Mental Health Nursing: Ethical Dilemmas and Decision Making, Exams of Psychology

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5.1. In response to a students question regarding choosing a psychiatric specialty, a charge nurse states, Mentally ill clients need special care. If I were in that position, I'd want a caring nurse also. From which ethical framework is the charge nurse operating? A. Kantianism B. Christian ethics C. Ethical egoism D. Utilitarianism - ANSWER: B RATIONALE: The charge nurse is operating from a Christian ethics framework. A basic principle in Christian ethics is to do unto others as you would have them do unto you. Kantianism states that decisions should be based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made with a focus on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual. 5.2. During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework? A. I would want to be treated in a caring manner if I were mentally ill. B. This job will pay the bills, and the workload is light enough for me. C. I will be happy caring for the mentally ill. Working in Med/Surg kills my back.

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D. It is my duty in life to be a psychiatric nurse. It is the right thing to do.

• ANSWER: B RATIONALE: The applicants comment reflects an ethical egoism framework. This framework promotes the idea that decisions are based on what is good for the individual and may not take the needs of others into account. 5.3. Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurses coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworkers lack of involvement? A. Taking no action is still considered an action by the coworker. B. Taking no action releases the coworker from ethical responsibility. C. Taking no action is advised when potential adverse consequences are foreseen. D. Taking no action is acceptable, because the coworker is only a bystander. - ANSWER: A RATIONALE: The coworkers lack of involvement can be interpreted as an action taken. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. Although the coworker may be struggling with ethical decision making, he or she has witnessed another nurse dispensing medication outside

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of the scope of practice; therefore, from a legal perspective, this should be reported. 5.4. Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit managers policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit managers policy preserve? A. Justice B. Autonomy C. Veracity D. Beneficence - ANSWER: B RATIONALE: The unit managers policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions. 5.5. Which is an example of an intentional tort? A. A nurse fails to assess a clients obvious symptoms of neuroleptic malignant syndrome. B. A nurse physically places an irritating client in four-point restraints. C. A nurse makes a medication error and does not report the incident.

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D. A nurse gives patient information to an unauthorized person. - ANSWER: B RATIONALE: A tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. A nurse who physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort. Examples of unintentional torts are malpractice and negligence actions. 5.6. An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? A. Verbally redirect the client, and then limit one-on-one interaction. B. Involve the hospitals security division as soon as possible. C. Notify the client that documenting personal staff information is against hospital policy. D. Continue professional attempts to establish a positive working relationship with the client. - ANSWER: D RATIONALE: The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed.

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5.7. Which statement should a nurse identify as correct regarding a clients right to refuse treatment? A. Clients can refuse pharmacological but not psychological treatment. B. Clients can refuse any treatment at any time. C. Clients can refuse only electroconvulsive therapy (ECT). D. Professionals can override treatment refusal if the client is actively suicidal or homicidal. - ANSWER: D RATIONALE: The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be a danger to self or others. This situation should be treated as an emergency, and treatment may be performed without informed consent. 5.8. Which client should a nurse identify as a potential candidate for involuntarily commitment? A. A client living under a bridge in a cardboard box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can - ANSWER: B

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RATIONALE: The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is a danger to self and requires emergency treatment. 5.9. A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the clients wishes? A. When the client makes inappropriate sexual innuendos to a staff member B. When the client constantly demands inappropriate attention from the nurse C. When the client physically attacks another client after being confronted in group therapy D. When the client refuses to bathe or perform hygienic activities - ANSWER: C RATIONALE: The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making rational choices. The clients refusal to accept treatment can be challenged because the client is endangering the safety of others.

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5.10. A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? A. Refusing to give any information to the caller, citing rules of confidentiality B. Refusing to give any information to the caller by hanging up C. Affirming that the person has been seen at the facility but providing no further information D. Suggesting that the caller speak to the clients therapist - ANSWER: A RATIONALE: The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent. 5.11. A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice - ANSWER: A

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RATIONALE: The nurse should provide the information to support the clients autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent. 5.12. An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice - ANSWER: D RATIONALE: The nurse should determine that the ethical principle of justice has been violated by the physicians actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief. 5.13. Which situation contradicts the ethical principle of veracity? A. A nurse provides a client with outpatient resources to benefit recovery.

