Chapter 08: Ethical Responsibilities and Legal Obligations for Psychiatric Mental Health Nursing Practice

Question 1

A psychiatric nurse best applies the ethical principle of autonomy by doing which of the following?

a. Exploring alternative solutions with a patient, who then makes a choice.
b. Suggesting that two patients who were fighting be restricted to the unit.
c. Intervening when a self-mutilating patient attempts to harm self.
d. Staying with a patient demonstrating a high level of anxiety.

Answer 1

ANS: A
Autonomy is the right to self-determination, that is, to make one’s own decisions. By exploring alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. The distracters demonstrate beneficence, fidelity, and justice.

Question 2

A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period when the patient was stable and competent. The nurse should do which of the following?

a. Review the directive with the patient to ensure it is current.
b. Ensure that the directive is respected in treatment planning.
c. Consider the directive only if there is a cardiac or respiratory arrest.
d. Encourage the patient to revise the directive in light of the current health problem.

Answer 2

ANS: B
The nurse has an obligation to honour the right to self-determination. An advance psychiatric directive supports that goal. Since the patient is currently psychotic, the terms of the directive now apply.

Question 3

Two hospitalized patients fight whenever they are together. During a team meeting, a nurse asserts that safety is of paramount importance, so treatment plans should call for both patients to be secluded to keep them from injuring each other. This assertion does which of the following?

a. Reinforces the autonomy of the two patients
b. Violates the civil rights of both patients
c. Represents the intentional tort of battery
d. Correctly places emphasis on safety

Answer 3

ANS: B
Patients have a right to treatment in the least restrictive setting. Safety is important, but less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion violates the patient’s autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment.

Question 4

In a team meeting a nurse says, “I’m concerned about whether we are behaving ethically by using restraint to prevent one patient from self-mutilation, while the care plan for another self-mutilating patient requires one-on-one supervision.” Which ethical principle most clearly applies to this situation?

a. Beneficence
b. Autonomy
c. Fidelity
d. Justice

Answer 4

ANS: D
The nurse is concerned about justice, that is, fair distribution of care, which includes 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.

Question 5

Select the response that is an example of a tort.

a. The plan of care for a patient is not completed within 24 hours of the patient’s admission.
b. A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short-staffed.
c. An advanced-practice nurse recommends hospitalization for a patient who is dangerous to self and others.
d. A patient’s admission status change from involuntary to voluntary after the patient’s hallucinations subside.

Answer 5

ANS: B
A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff controls behaviour in a manner similar to secluding a patient; thus, false imprisonment is a possible charge. The other options do not exemplify torts.

Question 6

What is the legal significance of a nurse’s action when a patient verbally refuses medication and the nurse gives the medication over the patient’s objection?

a. The nurse has been negligent.
b. The nurse has committed malpractice.
c. The nurse has fulfilled the standard of care.
d. The nurse can be charged with battery.

Answer 6

ANS: D
Battery is an intentional tort in which one individual violates the rights of another through touching without consent. Forcing a patient to take medication after the medication was refused constitutes battery. The charge of battery can be brought against the nurse. The medication may not necessarily harm the patient; harm is a component of malpractice.

Question 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 and attention-seeking much of the day. 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. The nurse rushes after the patient and convinces the patient to return to the unit.
d. An involuntarily hospitalized patient with homicidal ideation attempts to leave the facility. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

Answer 7

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. If a patient is not competent (confused), then the nurse should act with beneficence. Patients admitted involuntarily should not be allowed to leave without permission of the treatment team.

Question 8

Which of the following patients meets criteria for involuntary hospitalization for psychiatric treatment?

a. The patient who is noncompliant with the treatment regimen
b. The patient who fraudulently files for bankruptcy
c. The patient who sold and distributed illegal drugs
d. The patient who threatens to harm self and others

Answer 8

ANS: D
Involuntary hospitalization 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 behaviours described in the other options are not sufficient to require involuntary hospitalization.

Question 9

A nurse prepares to administer a scheduled injection of haloperidol decanoate (Haldol) to an outpatient 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 action.

a. Assemble other staff for a show of force and proceed with the injection, using restraint if necessary.
b. Stop the medication administration procedure and say to the patient, “Tell me more about the side effects you’ve been having.”
c. Proceed with the injection but explain to the patient that there are medications that will help reduce the unpleasant side effects.
d. 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 delaying next month’s dose.”

