A physician orders the elixir form of a medication. The nurse, familiar only with the injectable form of the medication, believes the order is incorrect. The nurse should: Ask the two physicians who are currently on the unit whether the medication should be given as the nurse understood the order. Ask the head nurse if the order is correct. Call the physician who ordered the medication. Contact the nursing supervisor about the problem. The nurse would be negligent for any untoward effects of the drug if she or he failed to contact the physician who ordered the drug before the nurse administered it. In Norton v. Argonaut Insurance Co. [144 So. 2nd 249 (La. Ct. App. 1962)], the court stated that it was the responsibility of the nurse to clarify the order with the physician involved, not with other nurses (Answers 2 and 4). Answer 1 is incorrect because the doctors on the unit are not the ones who wrote the order. Apply the concept of negligence: omission to do something that a reasonable person guided by ordinary considerations would do; and go directly to the source for clarification A patient had been receiving a drug by injection over a number of weeks. As the clinical symptoms changed, the physician wrote an order on the patient's order sheet changing the mode of administration from injection to oral. When the nurse on the unit, who had been off duty for several days, was preparing to give the medication by injection, the patient objected and referred the nurse to the physician's new orders. The nurse should: Go back to the order sheet and check for the order. Talk with the nurse who had taken care of this particular patient while he or she had been off duty. Talk with the head nurse about the advisability of using oral rather than injectable medications. Check the order sheet for the changed order and then speak with the attending physician concerning the changed order. Although Answer 1 is a correct answer, Answer 4 is the best answer because the nurse would validate the changed order and learn the physician's rationale for the change. In Larrimore v. Homeopathic Hospital Association [54 Del. 449, 181 A. 2d 573 (1962)], the court found that the nurse who went ahead and gave the medication was negligent. The courts went on to say that the jury could find the nurse negligent by applying ordinary common sense to establish the applicable standard of care. Answers 2 and 3 are incorrect because talking with nurses is not the direct way to clarify and validate an order. Eliminate two options related to talking to other nurses. Although the two other choices are good, select the more inclusive option A nurse had been caring for a patient whose vital signs had previously been unstable. The nurse had not had a coffee break or a lunch break all day. By 2 p.m. the patient had been stable for a number of hours. The physician in charge had seen the patient and had told the nurse that the patient appeared "much improved." The nurse should: Leave for lunch break. Forego lunch break because of the patient's previous unstable condition. Arrange to eat lunch in the patient's room. Discuss the situation with the nurse in charge of the unit and determine who should cover the patient while the staff nurse is at lunch. The nurse would come back to the patient revitalized after having a lunch break, and the patient would be covered the whole time the nurse is away. In deciding that the nurse would not be negligent to leave such a patient, the court would emphasize that the question of liability should be determined in light of the circumstances as they existed at the time. When the nurse left the patient, it was not foreseeable that an increased risk to the patient would result. On the contrary, the patient would be looked after, and the nurse's needs would also be met. Child v. Vancouver General Hospital [71 Patient's condition (stable) allows for continuity of care (by delegation) while the nurse is at lunch. Choose the option that is different (taking a lunch break) In a certain hospital, whenever there are patients in the recovery room, two nurses are usually present. The hospital policy expects the nurses to take their breaks before patients arrive from surgery. On this particular day, there are two nurses on duty and two patients in the recovery room who have had minor surgeries performed that morning. One nurse had not had a coffee break that morning. That nurse should: Stay because hospital policy expects there to be two nurses in attendance while there are patients in the recovery room. Leave for coffee break because there are only two patients in the recovery room and one nurse can handle two patients quite easily. Talk with the nursing supervisor and secure permission from him or her. Leave to get coffee and come right back. In a court of law, hospital policy may be used to set the standard of care by which the nurses' actions are judged. Because the hospital policy states that two nurses must be in attendance while patients are in the recovery room, both the nurse who left (Answers 2. and 4) and the