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B. A nurse refuses to give information to a physician who is not responsible for the clients care. C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. D. A nurse treats all of the clients equally regardless of illness severity. - ANSWER: C RATIONALE: The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to ones duty to always be truthful and not intentionally deceive or mislead clients. 5.14. A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? A. The client is paranoid. B. The client is 87 years old. C. The client incorrectly reports his or her spouses name, the date, and the time of day. D. The client relies on his or her spouse to interpret the information. - ANSWER: C RATIONALE: The nurse should question the validity of informed consent when the client incorrectly reports the spouses name, date, and time of

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day. This indicates that this client is disoriented and may not be competent to make informed choices. 5.15. A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? A. Allow the client to decline the medication and document. B. Tell the client that if the medication is refused, hospitalization will occur. C. Arrange with a relative to add medication to the clients morning orange juice. D. Call for help to hold the client down while the injection is administered. - ANSWER: A RATIONALE: It is ethically and legally appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The clients right to refuse treatment should be upheld unless the refusal puts the client or others in harms way. 5.16. Which situation exemplifies both assault and battery? A. The nurse becomes angry, calls the client offensive names, and withholds treatment.

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B. The nurse threatens to tie down the client and then does so against the clients wishes. C. The nurse hides the clients clothes and medicates the client to prevent elopement. D. The nurse restrains the client without just cause and communicates this to family. - ANSWER: B RATIONALE: The nurse in this situation has committed both the acts of assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent. 5.17. A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? A. The client is placed in seclusion. B. The client is placed in a geriatric chair with tray. C. The client is placed in soft Posey restraints. D. The client is monitored by an ankle bracelet. - ANSWER: D RATIONALE: The least restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified.

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5.18. A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the clients approved call list. What law has the nurse broken? A. The National Alliance for the Mentally Ill Act B. The Tarasoff Ruling C. The Health Insurance Portability and Accountability Act D. The Good Samaritan Law - ANSWER: C RATIONALE: The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client. 5.19. An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment teams next action? A. State law determines how long a psychiatric facility can hold a client. B. Federal law determines if the client is competent. C. The clients family involvement will determine if discharge is possible. D. Hospital policies will determine treatment team actions. - ANSWER: A

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RATIONALE: Most states commonly cite that in an emergency a client who is dangerous to self or others may be involuntarily hospitalized. 5.20. A client is concerned that information given to the nurse remains confidential. Which is the nurses best response? A. Your information is confidential. It will be kept just between you and me. B. I will share the information with staff members only with your approval. C. If the information impacts your care, I will need to share it with the treatment team. D. You can make the decision whether your physician needs this information or not. - ANSWER: C RATIONALE: Basic to the psychiatric clients hospitalization is his or her right to confidentiality and privacy. When admitted to an inpatient psychiatric facility, a client gives implied consent for information to be shared with health-care workers specifically involved in the clients care. 5.21. The nursing staff is discussing the concept of competency. Which information about competency should a urse recognize as true? A. Competency is determined with a clients compliance with treatment.

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B. Refusal of medication can initiate an incompetency hearing leading to forced medications. C. A competent client has the ability to make reasonable judgments and decisions. D. Competency is a medical determination made by the clients physician. - ANSWER: C RATIONALE: A competent individuals cognition is not impaired to an extent that would interfere with decision making. 5.22. A nursing instructor is presenting content on the provisions of the Nurse Practice Act as it relates to their state. Which student statement indicates a need for further instruction? A. The Nurse Practice Act provides a list of definitions of important terms, including the definition of nursing. B. The Nurse Practice Act lists education requirements for licensure and reciprocity. C. The Nurse Practice Act contains detailed statements that describe the scope of practice for registered nurses (RNs). D. The Nurse Practice Act lists the general authority and powers of the state board of nursing. - ANSWER: C The nurse practice act contains broad, not detailed, statements that describe the scope of practice for various levels of nursing (APN, RN,