Answer 9

ANS: B
Patients with mental illness retain their right to refuse treatment unless there is clear, cogent, and convincing evidence of harming themselves or harming others. The patient in this situation presents no evidence of harm. The nurse, as an advocate and educator, should seek more information about the patient’s decision and not force the medication.

Question 10

A nurse is concerned that an agency’s policies are inadequate. Which understanding about the relationship between substandard institutional policies and individual nursing practice should guide nursing practice?

a. Agency policies do not exempt an individual nurse of responsibility to practice according to 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. Faced with substandard policies, a nurse has a responsibility to inform the supervisor and discontinue patient care immediately.
d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

Answer 10

ANS: A
The weakness of individual institutions’ setting such criteria is that a particular hospital’s policy may be substandard. Substandard institutional policies, however, do not absolve the individual nurse of responsibility to practise on the basis of professional standards of nursing care. Nurses are professionally bound to uphold standards of practice regardless of lesser standards established by a health care agency or a province/territory. Conversely, if the agency standards are higher than 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.

Question 11

A newly admitted acutely psychotic patient is a private patient of the medical director and has private medical insurance. To whom does the psychiatric nurse assigned to the patient owe the duty of care?

a. Medical director
b. Hospital
c. Profession
d. Patient

Answer 11

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.

Question 12

Which action by a nurse constitutes a breach of a patient’s right to privacy?

a. Documenting the patient’s daily behaviour during hospitalization
b. Releasing information to the patient’s employer without consent
c. Discussing the patient’s history with other staff during care planning
d. Asking family to share information about a patient’s pre-hospitalization behaviour

Answer 12

ANS: B
Release of information without patient authorization violates the patient’s right to privacy. The other options are acceptable nursing practice and do not constitute a breach of the patient’s right to privacy of information (confidentiality).

Question 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 are right. Federal law requires me to keep clinical information private.”
b. “I am obligated to share that information with the treatment team.”
c. “Those kinds of thoughts will make your hospitalization longer.”
d. “You should share this thought with your psychiatrist.”

Answer 13

ANS: B
Breach of nurse–patient confidentiality does not pose a legal dilemma for nurses in these circumstances because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The CNA’s code of ethics clarifies that the person’s right to privacy is not absolute. In some situations, disclosure may be mandated to protect the patient, other persons, or public health. The patient should also know that the team has a duty to warn the father of the risk for harm.

Question 14

A voluntarily hospitalized patient tells the nurse, “Get me the forms for discharge. I want to leave now.” Select the nurse’s best response.

a. “I will get the forms for you right now and bring them to your room.”
b. “Since you signed your consent for treatment, you may leave if you desire.”
c. “I will get them for you, but let’s talk about your decision to leave treatment.”
d. “I cannot give you those forms without your health care provider’s permission.”

Answer 14

ANS: C
A voluntarily admitted patient has the right to decide to leave the hospital. 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. Facilitating discharge without consent is not in the patient’s best interests before exploring the reason for the request.

Question 15

A registered nurse requests that the unlicensed health care worker give a patient his or her medication at 1000 hrs as the nurse will be at coffee break. This represents an example of which of the following?

a. Malpractice
b. Intentional tort
c. Vicarious liability
d. Defamation of character

Answer 15

ANS: C
Vicarious liability, also known as supervisory liability, is demonstrated in the example as the RN is inappropriately delegating medication administration to an unlicensed health care worker.

Question 16

Which individual with mental illness may need emergency or involuntary admission?

a. An individual who resumes using heroin while still taking naltrexone (ReVia).
b. An individual who reports hearing angels playing harps during thunderstorms.
c. An individual who does not keep an outpatient appointment with the mental health nurse.
d. An individual who throws a heavy plate at a waiter at the direction of command hallucinations.

Answer 16

ANS: D
Throwing a heavy plate is likely to harm the waiter and is evidence of the possibility of harming others. This behaviour meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviours in the other options evidence mental illness but not imminent danger for harming self or others.

Question 17

A patient in alcohol rehabilitation reveals to the nurse, “I feel terrible guilt for sexually abusing my 6-year-old before I was admitted.” Select the nurse’s most important action.

a. Report the abuse to the local child welfare agency.
b. Reply, “I’m glad you feel comfortable talking to me about it.”
c. File a written report with the agency’s ethics committee.
d. Respect nurse–patient relationship confidentiality.

Answer 17

ANS: A
It is your legal and ethical responsibility to make a report of suspected abuse to your province’s or territory’s child welfare agency. Most statutes include the consequences of failure to report. Many provinces and territories specifically require nurses to report cases of suspected abuse.

Question 18

A family member of a patient with delusions of persecution asks the nurse, “Are there any circumstances under which the treatment team is justified in violating a patient’s right to confidentiality?” The nurse should reply that confidentiality may be breached in which of the following circumstances, if any?

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

Answer 18

ANS: D
The duty to warn a person whose life has been threatened by a psychiatric patient overrides the patient’s right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations.

Question 19

A new antidepressant is prescribed for an elderly patient with major depression, but the dose is more than the usual geriatric dose. What should the nurse do?

a. Consult a reliable drug reference.
b. Teach the patient about possible side effects and adverse effects.
c. Withhold the medication and confer with the health care provider.
d. Encourage the patient to increase oral fluids to reduce drug concentration.

Answer 19

ANS: C
The dose of antidepressants for elderly 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 practise according to professional standards as well as intervene and protect the patient.

Question 20

A patient diagnosed with schizophrenia believes a local minister stirred evil spirits. The patient threatens to bomb a local church. The psychiatrist notifies the minister. Select the answer with the correct rationale.

a. The psychiatrist released information without proper authorization.
b. The psychiatrist demonstrated the duty to warn and protect.
c. The psychiatrist violated the patient’s confidentiality.
d. The psychiatrist avoided charges of malpractice.

Answer 20

ANS: B
It is the health care provider’s duty 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 provider. It is not a violation of confidentiality.

Question 21

A patient with psychosis became aggressive, struck another patient, and required seclusion. Select the best documentation.

a. Patient struck another patient who attempted to leave day room to go to bathroom. Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these two patients away from each other for 24 hours.
b. Seclusion ordered by physician at 1415 after command hallucinations told the patient to hit another patient. Careful monitoring of patient maintained during period of seclusion.
c. Seclusion ordered by physician for aggressive behaviour. Begun at 1415. Maintained for 2 hours without incident. Outcome: Patient calmer and apologized for outburst.
d. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, “I’ll punch anyone who gets near me,” and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from physician at 1430.

Answer 21

ANS: D
Documentation must be specific and detail the key aspects of care. It should demonstrate implementation of the least restrictive alternative. Justification for why a patient was secluded should be recorded, along with interventions attempted in an effort to avoid seclusion. Documentation should include a description of behaviour and verbalizations, interventions tried and their outcomes, and the name of the health care provider ordering the use of seclusion.

Question 22

A person in the community asks, “Why aren’t people with mental illness kept in institutions anymore?” Select the nurse’s best response.

a. “Less restrictive settings are available now to care for individuals with mental illness.”
b. “There are fewer people with mental illness, so fewer hospital beds are needed.”
c. “Most people with mental illness are still in psychiatric institutions.”
d. “Psychiatric institutions violated patients’ rights.”

Answer 22

ANS: A
The community is a less restrictive alternative than hospitals for treatment of people with mental illness. Changes in the provincial/territorial acts over the years reflect a shift in emphasis from institutional care of people with mental illness to community-based care delivery models. The distracters are incorrect and part of the stigma of mental illness.

Question 23

A patient experiencing psychosis asks a psychiatric technician, “What’s the matter with me?” The technician replies, “Nothing is wrong with you. You just need to use some self-control.” The nurse who overheard the exchange should take action based on which of the following?

a. The technician’s unauthorized disclosure of confidential clinical information.
b. Violation of the patient’s right to be treated with dignity and respect.
c. The nurse’s obligation to report caregiver negligence.
d. The patient’s right to social interaction.

Answer 23

ANS: B
Patients have the right to be treated with dignity and respect. The technician’s comment disregards the seriousness of the patient’s illness. The Code of Ethics for Nurses requires intervention. Patient emotional abuse has been demonstrated, not negligence. An interaction with the technician is not an aspect of social interaction. The technician did not disclose clinical information.

Question 24

Which documentation of a patient’s behaviour best demonstrates a nurse’s observations?

a. Isolates self from others. Frequently fell asleep during group. Vital signs stable.
b. Calmer; more cooperative. Participated actively in group. No evidence of psychotic thinking.
c. Appeared to hallucinate. Frequently increased volume on television, causing conflict with others.
d. Wore four layers of clothing. States, “I need protection from evil bacteria trying to pierce my skin.”

Answer 24

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.

Question 25

After leaving work, a nurse realizes documentation of administration of a PRN medication was omitted. This off-duty nurse phones the nurse on duty and says, “Please document administration of the medication for me. My password is alpha1.” The nurse receiving the call should do which of the following?

a. Fulfill the request promptly.
b. Document the caller’s password.
c. Refer the matter to the charge nurse to resolve.
d. Report the request to the patient’s health care provider.

Answer 25

ANS: C
Fraudulent documentation may be grounds for discipline by provincial/territorial nursing associations or colleges. Referring the matter to the charge nurse will allow observance of hospital policy while ensuring that documentation occurs. Notifying the health care provider would be unnecessary when the charge nurse can resolve the problem. Nurses should not provide passwords to others.

Question 26

Which individual diagnosed with a mental illness may need involuntary hospitalization?

a. An individual who has a panic attack after her child gets lost in a shopping mall
b. An individual with visions of demons emerging from cemetery plots throughout the community
c. An individual who takes 38 acetaminophen tablets after his or her stock portfolio becomes worthless
d. An individual diagnosed with major depression who stops taking prescribed antidepressant medication

Answer 26

ANS: C
Involuntary hospitalization protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary hospitalization also protects other individuals in society. An overdose of acetaminophen indicates dangerousness to self. The behaviours described in the other options are not sufficient to require involuntary hospitalization.

Question 27

An unlicensed health care worker in a psychiatric hospital says to the nurse, “We don’t have time every day to help each patient complete a menu selection. Let’s tell dietary to prepare popular choices and send them to our unit.” Select the nurse’s best response.

a. “Thanks for the suggestion, but that idea may not work because so many patients take MAOI (monoamine oxidase inhibitor) antidepressants.”
b. “Thanks for the idea, but it’s important to treat patients as individuals. Giving choices is one way we can respect patients’ individuality.”
c. “Thank you for the suggestion, but the patients’ bill of rights requires us to allow patients to select their own diet.”
d. “Thank you. That is a very good idea. It will make meal preparation easier for the dietary department.”

Answer 27

ANS: B
The nurse’s response to the worker should recognize patients’ rights to be treated with dignity and respect as well as promote autonomy. This response also shows respect for the worker and fulfills the nurse’s obligation to provide supervision of unlicensed personnel. The incorrect responses have flawed rationale or do not respect patients as individuals.

Question 28

In order to release information to another health care facility or third party regarding a patient diagnosed with a mental illness, the nurse must obtain which of the following?

a. A signed consent by the patient for release of information stating specific information to be released.
b. A verbal consent for information release from the patient and the patient’s guardian or next of kin.
c. Permission from members of the health care team who participate in treatment planning.
d. Approval from the attending psychiatrist to authorize the release of information.

Answer 28

ANS: A
Nurses have an obligation to protect patients’ privacy and confidentiality. Clinical information should not be released without the patient’s signed consent for the release unless there is evidence of harm to self or others.

Question 29

In which situations would a nurse have the duty to intervene and report? Select all that apply.

a. A peer has difficulty writing measurable outcomes.
b. A health care provider gives a telephone order for medication.
c. A peer tries to provide patient care in an alcohol-impaired state.
d. A team member violates relationship boundaries with a patient.
e. A patient refuses medication prescribed by a licensed health care provider.

Answer 29

ANS: C, D
Both keyed answers are events that jeopardize patient safety. The distracters describe situations that may be resolved with education or that are acceptable practices.

Question 30

Which actions violate the civil rights of a psychiatric patient? Select all that apply.

a. The nurse performs mouth checks after overhearing a patient say, “I’ve been spitting out my medication.”
b. The nurse begins suicide precautions before a patient is assessed by the health care provider.
c. The nurse opens and reads a letter a patient left at the nurse’s station to be mailed.
d. The nurse places a patient’s expensive watch in the hospital business office safe.
e. The nurse restrains a patient who uses profanity when speaking to the nurse.

Answer 30

ANS: C, E
The patient has the right to send and receive mail without interference. Restraint is not indicated because a patient uses profanity; there are other less restrictive ways to deal with this behaviour. The other options are examples of good nursing judgement and do not violate the patient’s civil rights.