applying) REF: Page: 85
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

3. Two hospitalized patients fight 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. This assertion:
a. reveals that the nurse values the principle of justice.
b. reinforces the autonomy of the two patients.
c. violates the civil rights of the two patients.
d. represents the intentional tort of battery.
ANS: C
Patients have a right to treatment in the least restrictive setting. Less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion removes the patient’s autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment, not battery.

DIF: Cognitive Level: Application (Applying) REF: Pages: 84-85
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

4. In a team meeting a nurse says, “I’m concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision.” Which ethical principle most clearly applies to this situation?
a. Beneficence
b. Autonomy
c. Fidelity
d. Justice
ANS: D
The nurse is concerned about justice, that is, the fair treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one’s own decisions. Fidelity is the observance of loyalty and commitment to the patient.

DIF: Cognitive Level: Application (Applying) REF: Page: 80
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

5. Which scenario is an example of a tort?
a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient’s admission.
b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized.
c. A patient’s admission status is changed from involuntary to voluntary after the patient’s hallucinations subside.
d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violence because a unit is short staffed.
ANS: D
A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff members controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify torts.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 87-88
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment

6. 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.”
ANS: B
The community is a less restrictive alternative than hospitals for the treatment of people with mental illness. The remaining options are incorrect and part of the stigma of mental illness.

DIF: Cognitive Level: Application (Applying) REF: Pages: 80-81
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

7. 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 patient has been irritating, seeking the attention of nurses most of the day. Now 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 and uses established protocols to prevent the patient from leaving.
ANS: B
False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. The patient in one distractor is not competent, and the nurse is acting beneficently. The patients in the other distractors have been admitted as involuntary patients and should not be allowed to leave without permission of the treatment team.

DIF: Cognitive Level: Application (Applying) REF: Pages: 84-85 | Page: 88
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment

8. A patient should be considered for involuntary commitment for psychiatric care when he or she:
a. is noncompliant with the treatment regimen.
b. sells and distributes illegal drugs.
c. threatens to harm self and others.
d. fraudulently files for bankruptcy.
ANS: C
Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 81-82
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

9. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, “Stop! I don’t want to take that medicine anymore. I hate the side effects.” Select the nurse’s best initial action.
a. Stop the medication administration procedure and say to the patient, “Tell me more about the side effects you’ve been having.”
b. Say to the patient, “Since I’ve already drawn the medication in the syringe, I’m required to give it, but let’s talk to the doctor about skipping next month’s dose.”
c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects.
d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary.
ANS: A
Patients with mental illness retain their civil rights unless clear, cogent, and convincing evidence of dangerousness exists. The patient in this situation presents no evidence of being dangerous. The nurse, an as advocate and educator, should seek more information about the patient’s decision and should not force the medication.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 83 | Page: 88
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

10. Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice?
a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care.
b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care.
c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises.
d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.
ANS: A
Nurses are professionally bound to uphold the American Nurses Association (ANA) standards of practice, regardless of lesser standards established by a health care agency or state. Conversely, if the agency standards are higher than the ANA standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded.

DIF: Cognitive Level: Application (Applying) REF: Page: 89
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

11. 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
ANS: D
Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient.

DIF: Cognitive Level: Application (Applying) REF: Page: 80 | Page: 89
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

12. An example of a breach of a patient’s right to privacy occurs when a nurse:
a. asks a family to share information about a patient’s prehospitalization behavior.
b. discusses the patient’s history with other staff members during care planning.
c. documents the patient’s daily behaviors during hospitalization.
d. releases information to the patient’s employer without consent.
ANS: D
The release of information without patient authorization violates the patient’s right to privacy. The other options are acceptable nursing practices.

DIF: Cognitive Level: Application (Applying) REF: Pages: 85-86 | Page: 88
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

13. An adolescent hospitalized after a violent physical outburst tells the nurse, “I’m going to kill my father, but you can’t tell anyone.” Select 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 longer.”
c. “You really should share this thought with your psychiatrist.”
d. “I am required to share information with the treatment team.”
ANS: D
Breach of nurse-patient confidentiality does not pose a legal dilemma for the nurse in this circumstance because a team approach to the delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the father of the risk for harm.

DIF: Cognitive Level: Application (Applying) REF: Pages: 86-87
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

14. A voluntarily hospitalized patient tells the nurse, “Get me the forms for discharge against medical advice so I can leave 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.”
ANS: B
A patient who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient’s wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. The statement that discharge forms cannot be given without the health care provider’s knowledge is not true. Facilitating discharge without consent is not in the patient’s best interest before exploring the reason for the request.

DIF: Cognitive Level: Application (Applying) REF: Page: 83
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

15. 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.”
ANS: A
The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals with the enactment of the federal Hospitalization of Mentally Ill Act in 1964. Stating that the concern is justifiable supports the family’s erroneous belief. The provisions mentioned in the third and fourth options are not part of this or any other statute governing psychiatric care.

DIF: Cognitive Level: Application (Applying) REF: Pages: 83-84
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

16. Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who:
a. resumes using heroin while still taking methadone.
b. reports hearing angels playing harps during thunderstorms.
c. throws a heavy plate at a waiter at the direction of command hallucinations.
d. does not show up for an outpatient appointment with the mental health nurse.
ANS: C
Throwing a heavy plate is likely to harm the waiter and is evidence of being dangerous to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness.