supervisor who authorized the nurse's absence (Answer 3) would be held liable for any untoward effect on the patient. Laidlaw v. Lions Gate Hospital [70 W.W.R. 727 (1969)]. In following hospital policy, standards of care are met While driving down a freeway, a nurse spots an overturned car with the driver lying next to the car. The nurse: May drive on without stopping, or stop and render emergency first aid, without liability. May stop, start to render aid, and then leave, without liability. Must stop at the scene of an accident and render first aid. May stop and render aid, but if he or she performs a medical act, he or she may be charged with illegal practice of medicine. The court has stated that no one is obliged by law to assist a stranger, even if he or she can do so by a word and without the slightest danger to himself or herself. Hence, Answer 3 is incorrect. But once one has undertaken to give assistance, the law imposes on him or her a duty of care toward the person Answer 4. Apply the Good Samaritan Act A patient is terminally ill and has asked the nurse to witness a will. Which statement is true? The nurse has a legal obligation to act as a witness to a will. The nurse should help the patient draw up a will. The nurse should make sure that the patient is of sound mind, is lucid (not under the influence of drugs or alcohol), and understands what he or she is doing. Only lawyers or family members can act as a witness to a will. If the nurse acts as a witness, the will may automatically be declared invalid. Anyone can act as a witness. Answer 1 is incorrect because a nurse has no legal obligation to participate as a witness, only a moral and ethical obligation. Answer 2 is incorrect because only a lawyer or the patient can draw up a will. If the nurse draws up the will, she or he could be charged with Eliminate the three false statements A patient, just returned from the recovery room, complains of pain that is "not too severe" and requests pain medication. The nurse notes that the patient has been given pain medication in the recovery room. Which statement indicates the best action to take? Administer the dosage the physician had ordered on a prn basis. Consult the physician and let him or her know that the patient is requesting medication for pain that is "not too severe." Give half of the pain medication dosage ordered as prn by the physician. Chart that the patient was complaining of pain but that it was "not too severe." The physician should be notified of the patient's complaints, and the new orders should be established. This is what the courts would consider prudent under the circumstances and what a reasonable nurse should do. Answer 1 would not be the best choice because the patient had already been given pain medication in the recovery room, and another full dose might be too much. Without further information, this is a very dangerous choice, and the nurse would be held liable for any untoward effects. Answer 3 would also be incorrect because a nurse cannot substitute his or her judgment for the physician's without consulting the physician first. If a nurse alters the amount prescribed without an order from the physician, the nurse could be charged with practicing medicine without a license. Answer 4 is incomplete. A nurse must chart the patient's complaints but must also indicate what was done about them. Consultation with physician is necessary When a nurse is being sued for malpractice, what will occur? The nurse's license will be revoked or suspended automatically. The nurse will automatically be put on probation until the matter is cleared up. The nurse will automatically be charged with a crime. The State Board of Registered Nurses will be notified of the suit, and, depending on the offense and outcome of the suit, it might hold a hearing to determine the status of the license. Only the State Board of Registered Nurses has the authority to revoke or suspend a license. This can occur only after the nurse has been given a fair hearing before an impartial hearing body. Hence, Answers 1, 2, and 3 are incorrect because they assume a penalty should be applied before the State Board is notified. For an educated guess, choose the option that is different (three options state "automatically," one does not) A nurse's license will be revoked or she or he will be put on probation for which reason? The nurse lost a malpractice suit. The nurse was found guilty of practicing while under the influence of drugs or alcohol. The nurse was accused of negligence. The nurse gave a wrong medication. All State Practice Acts list "guilty of practicing while under the influence of drugs or alcohol" as a reason for revocation of a license or for putting a nurse on probation. Answers 1, 3, and 4 may cause revocation of a license; however, other circumstances would have to be considered first, such as the frequency with which these had occurred. Refer to the State Practice Acts for reasons for license revocation A nurse who applies restraints on a patient may be held liable by the patient for restraint of freedom of movement (false imprisonment) if the nurse: Does not immediately obtain an order from the physician. Does so after other means to subdue the patient have failed. Tries but fails to obtain the patient's consent. Applies restraints for the convenience of the personnel. Freedom from unlawful restraint is a basic human right. Restraints of any type may constitute false imprisonment. False imprisonment is an actionable tort for which a nurse may be held liable by a patient. The patient may have an actionable case of false imprisonment if the restraints were applied for staff convenience only. Most likely the nurse would not be held liable for false imprisonment even if the nurse does not immediately obtain an order from the physician for the restraints. However, Answer 1 is not the best choice. Restraints should be used only in emergency situations, for a limited time, for the limited purpose of protecting the patient, and not for the convenience of the staff. Even though the patient's consent (Answer 3) is not usually obtainable under the circumstances, the nurse should try in order to avoid being held liable for false imprisonment. However, these restraints should only be applied as a last resort (Answer 2). Select the option that violates patient's rights The nurse has been working with a terminally ill male patient for weeks. The patient is lucid. His wife pleads with the nurse not to use heroic measures on her husband but to let him die "with dignity." The nurse should: Tell the wife that she needs to talk with the attending physician, patient (if possible), and other significant people about her concerns. Act on the wife's request. Ignore the wife's request and proceed with the patient's care. Tell the wife that to do as she requested would be equivalent to murdering the patient. This type of case is an example of the most difficult medical ethical and legal questions today. The answers are ambiguous at best. However, in this case Answer 1 would be best because neither the nurse (Answer 3), the wife (Answer 2), nor the doctor can make that decision as long as the patient is a competent adult. Answer 4 is incorrect because the nurse's values should not supersede the wife's concerns for her husband's welfare. The best answer includes the patient; the decision is not the nurse's to make, and the nurse should not ignore the wife's request A physician calls the unit, wishing to leave an important order. A new nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not know the physician nor the patient to whom the order pertains. The nurse should: Take the telephone order. Refuse to take the telephone order. Ask the charge nurse or one of the other senior staff nurses to take the telephone order. Ask the physician to call back after the nurse has read the hospital policy manual. Get a senior nurse who knows the policies, the patient, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital's policy regarding telephone orders. Failure to follow hospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital's policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the patient. Therefore the nurse should not take the order unless (a) no one else is available and (b) it is an emergency situation. Answers 1 and 2 are both incomplete, because they do not take into account the mitigating circumstances. The doctor has said that the order is important; therefore the nurse should not delay the doctor while she or he reads the manual. Hence, Answer 4 is incorrect. Look for an option calling for supervision of a new nurse Which statement concerning consent is false? If an informed consent is not obtained from the patient, the nurse, doctor, and/or hospital may be liable for assault. One need only obtain a general consent to treatment. In an emergency a nurse may do what she or he can do to save life and limb, even in cases in which she or he has no consent. Consent may be given by conduct as well as expressed words. Assault is the unjustifiable attempt to touch another person or the threat to do so in such circumstances as to cause the other reasonably to believe that it will be carried out. The lack of informed consent is an important part of the meaning of assault. Consent is a defense to an action for assault. However, if the treatment or procedure goes beyond the patient's consent (as it probably would if consent was only to "general" treatment, as in Answer 2), the nurse, the doctor, and/or the hospital may be liable. Hence, Answer 1 is a true statement. In an emergency situation in which the nurse is trying to save the patient's life, if the patient does not or cannot consent to treatment, the nurse usually will not be held to have assaulted the patient. Hence, Answer 3 is also a true statement. Consent may be given by conduct as well as by expressed words, as in Answer 4. For example, in a case in which a person held up his arm to be vaccinated, the court said he had consented. However, it is best to get the consent in writing, specifically outlining the treatment or procedure to be performed. The consent will most likely be deemed invalid, however, if the patient is a child, is mentally incompetent, or is intoxicated. Eliminate the three true statements A nurse gave a patient the wrong medication. The patient was seriously injured. The patient sued. Who will most likely be held liable? The nurse. No one, because it was just an accident. The hospital. The nurse and the hospital. Both the nurse and the hospital can be sued for damages if a mistake the nurse makes injures the patient. The nurse is always responsible for his or her own actions. The hospital, as the employer, will be vicariously liable under the respondeat superior doctrine—the employer is liable for the negligent conduct of its nurses when the act was committed within the scope of employment. Answers 1 and 3 are incomplete; Answer 2 is incorrect. The best answer is based on the respondeat superior doctrine, under which the hospital is also liable The supervisor of a cardiovascular unit, responsible for checking staffing patterns, assigned a particular staff nurse to work on the unit because that nurse had many years of experience on that unit. That evening, this staff nurse made a treatment error and a patient was injured. Who is liable? The staff nurse. The staff nurse and the supervisor. The staff nurse and the hospital. The staff nurse, the supervisor, and the hospital. The hospital is always initially held liable under the theory of respondeat superior—vicarious liability of the employer. Answers 2 and 4 are incorrect because the supervisor would not be responsible unless the court thought that the supervisor was negligent in supervising or assigning a task beyond the capabilities of another. In this case, the staff nurse had had numerous years of experience on the cardiovascular unit. Without further data, the supervisor would not be considered negligent for assigning this nurse to the cardiovascular unit. Answer 1 is incomplete. The best answer is based on respondeat superior, under which the hospital is also liable Nurse A noticed that Nurse B was intoxicated while giving care. However, Nurse A did not report this fact to the super visor. That same day, Nurse B made a medication error and a patient was injured. Who may be held responsible? Nurse B (the one intoxicated). Nurse A, Nurse B, and the hospital. Nurse A (the one who did not report Nurse B). Nurse B (the one intoxicated) and the hospital. This answer includes all parties: the hospital, Nurse A, and Nurse B. The hospital, as the employer, might be held liable under the theory of respondeat superior—vicarious liability. Nurse B would be held responsible because each nurse is personally liable for his or her own negligent actions. Nurse A might also be held responsible because every nurse is obligated to act so that patients are safe from injury. In this case, Nurse A knew of B's intoxicated state. Nurse A did not act as a reasonably prudent nurse in failing to inform a supervisor. Answers 1, 3, and 4 are incomplete. The best answer is based on both the doctrine of respondeat superior and reasonably prudent behavior A graduate nurse who was new to a unit was caring for an elderly patient. The physician on call ordered a treatment that the nurse had not heard of. The nurse should: Inform the physician of the nurse's lack of education and experience and refuse to do the treatment without supervision. Inform the physician of the nurse's lack of education and experience and then proceed to perform the treatment. Refuse to perform the treatment. Carry out the treatment to the best of the nurse's ability. If the nurse informs the physician and still carries out the treatment (Answer 2), both the nurse and the physician could be held liable if the patient is negligently harmed. The nurse would be liable for not acting as a reasonably prudent nurse, and the physician would be liable because he or she knew of the nurse's lack of knowledge and did not step in to protect the patient. If the nurse does not tell the physician and still carries out the treatment (Answer 4), the nurse would be solely liable. The nurse should not refuse to perform the treatment (Answer 3) unless she or he has no supervision. For an educated guess, first eliminate the two options in which the nurse performs the treatment (Answers 2 and 4). Then eliminate Answer 3 because to refuse without notifying the MD is not enough Which is not true about informed consent? Obtaining consent is the responsibility of the physician. A nurse may accept responsibility for witnessing a consent form. A physician subjects himself or herself to liability if he or she withholds any facts that are necessary to form the basis of an intelligent consent. If a nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the patient is "informed." The nurse who witnesses a consent for surgery or other procedure is witnessing only that the signature is that of the purported person and that the person's condition is as indicated at the time of signing. The nurse is not witnessing that the patient is "informed." Answers 1, 2, and 3 are all true statements. Look for the false option; eliminate the three true options that pertain to informed consent The day nurse tells the night nurse that the suction equipment in a patient's room is not working properly. The night nurse, who will be working with this patient, should: Follow the day nurse's suggestions on how to get the malfunctioning equipment to work. Continue to use the malfunctioning machine, hoping that it will function for the night shift. Ask the supervisor how to work with the malfunctioning equipment. Replace the equipment or report it to whomever is responsible for maintaining equipment in proper working condition. As a nurse, you should not plan to use equipment that you know is malfunctioning. You could be held liable because you were on notice and could reasonably foresee that properly functioning equipment would he needed by your patient. Hence, Answers 1, 2, and 3 are incorrect. Eliminate the three options that involve working with malfunctioning equipment A competent adult patient has refused treatment and wishes to leave AM A (against medical advice). The patient has also refused to sign any of the appropriate AMA forms. Which statement is inaccurate? The physician and/or hospital is always liable for any injury that might occur as a result of the patient's decision to leave AMA. The law usually permits competent adult patients to make decisions that may not be in their own best health interest. Even if the patient is a competent adult, the law may interfere with the patient's decision to refuse medical treatment if the patient has small children that need care. The physician might be held liable if it can be proved that the patient did not receive sufficient information about risks involved with leaving AMA. This is the only clearly false option. Neither the physician nor the hospital would ordinarily be liable if (a) the medical risk is explained and a full report concerning the incident is documented and (b) the patient is a competent adult. The court does not usually interfere with one's right to refuse treatment, as in Answer 2. However, the court will closely scrutinize a situation in which the patient's refusal to accept treatment results in death or in the patient's inability to care for children. If the children might be left as wards of the court, the court may force the patient to accept treatment, as in Answer 3. Hence, Answers 2, 3, and 4 do not apply, because they are true. Eliminate the three true/correct options pertaining to AMA The only Spanish-speaking nurse in the emergency department admitted a 6-year-old child. The child's mother explained in Spanish that she had removed two ticks from the child the previous day. The child was now running a very high temperature and had a rash on the abdomen. The nurse reported the information to the emergency department physician, who did not speak Spanish. The nurse failed to tell the doctor about the ticks. The physician diagnosed the child as having measles. Over the course of the day, the child's health deteriorated until the child died. Who is liable? The nurse. The nurse and the physician. The nurse and the hospital. The physician. The court in John Ramsey, Jr. et al. v. Physicians Memorial Hospital, Inc. et al. stated that "evidence supported finding that the failure of nurse to notify physician of client history involving removal of ticks from one of the children constituted a violation of her duties as a nurse, and failure to relate the information to the physician was the contributing proximate cause of death of the child." The hospital is also held liable under the doctrine of respondeat superior for the negligent conduct of its nurses when committed within the scope of their employment. Hence, Answer 1 is incomplete because it does not include the hospital. The physician would most likely not be held liable because of the language barrier and the nurse's clear failure to communicate. Hence, Answers 2 and 4 are incorrect. Choose the option that involves the hospital under respondeat superior doctrine A nurse was on weekend call for the operating room. Late Saturday night, the nursing supervisor called the nurse to say that they were expecting an emergency appendectomy within the hour. While gowning the surgeon, the nurse smelled alcohol on the doctor's breath. The nurse mentioned this to the anesthesiologist, who also admitted smelling alcohol on the surgeon. Both the nurse and the anesthesiologist felt the surgeon was somewhat unstable on his feet. However, neither the nurse nor the other doctor said anything. If the patient had been injured during the surgery, who would have been liable? Nurse, anesthesiologist, surgeon, and hospital. Nurse and surgeon. Surgeon and hospital. Hospital, surgeon, and anesthesiologist. Both nurses and doctors are under a duty to protect the safety of their patients. In this case, the patient's safety was potentially jeopardized, yet neither the anesthesiologist nor the nurse reported the situation. Therefore, if something had happened to the patient during surgery, the court could have made a good argument that all were negligent. Hence, Answers 2, 3 and 4 are incomplete. What can a nurse do in a situation as described here? First, for the nurse's own safety, he or she should prepare a summary of the incidents. The nurse might also consult with nurse colleagues who have worked with the physician, because they could confirm or deny the problem and possibly offer support. Second, the nurse should report the incident to the supervisor and director of nursing, who have a liaison with the surgical/medical staff. If the action is not pursued successfully, the nurse can bring the problem to the attention of the hospital administrator. Again, if no action is forthcoming, the nurse may seek out a board member who might be sensitive to the situation. In any case, these are difficult situations that may arise. There is no easy solution. The best answer is the most inclusive; failure to report by both nurse and doctor can he seen as negligence, and the hospital will also be liable A child about 11 months old was brought by the mother to a hospital for examination, diagnosis, and treatment. The child was seen by a nurse and physician. At the time, the child was suffering from a comminuted spiral fracture of the right tibia and fibula that gave the appearance of having been caused by twisting. The child also had numerous bruises and burns on the body. In addition, there was a nondepressed linear fracture of the skull in the process of healing. When approached, the child demonstrated fear and apprehension. The mother had no explanation for the child's wounds. No further x-rays were taken, and the child was released to the mother without report to concerned agencies. One month later the child was brought in again by the mother and was seen by a different physician. The second physician correctly diagnosed the battered-child syndrome and filed the proper reports. The child was placed in a foster home, and the foster home filed suit. Who may be liable? First nurse, first doctor, and hospital. First doctor. No one. First nurse. Most state statutes provide that every hospital to which any person is brought who is suffering from any injuries inflicted by another must report the fact immediately to the local law enforcement authorities. Most state statutes also impose the same duty on other health care professionals, school officials and teachers, child care supervisors, and social workers. Hence Answers 2 and 4 are incomplete; Answer 3 is incorrect. From Landeros v. Flood as well as other cases, it seems clear that the responsibility of professional people—doctors, nurses, and others who must deal with injured children—includes the duty to report suspicious evidence to the proper authorities. Choose the most inclusive answer, involving all concerned as mandated by state laws regarding reporting suspected abuse While getting a patient ready for surgery, the nurse removed the patient's dentures. The nurse wrapped the dentures in a towel so as not to break them and left them on the bedside stand. While the nurse was out of the room, two nursing aides stripped the bed and threw all the linen, including the towel, in the laundry hamper. Upon returning from surgery, the patient requested the dentures. However, the nurse and nursing aides were unable to find them. Who is liable? The nurse. The nurse and the hospital. The nurse and nursing aides. The nurse, nursing aides, and hospital. However, it could be argued that Answer 1 is correct. The nurse's liability for the negligent loss of or damage to a patient's property is based on the nurse's duty as a person, trained or untrained, to act as a reasonable and ordinary, prudent person. In this case, the nurse put the dentures in a towel without a label. The nurse might reasonably expect that aides would be stripping the linen after the patient left for surgery. Therefore, this act was not that of an ordinary prudent person. The nurse would be liable. Because the nurse is liable, the hospital, as employer, might also be held liable. This would be for court determination. Because the aides had no knowledge of the dentures, and they were acting reasonably, they would not be liable for the lost dentures. Hence, Answers 3 and 4 are incorrect. Remember, the hospital may also be liable under respondeat superior. Eliminate the two options that include the aides, who were acting as an ordinary prudent person would act A teenage girl who had complained of dizziness the previous day wanted to take a shower. The physician gave permission for the patient to shower with assistance. The nurse started to get the girl out of bed and over to the shower. The nurse questioned the patient about her dizziness. The girl replied that she was not dizzy. The mother then said that she would watch her daughter in the shower and help her back to bed. The nurse then left the room. While the nurse was out, the patient fainted getting back into bed. The patient injured her head. Who is liable? The nurse. The doctor, nurse, and hospital. The nurse and the hospital. No one. Although Answer 4 is best, this is a very close case. When family members help with a hospitalized patient, liability becomes complicated. Where members of the nursing team offer to assist patients in bathing, feeding, and so on, and an apparently capable family member prefers to assist the patient, this is usually acceptable and neither the hospital nor the health care team is liable. Thus, Answers 1, 2, and 3 can be eliminated as correct choices. However, the nurse should never assume that the presence of a family member obviates the nurse helping the patient. Eliminate options 1, 2, and 3 that include the nurse and the hospital, because they are not liable when family members prefer to assist What does the Durham Test state about the accused? The same thing as the M'Naghten Rule. Accused is not criminally responsible if the act was the product of mental disease. Accused is not criminally responsible if the act was a result of impulsiveness. Accused is not criminally responsible if he or she does not appreciate the wrongfulness of the act. The Durham Test says that a person is not criminally responsible if the act was a product of mental disease. Answer 1 is incorrect because the M'Naghten Rule states that a person is insane if he or she cannot determine right from wrong. Answer 3 is wrong because it is not what the Durham Test states. Answer 4 is wrong because it is an interpretation of the M'Naghten Rule. Know the difference between the Durham Test and M'Naghten Rule, to eliminate 1 and 4. What does voluntary admission require of the individual? The individual must ask to be admitted to a psychiatric hospital and must agree to abide by its rules. The request for hospitalization must originate with the individual to be admitted. The individual must make written application to a hospital, agree to treatment, and agree to abide by the rules. The individual is responsible for the hospital bill. The request must be in writing. Answers 1 and 2 are true but incomplete. Answer 4 has nothing to do with voluntary admission. Choose the complete response (Answer 3) and eliminate Answers 1 and 2 as incomplete. Eliminate Answer 4 as irrelevant to the question Standards of practice for psychiatric mental health nursing have been developed by: A joint commission of psychiatric nurses and psychiatrists. Psychiatric nurses who are members of the American Nurses' Association. A panel of representative psychiatric nurses in the United States. The Division on Psychiatric and Mental Health Nursing Practice of the American Nurses' Association. This division of the ANA sets the standards; therefore, Answer 1 cannot be correct. Answers 2 and 3 are also incorrect, although they may be part of Answer 4. When two or more options are correct (Answers 2 and 3), choose the one that encompasses them (Answer 4). Eliminate Answer 1 because it includes an MD. The standards of practice for psychiatric mental health nursing are organized around: Different models of treatment. Rights of the clients. The nursing process. Legal aspects of treatment. Answers 1, 2, and 4 may be referred to in the standards, but the standards were organized around the nursing process. When all four options are right, choose the umbrella option that includes them all. The Community Mental Health Centers Amendments of 1975, Title III of Public Law 94-63: Cut the flow of funds to community mental health centers and set forth general guidelines for service. Extended the flow of funds to community mental health centers and set forth specific guidelines for service. Cut the flow of funds to community mental health centers and set forth specific guidelines for service. 4 Extended the flow of funds to community mental health centers and set forth general guidelines for service. The Amendments extended the flow of funds and set forth specific guidelines for service. Answer 1 is incorrect because it did not cut funds or set general guidelines. Answer 3 is incorrect because it did not cut funds. Answer 4 is incorrect because it did not set general guidelines. Eliminate two options that cut the funding; select the option regarding specific guidelines, rather than general. Congress, in the Mental Health Centers Act of 1974, also stated that it wanted to: Increase federal operation funds to centers and have centers under federal support. Provide funding on a declining basis at the federal level and encourage the goal of independence from federal support. Provide funding on a declining basis at the federal level but maintain federal control. Get out of the community mental health business. Congress intended to provide funding on a declining basis and to encourage independence from federal support. Answer 1 is incorrect because Congress does not want centers under continual federal support. Answer 3 is incorrect because it did not want to maintain federal control. Answer 4 is incorrect because although Congress wanted declining funding and control, it remains interested in community mental health centers. Eliminate two options that