In response to a student’s 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?
- Christian ethics
- Ethical egoism
Rationale: The charge nurse is operating from a Christian ethics framework. The imperative demand of Christian ethics is that all decisions about right and wrong should be centered in love for God and in treating others with the same respect and dignity with which we would expect to be treated. Kantianism states that decisions should be made based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made focusing on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual.
During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework?
- “I would want to be treated in a caring manner if I were mentally ill.”
- “This job will pay the bills, and the workload is light enough for me.”
- “I will be happy caring for the mentally ill. Working in med/surg kills my back.”
- “It is my duty in life to be a psychiatric nurse. It is the right thing to do.”
Rationale: The applicant’s comment reflects the ethical egoism framework. This framework promotes the idea that decisions are made based on what is good for the individual and may not take the needs of others into account.
Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse’s coworker observes this action but does nothing for fear of retaliation. What is the ethical interpretation of the coworker’s lack of involvement?
- Taking no action is still considered an unethical action by the coworker.
- Taking no action releases the coworker from ethical responsibility.
- Taking no action is advised when potential adverse consequences are foreseen.
- Taking no action is acceptable, because the coworker is only a bystander.
Rationale: The coworker’s lack of involvement can be interpreted as an unethical action. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. The coworker has a responsibility to report any observed unethical actions.
Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager’s policy preserve?
Rationale: The unit manager’s 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.
Which is an example of an intentional tort?
- A nurse fails to assess a client’s obvious symptoms of neuroleptic malignant syndrome.
- A nurse physically places an irritating client in four-point restraints.
- A nurse makes a medication error and does not report the incident.
- A nurse gives patient information to an unauthorized person.
Rationale: A tort, which can be intentional or unintentional, is a violation of civil law in which an individual has been wronged. A nurse who intentionally physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort.
An involuntarily committed client is verbally abusive to the staff, 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?
- Verbally redirect the client, and then refuse one-on-one interaction.
- Involve the hospital’s security division as soon as possible.
- Notify the client that documenting personal staff information is against hospital policy.
- Continue professional attempts to establish a positive working relationship with the client.
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.
Which statement should a nurse identify as correct regarding a client’s right to refuse treatment?
- Clients can refuse pharmacological but not psychological treatment.
- Clients can refuse any treatment at any time.
- Clients can refuse only electroconvulsive therapy (ECT).
- Professionals can override treatment refusal by an actively suicidal or homicidal client.
Rationale: The nurse should understand that health-care professionals could override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be in danger or a danger to others. This situation should be treated as an emergency, and treatment may be performed without informed consent.
Which potential client should a nurse identify as a candidate for involuntarily commitment?
- The client living under a bridge in a cardboard box
- The client threatening to commit suicide
- The client who never bathes and wears a wool hat in the summer
- The client who eats waste out of a garbage can
Rationale: The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is in danger and needs emergency treatment.
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 client’s wishes?
- A client makes inappropriate sexual innuendos to a staff member.
- A client constantly demands attention from the nurse by begging, “Help me get better.”
- A client physically attacks another client after being confronted in group therapy.
- A client refuses to bathe or perform hygienic activities.
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 informed choices. The client’s refusal to accept treatment can be challenged, because the client is endangering the safety of others.
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?
- The nurse refuses to give any information to the caller, citing rules of confidentiality.
- The nurse hangs up on the caller.
- The nurse confirms that the person has been at the facility but adds no additional information.
- The nurse suggests that the caller speak to the client’s therapist.
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.
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?
Rationale: The nurse should provide the information to support the client’s 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.
An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which ethical principle should a nurse determine has been violated based on these actions?
Rationale: The nurse should determine that the ethical principle of justice has been violated by the physician’s 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.
Which situation reflects violation of the ethical principle of veracity?
- A nurse discusses with a client another client’s impending discharge.
- A nurse refuses to give information to a physician who is not responsible for the client’s care.
- A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room.
- A nurse does not treat all of the clients equally, regardless of illness severity.
Rationale: The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to one’s duty to always be truthful and not intentionally deceive or mislead clients.
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?
- The client is paranoid.
- The client is 87 years old.
- The client incorrectly reports his or her spouse’s name, date, and time of day.
- The client relies on his or her spouse to interpret the information.
Rationale: The nurse should question the validity of informed consent when the client incorrectly reports the spouse’s name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices.
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?
- Allow the client to decline the medication and document the decision.
- Tell the client that if the medication is refused, hospitalization will occur.
- Arrange with a relative to add the medication to the client’s morning orange juice.
- Call for help to hold the client down while the injection is administered.
Rationale: It is ethically appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client’s right to refuse treatment should be upheld, unless the refusal puts the client or others in harm’s way.
Which situation exemplifies both assault and battery?
- The nurse becomes angry, calls the client offensive names, and withholds treatment.
- The nurse threatens to “tie down” the client and then does so, against the client’s wishes.
- The nurse hides the client’s clothes and medicates the client to prevent elopement.
- The nurse restrains the client without just cause and communicates this to family.
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.
A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client?
- The client is placed in seclusion.
- The client is placed in a geriatric chair with tray.
- The client is placed in soft Posey restraints.
- The client is monitored by an ankle bracelet.
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.
A brother calls to speak to his sister, who has been admitted to a 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 client’s approved call list. What law has the nurse broken?
- The National Alliance for the Mentally Ill Act
- The Tarasoff Ruling
- The Health Insurance Portability and Accountability Act
- The Good Samaritan Law
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.
After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department. The client threatens suicide. Which of the following criteria would enable a physician to consider involuntary commitment? (Select all that apply.)
- Being dangerous to others
- Being homeless
- Being disruptive to the community
- Being gravely disabled and unable to meet basic needs
- Being suicidal
ANS: 1, 4, 5
Rationale: The physician could consider involuntary commitment when a client is dangerous to others, gravely disabled, or is suicidal. If the physician determines that the client is mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator. A hospital administrator may give permission for involuntary commitment when time does not permit court intervention.