Ethics in Community Health Nursing Practice

1. When and by whom was nursing’s first code of ethics written?

a.
1893, by Lystra Gretter
b.
1950, by the ANA House of Delegates
c.
1953, by the International Council of Nurses (ICN)
d.
2001, by the ANA House of Delegates

ANS: A

The Nightingale Pledge, considered nursing’s first code of ethics, was written by Lystra Gretter in 1893.

DIF: Cognitive Level: Remember (Knowledge) REF: p. 53

2. A nurse didn’t know what to do when faced with a particular ethical dilemma because an option that would have a good outcome didn’t seem possible. The nurse decided to talk to the agency supervisor and decide what action to take. Which of the following best describes the nurse’s actions?

a.
Appropriate, because the supervisor is responsible for the nurse’s choices
b.
Intelligent, because the supervisor has access to resource persons (clergy, physicians, administrators) who might know of options the nurse hadn’t considered
c.
Justified, because this provides an opportunity to discuss the issue but the nurse maintains responsibility for the decision
d.
Wise, because the supervisor would be more knowledgeable concerning agency priorities and traditional practices

ANS: C

Ethically, each nurse is responsible for his or her own decisions and cannot avoid ethical accountability by relying on obedience to a supervisor or any external rule or policy.

DIF: Cognitive Level: Apply (Application) REF: p. 54

3. Which of the following is the first and most crucial step in the ethical decision-making process?

a.
Assess the context or environment in which the decision must be made.
b.
Consider the various ethical principles or theories.
c.
Identify the ethical concerns.
d.
Make a decision and act on it.

ANS: C

The first step in the ethical decision-making framework is to carefully identify the ethical issue or dilemma.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 54

4. A nurse is asked to meet with a family who recently emigrated from Botswana (Africa). After the clinical doctor tells the husband the wife’s diagnosis of breast cancer, the family thanks the physician and starts to leave. Ethically, which of the following is the nurse’s most important action?

a.
Emphasizing that the family must set up a surgical appointment for the wife immediately
b.
Assessing the family’s current living situation, including insurance and other assets
c.
Educating the family concerning the usual treatment and the prognosis of breast cancer
d.
Interviewing the family concerning their perspective of the threat to the family’s well-being

ANS: D

Any of the actions might be taken. However, the United States is a multicultural nation with diverse ethnic groups and diverse values. Before any intervention can be made, the health care professionals must understand the family’s cultural, psychological, social, communal, and environmental contexts, because these contexts affect the way issues are formulated and decisions are made. Consequently, it is crucial to interview the family to determine their understanding of the situation before deciding what, if any, intervention must be made. In many cultures the family, rather than the individual, is the unit of primary concern.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 54

5. The nurse learns that a family has decided not to accept medical intervention for a health care problem because paying for the care would drastically reduce the family’s resources and ability to meet the needs of other family members. Ethically, which of the following actions should be taken by the nurse?

a.
Appreciate that the family has made the decision that it feels is best and take no further action if it is clear the family has made an informed choice.
b.
Stress that each individual in society has a right to health care and the family will have to create some way to raise funds for the needed treatment.
c.
Talk to the media to see whether a campaign to raise funds for the family can be created.
d.
Try to convince the agency to give the care for free, even if it means economic stress for the agency, because the medical need is obvious.

ANS: A

As Callahan described, although the nurse may attempt moral persuasion to change the family’s values, in the absence of immediate and grievous harm, no ethical requirement exists to interfere with the family’s values.

DIF: Cognitive Level: Apply (Application) REF: p. 54

6. Some nurses are debating about the appropriate action to take in relation to a particular family. The father is ill, and the other family members have chosen to continue working rather than take time off to care for the ill family member. One nurse states, “It is a wife’s responsibility to care for an ill husband.” Which of the following ethical approaches is being used by this nurse?

a.
Consequentialism
b.
Communitarianism
c.
Deontological ethics
d.
Principlism

ANS: C

The nurse is focusing on duty, which is a deontological approach based on the moral obligation to engage in certain actions.

DIF: Cognitive Level: Apply (Application) REF: p. 55

7. Some nurses are debating about the appropriate action to take in relation to a particular family. One member of the family is ill, and the other family members have chosen to continue working rather than take time off to care for the ill family member. One nurse states, “The whole family is being affected and will fall apart if they don’t focus on their family’s needs first before anything else.” Which of the following ethical approaches is being used by this nurse?

a.
Communitarianism
b.
Deontological ethics
c.
Principlism
d.
Utilitarianism

ANS: D

By focusing on the whole family, not individual members, and the consequences or outcomes for the whole family during this time of stress, the nurse is taking a utilitarian approach.

DIF: Cognitive Level: Apply (Application) REF: p. 55

8. Some nurses are debating about the appropriate action to take in relation to a particular family. One member of the family is ill, and the other family members have chosen to continue working rather than take time off to care for the ill family member. One nurse states, “But it doesn’t have to be an either/or situation. Perhaps each family member could take a turn calling in sick just 2 or 3 days. That way they could all take a turn at helping and yet not upset their employers. Wouldn’t that be fair?” Which of the following ethical approaches is being used by this nurse?

a.
Communitarianism
b.
Deontological ethics
c.
Principlism
d.
Utilitarianism

ANS: C

The nurse is focusing on ethical principles—in this case, beneficence (do good for the ill family member), nonmaleficence (do no harm, even to the employer), and justice (everyone takes a turn and shares equally).

DIF: Cognitive Level: Apply (Application) REF: p. 56

9. Some nurses are debating about the appropriate action to take in relation to a particular family. One member of the family is ill, and the other family members have chosen to continue working rather than take time off to care for the ill family member. One nurse states, “It’s not up to us; it’s the family’s decision. They know what is best for them.” Which of the following ethical approaches is being used by this nurse?

a.
Communitarianism
b.
Deontological ethics
c.
Principlism
d.
Utilitarianism

ANS: C

The nurse is using an ethical principle, namely autonomy, in which each person or group can choose those actions that fulfill its values and goals. Therefore, the nurse is using principlism—that is, basic principles are the basis of the nurse’s actions.

DIF: Cognitive Level: Apply (Application) REF: p. 56

10. Which of the following is the dominant issue in ethical debate around an issue such as continuing or withdrawing treatment in acute health care?

a.
Doing what is best for the community
b.
Doing what is best for the family
c.
Obeying legal mandates
d.
Upholding ethical principles

ANS: D

In acute care settings with a single localized issue, the primary ethical principles are usually applied, with patient autonomy being the dominant or most crucial principle.

DIF: Cognitive Level: Understand (Comprehension) REF: pp. 56-57

11. The staff cannot reach an agreement on what is the right thing to do in relation to a specific patient. Which of the following approaches should the nurse use in personally deciding what is right?

a.
Do whatever will not get the nurse in trouble with employer
b.
Do whatever is supported by an ethical expert, such as the hospital chaplain
c.
Do whatever the nurse would recommend to anyone in a similar situation
d.
Do whatever the nurse supervisor would feel comfortable reporting to administration

ANS: C

One of the rules in deontological decision making is to determine whether the proposed actions can be generalized so that all persons in similar situations are treated similarly. In the same way, principlism suggests the nurse examine the context and make the decision that can be morally justified within that context.

DIF: Cognitive Level: Apply (Application) REF: p. 55

12. A man entered the emergency department bleeding profusely and screaming, “I’ve got to see a doctor right now! I’ve got a right to see a doctor! I’m hurt. You have to take care of me!” Which of the following premises would ethically justify such a demand for immediate attention?

a.
All hospitals receive federal money and all capable employed adults pay taxes, so all adults have a right to what their tax money has purchased.
b.
Saving an individual’s life improves society and upholds tradition.
c.
Our society believes that all persons should be treated equally and that basic needs, such as not dying if death can be avoided, should be met.
d.
The man has a property right to his own body, and the government is responsible to ensure that property rights are protected.

ANS: C

The ethical theory of egalitarianism suggests that everyone is entitled to equal rights, equal treatment, and an equal share of the goods of society—and that the government’s role is to ensure this happens, at least on a basic level. Therefore, the man has a right to emergency care.

DIF: Cognitive Level: Apply (Application) REF: p. 57

13. From an ethical standpoint, what is the problem with the belief that everyone should receive his or her fair share, that life should always be fair, and that everyone should make his or her own decisions?

a.
With this belief, the needs of society as a whole are ignored.
b.
Insufficient resources exist to give everyone a fair share.
c.
This belief leads to a propensity for some people to like to be taken care of.
d.
Some people think they deserve more than their fair share.

ANS: A

All principles of justice focus on the individual, which ignores the needs of society as a whole. Indeed, the rights of an individual may conflict with the rights of the community as a whole.

DIF: Cognitive Level: Apply (Application) REF: p. 57

14. A physician refuses to order pain medication for a drug addict who has been severely injured in a car accident. When reminded by nurses that pain medication has not been ordered, the physician merely replies that the patient’s suffering from the pain of his injuries will build character and that the addicted patient needs to get off drugs. Which of the following ethical theories is the physician using (or misusing)?

a.
Consequentialism
b.
Communitarianism
c.
Deontological ethics
d.
Virtue ethics

ANS: D

Virtue ethics emphasizes practical reasoning applied to character development. Although such action by a care provider is paternalistic and unethical on many grounds, the physician may truly be concerned with enabling the injured addict to learn from his experience and possibly develop into a drug-free person.

DIF: Cognitive Level: Apply (Application) REF: p. 58

15. Which of the following is considered the most important goal in nursing today?

a.
Adapting to technological advances such as electronic medical records
b.
Demonstrating caring as the basis of nursing practice
c.
Distinguishing nursing care from medical care
d.
Seeking evidence-based outcomes to demonstrate nursing’s contribution to care

ANS: B

Since the mid-1980s, nurses have written about caring as the essence of nursing and as the ethical and moral ideal of nursing practice.

DIF: Cognitive Level: Remember (Knowledge) REF: p. 58

16. With which of the following ethical approaches are Gilligan and Noddings associated?

a.
Distributive justice approach
b.
Feminine ethic
c.
Principled approach
d.
Virtue ethics

ANS: B

Gilligan and Noddings are associated with the approach known as the feminine ethic, which focuses on the morality of responsibility in relationships that emphasize connection and caring as a moral imperative.

DIF: Cognitive Level: Remember (Knowledge) REF: pp. 58-59

17. How are ethics and public policies similar?

a.
Both are abstract principles that often differ in actual practice.
b.
Both are best achieved by persons in high political office who can effect change.
c.
Both strive for the public good.
d.
Both use general principles in making decisions.

ANS: C

An important goal of both policy and ethics is to achieve the public good, and both are involved in good citizenship.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 60

18. A new nurse states to a nursing colleague, “But why do I have to be involved in politics? I just want to be the very best clinical nurse I can.” Which of the following would be the best response from the nursing colleague?

a.
“As long as you pay your membership fee to the American Nurses Association, you have participated in the profession’s political endeavors.”
b.
“Political action is the way you try to fulfill your ethical responsibilities to clients.”
c.
“You’re absolutely right; if you are good clinically, you have fulfilled your obligation.”
d.
“When you’ve completed your clinical orientation, then you’ll have time to be involved in politics.”

ANS: B

To be a good clinical nurse, the nurse needs resources and supportive policies that can be obtained only through political action to ensure those very resources and policies. Many clients are members of vulnerable groups who have often previously lacked access to quality care at an affordable cost. The American Nurses Association Code of Ethics for Nurses emphasizes political action as the mechanism to effect social justice and reform regarding homelessness, violence, and stigmatization.

DIF: Cognitive Level: Apply (Application) REF: p. 62

19. Which of the following would confirm that the nurse’s advocacy has been truly successful or effective?

a.
Audiences agree with the nurse who is serving as advocate.
b.
Legislators discuss appropriate legislation to better allocate resources.
c.
People verbalize that the disenfranchised should be better treated.
d.
Systematic social changes are made to improve quality of life.

ANS: D

Advocacy is the application of information and resources to effect systematic changes that shape the way people in a community live to reduce death and disability and improve quality of life in the community. Although all of these options could be seen as beneficial, only when systematic social changes are made to improve quality of life can advocacy be considered truly effective.

DIF: Cognitive Level: Apply (Application) REF: p. 63

20. How can nurses know whether they have been effective in assessing the community and planning and implementing appropriate interventions?

a.
Ask community leaders for their opinion of the interventions.
b.
Examine the morbidity and mortality rate of the community.
c.
Reassess the community to determine whether obvious needs have been met.
d.
Systematically survey community residents regarding their perception.

ANS: B

Although all these options might be useful, the end products of appropriate advocacy are decreased morbidity and mortality. In other words, if advocacy has been effective, public health problems will be decreased.

DIF: Cognitive Level: Apply (Application) REF: p. 63

21. What is the relationship between ethics and a community health nursing practice?

a.
Ethics and actual nursing practice are not related.
b.
Knowing ethics allows nurse to recognize the source of most problems.
c.
Ethics is constantly involved in nurses’ clinical decisions.
d.
Although ethics is important, political and legal responsibilities are more important in practice.

ANS: C

Ethical problems in public health nursing include inequities in power, unacceptable practices, inequitable resource allocation, conflict between ethics and law, and inadequate systems support for nursing. Therefore, ethics permeates every aspect of public health nursing as nurses attempt to meet the needs of the community.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 52

MULTIPLE RESPONSE

1. Three nurses disagree over the appropriate treatment for a woman who is an excellent candidate for hospice care. The first nurse believes that deciding on care rather than cure is the woman’s decision and no one else can decide for her. The second nurse says that it is the responsibility of the health care team to do good for the woman, and if the physician thinks there is still a possibility of cure, then the nurses should do everything they can to implement the treatment plan. The third nurse states that it isn’t fair for the family members to expend all their resources on the woman, who is probably going to die anyway. Which of the following conclusions can be drawn from this dispute? (Select all that apply.)

a.
Ethical principles can conflict with one another.
b.
The nurses are each using different ethical approaches.
c.
The first nurse is correct because autonomy demands that the woman decide for herself.
d.
There is no single accepted approach for resolving such disagreements.

ANS: A, D

One of the criticisms of using ethical principles is that they can conflict with one another in any given situation. No rule exists for helping resolve such conflicts.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 56