DIF: Cognitive Level: Application (Applying) REF: Pages: 81-82
TOP: Nursing Process: Analysis| Nursing Process: Diagnosis
MSC: NCLEX: Safe, Effective Care Environment

17. 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, the best action for the nurse to take is to:
a. anonymously report the abuse by telephone to the local child abuse hotline.
b. reply, “I’m glad you feel comfortable talking to me about it.”
c. respect the nurse-patient relationship of confidentiality.
d. file a written report on the agency letterhead.
ANS: A
Laws regarding reporting child abuse discovered by a professional during a suspected abuser’s alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility. Anonymously reporting the abuse by telephone to the local child abuse hotline meets federal criteria. Respecting nurse-patient confidentiality and replying “I’m glad you feel comfortable talking to me about it” do not accomplish reporting. Filing a written report on agency letterhead violates federal law.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 86-87
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

18. The spouse of a patient who has delusions asks the nurse, “Are there any circumstances under which the treatment team is justified in violating the patient’s right to confidentiality?” The nurse must reply that confidentiality may be breached:
a. under no circumstances.
b. at the discretion of the psychiatrist.
c. when questions are asked by law enforcement.
d. if the patient threatens the life of another person.
ANS: D
The duty to warn a person whose life has been threatened by a patient under psychiatric treatment overrides the patient’s right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 85-87
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

19. A nurse cares for an older adult patient admitted for treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should:
a. implement the order.
b. consult a drug reference.
c. give the usual geriatric dosage.
d. hold the medication and consult the health care provider.
ANS: D
The dose of an antidepressant medication for older adult patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse’s duty is to intervene and protect the patient. Consulting a drug reference is unnecessary because the nurse already knows the dose is excessive. Implementing the order is negligent. Giving the usual geriatric dose would be wrong; a nurse without prescriptive privileges cannot change the dose.

DIF: Cognitive Level: Application (Applying) REF: Pages: 88-89
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

20. A patient diagnosed with schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has:
a. released information without proper authorization.
b. demonstrated the duty to warn and protect.
c. violated the patient’s confidentiality.
d. avoided charges of malpractice.
ANS: B
The duty of a health care professional is to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional and not considered a violation of confidentiality.

DIF: Cognitive Level: Application (Applying) REF: Pages: 86-87 | Page: 90
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

21. 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 alpha1.” The nurse should:
a. fulfill the request.
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.
ANS: B
At most hospitals, termination is a possible penalty for unauthorized entry into a patient record. Referring the matter to the charge nurse will allow the observance of hospital policy while ensuring that documentation occurs. Making an exception and fulfilling the request places the on-duty staff nurse in jeopardy. Reporting the request to the patient’s health care provider would be unnecessary. Accessing the record and documenting the information would be unnecessary when the charge nurse can resolve the problem.

DIF: Cognitive Level: Application (Applying) REF: Page: 89 | Pages: 91-92
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

22. 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:
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.
ANS: A
Patients have the right to be treated with dignity and respect. Patients should never be made the butt of jokes about their illness. Patient emotional abuse has been demonstrated, not negligence. The technician’s response was not clearly defamation. Patient abuse, not supervisory liability, is the issue.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 85
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

23. 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.”
ANS: D
The documentation states specific observations of the patient’s appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways.

DIF: Cognitive Level: Application (Applying) REF: Pages: 91-92
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

1. A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? Select all that apply.
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 for Psychiatric–Mental Health Nursing
ANS: C, E
Regulations regarding hospitals provide information about the minimal standard. The American Nurses Association (ANA) national standards focus on elevating practice by setting high standards for nursing practice. The DSM-5 and the state’s nurse practice act would not provide relevant information. A summary of common practices of several local hospitals cannot be guaranteed to be helpful because the customs may or may not comply with laws or best practices.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 82-85 | Page: 89
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

2. In which situations does a nurse have a duty to intervene and report? Select all that apply.
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.
ANS: C, D
Both instances jeopardize patient safety. The nurse must practice within the Code of Ethics for Nurses. A peer being unable to write behavioral outcomes is a concern but can be informally resolved. A health care provider consulting the Physicians’ Desk Reference is acceptable practice.

DIF: Cognitive Level: Application (Applying) REF: Page: 85 | Pages: 89-90
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment

3. Which situations qualify as abandonment on the part of a nurse? (Select all that apply.) The nurse:
a. allows a patient with acute mania to refuse hospitalization without taking further action.
b. terminates employment without referring a seriously mentally ill for aftercare.
c. calls police to bring a suicidal patient to the hospital after a suicide attempt.
d. refers a patient with persistent paranoid schizophrenia to community treatment.
e. asks another nurse to provide a patient’s care because of concerns about countertransference.
ANS: A, B
Abandonment arises when a nurse does not place a patient safely in the hands of another health professional before discontinuing treatment. Calling the police to bring a suicidal patient to the hospital after a suicide attempt and referring a patient with schizophrenia to community treatment both provide for patient safety. Asking another nurse to provide a patient’s care because of concerns about countertransference demonstrates self-awareness.

DIF: Cognitive Level: Application (Applying) REF: Pages: 90-91
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment