Chapter 8: Legal and Ethical Context of Psychiatric Nursing Care

Question 1

1. A patient with severe depression signed permission for electroconvulsive therapy (ECT). Later, the patient tells the nurse, “I signed permission for treatment after my spouse told me I could be deported if my depression can’t be cured.” The nurse assesses that:
   a. the patient’s consent may have been coerced.
   b. all the elements of informed consent were met.
   c. the patient may not fully understand the risks and benefits.
   d. the patient is not competent to sign permission for treatment.
   Q

Answer 1

ANS: A

The decision may have been coerced based on family pressure. Informed consent requires that the choice be freely made.

Question 2

2. When a patient who immigrated to the United States tells a nurse that consent to electroconvulsive therapy (ECT) was only given because the patient’s spouse said, “They will deport you if you didn’t do what they said to do,” the nurse should initially:
   a. reassure the patient that the decision is sound.
   b. discuss the reasons the spouse believed they must consent.
   c. explain that consenting to treatment will not stop deportation.
   d. document the comment and notify the health care provider immediately.

Answer 2

ANS: D
When requirements for making an informed decision are not met, the health care provider will need to confer with the patient.

Question 3

3. A patient with a history of assaulting several family members is voluntarily admitted for alcohol detoxification. A nurse suggests use of physical restraints to minimize the risk to the milieu and to manage the patient’s anticipated aggressive behavior. The primary principle guiding the manager’s response is:
   a. the right to the least restrictive measure of restriction possible.
   b. that legal considerations exist when physical restraints are used.
   c. the limitations for the use of physical restraints on voluntarily admitted patients.
   d. that thorough documentation is needed whenever physical restraints are applied.

Answer 3

ANS: A

The primary concern is a patient’s right to be treated using the least restrictive setting and method.

Question 4

4. A patient was admitted involuntarily. What assumption can the nurse make about the patient?
   a. The patient may leave the unit whenever he or she chooses to do so.
   b. For the first 48 hours, the patient may be compelled to take prescribed medication.
   c. The patient has, through informed consent, agreed to accept treatment and participate fully in care planning.
   d. When admitted, the patient was an imminent danger to self or others or was deemed unable to provide for his or her own basic needs.

Answer 4

ANS: D
Involuntary commitment means that the patient did not request hospitalization and may have opposed it or was indecisive but did not resist it. Further, most involuntary commitments are made on the grounds that the patient is dangerous to self or others, is mentally ill and in need of treatment, or is unable to provide for his or her own basic needs.

Question 5

5. What is the new staff nurse’s immediate duty when a patient discloses a plan to kill a family member upon release from the hospital?
   a. Discuss the statement with the patient’s mental health team but otherwise keep the information confidential.
   b. Immediately contact the family member and provide a verbal warning concerning his or her physical safety.
   c. Inform the patient that the local police department will be called and that oral and written reports will be filed.
   d. Document the information in the patient’s medical record, and notify the nursing supervisor of the statement.

Answer 5

ANS: D
The Tarasoff decision gives mental health professionals a duty to warn prospective victims. The initial step in this process is to document the statement and to notify the nursing supervisor that the statement was made and documented.

Question 6

6. A patient was admitted voluntarily to the psychiatric unit. A nurse must understand that voluntary status confers the right of the patient to:
   a. have visitors at any desired time.
   b. come and go from the unit at will.
   c. choose the nursing staff assigned to the patient’s care.
   d. accept or refuse any recommended treatment modalities.

Answer 6

ANS: D
Patients who are admitted voluntarily lose none of their civil rights; they retain the right to make decisions to accept or reject specific treatments. The other items are matters that are unit policy rather than individual rights.

Question 7

7. An individual is advised to seek psychiatric hospitalization and agrees to receive treatment and abide by hospital rules. What type of admission is this?
   a. Legal
   b. Informal
   c. Voluntary
   d. Involuntary

Answer 7

ANS: C
Under voluntary admission, any citizen of lawful age may apply in writing for admission to a public or private psychiatric hospital. The person agrees to receive treatment and abide by hospital rules. Voluntary admission is similar to medical hospitalization.

Question 8

8. Regardless of the type of commitment, which right is guaranteed to a hospitalized psychiatric patient?
   a. The right to consult a lawyer
   b. The right to release after 72 hours
   c. The right to choose agency caregivers
   d. The right to keep all personal effects

Answer 8

ANS: A
Consulting a lawyer is the right of all psychiatric patients. Release is determined by the type of commitment; choice of agency caregiver and keeping all personal effects are not basic patient rights. Safety considerations override the right to personal property.

Question 9

9. The staff members notify the police that a court-committed patient has eloped. What is the initial action for the staff to take when the patient is returned to the hospital?
   a. Discuss with the patient the reason for the elopement.
   b. Ask the patient to sign an “against medical advice” release.
   c. Request that the patient give written notice of intent to leave.
   d. Readmit the patient under the original court-ordered commitment.

Answer 9

ANS: D

Elopement does not cancel court commitment.

Question 10

10. Two nurses are discussing the rights of hospitalized psychiatric patients. Which of their beliefs requires follow-up by the nurse manager?
    a. The hospital is responsible for the patient’s safety.
    b. If a committed patient is judged to be incompetent, he or she retains the right of habeas corpus.
    c. Privileged communication does not apply to hospital charts, so they can be used in court.
    d. Disclosure of patient information to law enforcement agencies is permitted without patient consent.

Answer 10

ANS: D

Information about patients may not be shared with individuals outside the circle of confidentiality.

Question 11

11. Which action by a nurse violates the rights of a psychiatric patient?
    a. Arranging for a patient to work in the hospital kitchen for minimum wage
    b. Refusing to mail letters to the local newspaper written by a committed patient
    c. Placing the wristwatch of a patient with delusions in the hospital’s main safe
    d. Discouraging a patient with paranoid delusions to sign a contract to sell a home

Answer 11

ANS: B

Psychiatric patients have the right to communicate with others outside the hospital.

Question 12

12. A patient tells a nurse, “My children had me ruled incompetent. I’m going to ask the doctor to reverse that ruling.” The nurse’s reply should be based on the fact that:
    a. incompetency may only be reversed by a court.
    b. competency is automatically restored upon discharge from the hospital.
    c. being declared incompetent is associated with specific medical diagnoses.
    d. competency is not a major issue since it does not interfere with the right to vote, marry, and divorce.

Answer 12

ANS: A

Competence or incompetence is determined in a court; it is not a medical decision.

Question 13

13. A psychiatric nurse working in a community health center receives a call asking whether a family friend has been a patient in the facility. The nurse should:
    a. ask why the information is being sought.
    b. suggest that the caller speak to the patient’s therapist.
    c. state that he or she is unable to give any information to the caller.
    d. state that the patient has been seen at the center but should give no further information.

Answer 13

ANS: C
Confidentiality requires that the nurse impart no information whatsoever, including acknowledging whether or not the person has been a patient at the facility.

Question 14

14. While making a home visit, a community health nurse sees evidence that the child of a patient has been abused. What rationale should be the basis for the nurse’s nursing action?
    a. Privileged patient communication prevents the nurse from reporting the abuse.
    b. Documenting the evidence in the medical record supports the observation.
    c. A federal ruling requires that the nurse report the suspected abuse.
    d. A signed patient release is needed before action can be taken.

Answer 14

ANS: C

Nurses are mandated reporters of suspected child abuse. To report or not is not discretionary.

Question 15

15. A patient is about to receive electroconvulsive therapy (ECT) when a nurse sees that a consent form for treatment has not been signed. Which fact should determine the nurse’s immediate action?
    a. Verbal consent by the patient is sufficient.
    b. A staff member is needed to witness the consent form.
    c. Failure to obtain the patient’s written consent constitutes battery.
    d. Permission was implied when the patient signed the hospital’s admission form.

Answer 15

ANS: C
A consent form for the specific treatment is required. Unless informed consent is given, the patient may sue the agency, the health care provider, and all who participated in the treatment.

Question 16

16. Although not assessed to be dangerous to self or others, a patient diagnosed with borderline personality disorder has created many problems on the unit and consistently refuses to accept prescribed medication. Nursing actions must be guided by the realization that legally this patient may:
    a. refuse any type of treatment.
    b. receive forced treatment if the treatment team concurs.
    c. be medicated if family members sign permission for treatment.
    d. be made to accept treatment recommendations through the loss of privileges.

Answer 16

ANS: A

Patients have the right to refuse treatment, even when treatment would be in their best interest.

Question 17

17. A nurse was sued for malpractice but not convicted. Which fact from the case would have been decisive in determining its outcome?
    a. The patient was verbally and physically combative.
    b. The nurse was being oriented to the mental health unit.
    c. The nurse has expressed a fear of the patient to the manager.
    d. The patient did not suffer any physical or any emotional harm.

Answer 17

ANS: D
Four elements are necessary to prove liability for malpractice: duty, negligent performance, harm to the patient, and proximate cause. If the patient sustained no harm, no tort liability exists.

Question 18

18. A patient tried for the murder of a spouse and child was found guilty but mentally ill (GBMI). A psychiatric nurse is asked, “Does that mean this patient will be walking the streets after a short hospitalization?” Which reply shows the best understanding of GBMI?
    a. “The patient will be hospitalized and released when no longer mentally ill.”
    b. “A person found guilty but mentally ill will be treated while serving the sentence.”
    c. “You sound as though you are angry with the way our criminal justice system works.”
    d. “It will depend on whether the American Law Institute’s Test was applied or whether the Irresistible Impulse Test was used.”

Answer 18

ANS: B
GBMI individuals who have committed capital crimes are never freed. They are usually held in penal institutions or maximum-security forensic psychiatric hospitals.

Question 19

19. The parents of a patient with schizophrenia ask whether their child is likely to become violent. The best answer the nurse can give is that the vast majority of mentally ill individuals are:
    a. somewhat more dangerous than ordinary people.
    b. definitely more violence-prone than others on the street.
    c. no more dangerous than other individuals in the population.
    d. considerably more dangerous than others in the population.

Answer 19

ANS: C
Studies show that the vast majority of people with serious mental illness are not inherently violent and are no more dangerous than people in the general population.

Question 20

20. A patient signed a sales contract to purchase a new home and 1 week later was voluntarily hospitalized for treatment of depression. The sales contract is now most likely:
    a. invalid.
    b. still valid.
    c. postponed.
    d. in litigation.

Answer 20

ANS: B
If the patient is competent, the signed contracts are legal and binding. Depression does not necessarily render one incapable of handling personal affairs.

Question 21

21. A patient in the process of being involuntarily committed demands to be evaluated by his own private psychiatrist. To preserve the patient’s rights, the treatment team must:
    a. stop the commitment process.
    b. notify the unit psychiatrist immediately.
    c. provide access to the private psychiatrist.
    d. determine why the patient is resisting staff care.

Answer 21

ANS: C

Patients’ rights include the right to consult with one’s own private psychiatrist.

Question 22

22. A patient claims to have been denied the right to confidentiality. To best preserve the patient’s rights, the treatment team must:
    a. re-explain the guidelines for confidentiality to the patient.
    b. provide in-service to the unit’s staff regarding confidentiality.
    c. educate the patient about the process required for the filing of a formal complaint.
    d. determine why the patient feels that the right to confidentiality has been denied.

Answer 22

ANS: C

Patients may file a formal complaint and are entitled to information regarding how to go about doing so.

Question 23

MULTIPLE RESPONSE

1. A patient, who is homeless and known to be schizophrenic, was arrested after vandalizing parked cars while naked. Which behaviors will be considered when determining if the patient should be involuntarily committed for care? Select all that apply.
   a. The patient is a possible danger to others.
   b. The patient is a diagnosed schizophrenic.
   c. The patient is a disruptive factor to the community.
   d. The patient is unable to provide for his or her own basic needs.
   e. The patient is in need of either physical or mental health treatment.

Answer 23

ANS: A, D, E
The criteria for involuntary commitment include the following: the patient is dangerous to self or others, in need of physical and/or mental health treatment, and unable to provide for his or her own basic needs. One cannot be involuntarily committed based on being disruptive or for having a previous mental health diagnosis.

Question 24

MULTIPLE RESPONSE

2. Which patient is apt to display violent behavior directed at others? (Select all that apply.)
   a. A patient with a history of obsessive compulsive behaviors who displays signs of severe depression after the loss of a job held for 20 years
   b. A patient who has a history of assaulting people when commanded to do so by “the voices”
   c. A patient who has been noncompliant with prescribed psychotropic medication and whose manic behavior has escalated
   d. A patient who has an antisocial personality disorder and who has been abusing amphetamines for 3 years
   e. A patient who was diagnosed with posttraumatic stress disorder (PTSD) who recently lost a limb in an automobile accident

Answer 24

ANS: B, C, D
The predictors of violence include prior violent behavior, noncompliance with medications, current substance abuse, and antisocial personality disorder.