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LPN), not just for the RN. This student statement indicates a need for further instruction. 5.23. Which is an accurate description of a common law? A. A common law would be invoked to deal with a nurse who, without justification, threatens a client with restraints. B. A common law would be invoked to deal with a nurse who touches a client without the clients consent. C. A common law would be invoked to deal with a hospital employee who steals drugs, hospital equipment, or both. D. A common law would be invoked to deal with a nurses refusal to provide care for a specific client. - ANSWER: D RATIONALE: Common laws apply to a body of principles that evolve from court decisions resolving various controversies. Common law may vary from state to state. Assault (threats) and battery (touch) are governed by civil law. Stealing is governed by criminal law. 5.24. The experience of being physically restrained can be traumatic. Which nursing intervention would best help the client deal with this experience? A. Administering a tranquilizing medication before applying the restraints

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B. Talking to the client at brief but regular intervals while the client is restrained C. Decreasing stimuli by leaving the client alone most of the time D. Checking on the client infrequently, in order to meet documentation requirements - ANSWER: B RATIONALE: Restraints are never to be used as punishment or for the convenience of the staff. Connecting with the client by maintaining communication during the period of restraint will help the client recognize this intervention as a therapeutic treatment versus a punishment. 5.25. There is one bed available on an inpatient psychiatric unit. For which client should a nurse advocate emergency commitment? A. An individual who is persistently mentally ill and evicted from an apartment B. An individual treated in the emergency department (ED) for generalized anxiety disorder C. An individual who is delusional and has a plan to kill his wife D. An individual who rates mood 4/10 and is participating in a no-harm safety plan - ANSWER: C RATIONALE: The criteria for involuntary emergency commitment include danger to self and/or others. Of the four clients considered, the

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client who is delusional and has a plan to kill his wife meets this criterion as a danger to others. 5.26. What is the legal significance of a nurses action when a nurse threatens a demanding client with restraints? A. The nurse can be charged with assault. B. The nurse can be charged with negligence. C. The nurse can be charged with malpractice. D. The nurse can be charged with beneficence. - ANSWER: A RATIONALE: Assault is an act that results in a persons genuine fear and apprehension that he or she will be touched without consent. 5.27. In the situation presented, which nursing intervention constitutes false imprisonment? A. The client is combative and will not redirect, stating, No one can stop me from leaving. The nurse seeks the physicians order after the client is restrained. B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion. C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return.

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D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving. - ANSWER: B RATIONALE: False imprisonment is the deliberate and unauthorized commitment of a person within fixed limits by the use of verbal or physical means. Seclusion should only be used in an emergency situation to prevent harm after least restrictive means have been unsuccessfully attempted. 5.28. After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department by police. The client threatens suicide. Which criteria would enable a physician to consider involuntary commitment? Select all that apply. A. Being dangerous to others B. Being homeless C. Being disruptive to the community D. Being gravely disabled and unable to meet basic needs E. Being suicidal - ANSWER: A, D, E RATIONALE: The physician could consider involuntary commitment when a client is being dangerous to others, is gravely disabled, or is suicidal. If the client is determined to be mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian

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or conservator. A hospital administrator may give permission for involuntary commitment when time does not permit court intervention. 21.1. A nursing instructor is teaching about recovery as it applies to mental illness. Which student statement indicates that further teaching is needed? A. The goal of recovery is improved health and wellness. B. The goal of recovery is expedient, comprehensive behavioral change. C. The goal of recovery is the ability to live a self-directed life. D. The goal of recovery is the ability to reach full potential. - ANSWER: B RATIONALE: The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery from mental health disorders and substance use disorders as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Change in recovery is not an expedient process. It occurs incrementally over time. 21.2. Which situation presents an example of the basic concept of a recovery model? A. The clients family is encouraged to make decisions in order to facilitate discharge.

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B. A social worker, discovering the clients income, changes the clients discharge placement. C. A psychiatrist prescribes an antipsychotic drug on the basis of observed symptoms. D. A client diagnosed with schizophrenia schedules follow-up appointments and group therapy. - ANSWER: D RATIONALE: The basic concept of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care. 21.3. A nursing instructor is teaching about the guiding principles of the recovery model, as described by the SAMHSA. Which student statement indicates that further teaching is needed? A. Recovery occurs via many pathways. B. Recovery emerges from strong religious affiliations. C. Recovery is supported by peers and allies. D. Recovery is culturally based and influenced. - ANSWER: B RATIONALE: SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person- driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by

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peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. Recovery emerges from hope, but affiliation with any particular religion would have little bearing on the recovery process. 21.4. A client diagnosed with alcohol abuse disorder is referred to a residential care facility after discharge. According to the SAMHSA, which dimension of recovery is supporting this client? A. Health B. Home C. Purpose D. Community - ANSWER: B RATIONALE: SAMHSA describes the dimension of Home as a stable and safe place to live. 21.5. A client diagnosed with obsessive-compulsive disorder states, I really think my future will improve because of my successful treatment choices. I'm going to make my life better. Which guiding principle of recovery has assisted this client? A. Recovery emerges from hope. B. Recovery is person-driven.

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C. Recovery occurs via many pathways. D. Recovery is holistic. - ANSWER: A. RATIONALE: The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person- driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. This client has internalized hope. This hope is the catalyst of the recovery process. 21.6. A nurse maintains a clients confidentiality, addresses the client appropriately, and does not discriminate on the basis of gender, age, race, or religion. Which guiding principle of recovery has this nurse employed? A. Recovery is culturally based and influenced. B. Recovery is based on respect. C. Recovery involves individual, family, and community strengths and responsibility. D. Recovery is person-driven. - ANSWER: B RATIONALE: The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person-

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driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. This nurse accepts and appreciates clients who are affected by mental health and substance use problems. This nurse protects the rights of clients and does not discriminate against them. 21.7. A nurse on an inpatient unit helps a client understand the significance of treatments and provides the client with copies of all documents related to the plan of care. This nurse is employing which commitment in the Tidal Model of Recovery? A. Know that Change Is Constant B. Reveal Personal Wisdom C. Be Transparent D. Give the Gift of Time - ANSWER: C RATIONALE: Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. This nurse is employing the Be Transparent commitment.

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21.8. Which is the priority focus of recovery models? A. Empowerment of the health-care team to bring their expertise to decision-making B. Empowerment of the client to make decisions related to individual health care C. Empowerment of the family system to provide supportive care D. Empowerment of the physician to provide appropriate treatments - ANSWER: B RATIONALE: The basic concept of a recovery model is empowerment of the client. The recovery model is designed to allow clients primary control over decisions about their own care. 21.9. A client experiences an exacerbation of psychiatric symptoms to the point of threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) model should be employed, and what action reflects this step? A. Step 3: Triggers that cause distress or discomfort are listed. B. Step 4: Signs indicating relapse are identified and plans for responding are developed. C. Step 5: A specific plan to help with symptoms is formulated. D. Step 6: Following client-designed plan, caregivers now become decision-makers. - ANSWER: D

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RATIONALE: The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include Step 1, Develop a Wellness Toolbox; Step 2, Daily Maintenance List; Step 3, Triggers; Step 4, Early Warning Signs; Step 5, Things Are Breaking Down or Getting Worse; and Step 6, Crisis Planning. In Step 6 (Crisis Planning), clients can no longer care for themselves, make independent decisions, or keep themselves safe. Caregivers take an active role in this step on behalf of the client and implement the plan that the client has previously developed. All other actions presented require the client to be functionally capable. 21.10. A nursing instructor is teaching about components present in the recovery process, as described by Andersen and associates, which led to the development of the Psychological Recovery Model. Which student statement indicates that further teaching is needed? A. A client has a better chance of recovery if he or she truly believes that recovery can occur. B. If a client is willing to give the responsibility of treatment to the health-care team, he or she is likely to recover. C. A client who has a positive sense of self and a positive identity is likely to recover. D. A client has a better chance of recovery if he or she has purpose and meaning in life. - ANSWER: B