maintain federal control (Answers 1 and 3); choose the option that is the opposite of "control," that is, independence from federal control. The principal recommendation of the Report of the President's Commission on Mental Health, 1978, was: The federal government should get out of mental health. The government should upgrade the old federal grant program for community mental health to encourage the creation of necessary services where they are inadequate and to increase the flexibility of communities planning a comprehensive network of services. Community mental health programs should strictly adhere to the provision of specific services to all communities. A new federal grant program should be established for community mental health to encourage the creation of necessary services where they are inadequate and to increase the flexibility of communities planning a comprehensive network of services. This was the principal recommendation. Answer 1 is incorrect. Answer 3 is incorrect because the commission wanted flexibility in services. Answer 2 is incorrect because the commission did not want to upgrade the old grant; it wanted to provide a new one. Eliminate Answer 1 as totally wrong; eliminate Answer 2 because flexibility is desirable; narrow the choice to upgrade old or provide new grant; choose "new." For nurses to control their own profession, they must demonstrate: Expertise in implementing patient care levels already determined by law. The ability to participate in the drafting of health care laws that directly reflect patient care levels. The ability to participate in the drafting of laws at all levels and in all areas of health care. Neutrality by ignoring political power, thus being free from political influence in giving health care. Nurses, for control and better health care, should be active at all levels and in all areas of health care. Answer 1 passively carries out others' ideas. Answer 2 is too limited in scope. Answer 4 is also passive, with an additional loss of control. Choose the broadest scope of involvement ("all areas of health care") The lCN's Code for Nurses, "Ethical Concepts Applied to Nursing," approved by the Council of Nurse Representatives in 1973, states that: The professional body of nurses of a particular country carries the responsibility for nursing practice and for maintaining competence. The hospital employing the nurse carries the responsibility for nursing practice and for maintaining competence. The laws of the country in which the nurse works carry the responsibility for nursing practice and for maintaining competence. The individual nurse carries personal responsibility for nursing practice and for maintaining competence by continual learning. This is what the document states. Other choices (1, 2, 3) do not give the individual nurse primary responsibility. Eliminate the three options ("body of nurses," "hospital," "laws") that do not focus on the individual nurse (Answer 4). The National Health Planning and Resource Development Act of 1974 allows: Physicians the largest representation on local and state health care boards that make decisions about health care. Hospital administrators the largest representation on local and state health care boards that make decisions about health care. The consumer the largest representation on local and state health care boards that make health care decisions. Health professionals as a group the largest representation on local and state health care boards that make health care decisions. The Act states that the boards must be composed of 60% consumers who are not affiliated with any health professional group; hence, Answers 1,2, and 4 are incorrect. Choose the option that focuses on the consumer. In which situation should the nurse submit a report as a legally mandated reporter? A pregnant patient states that her boyfriend hit her once when he was drunk. A patient in the Family Planning Clinic has a positive HIV screening test result. An elder who is disoriented states that the nurses are yelling at her and calling her names at night. The neighbors of an elder complain that her son is verbally abusive to her She denies it. Emotional abuse of an elder is reportable, and the complaint of neighbors is a reasonable suspicion even if the elder denies it. Answer 1 is incorrect because, between adults, actual observation of the abuse or of trauma from the abuse is necessary for a report. Answer 2 is incorrect because HIV results are strictly confidential and may not be disclosed with out the patient's permission under any circumstances. Answer 3 is incorrect because, without corroborating reports, confusion may be causing the elder to misinterpret the situation. It is not enough for a reasonable suspicion. The abused person does not have to admit to the abuse, may deny it, and may even beg to have it go unreported. The nurse is still obligated to file the report The nurse is reviewing medications on the MD's order sheet and notes a medication with a dose that is two times greater than the customary dose. The nurse should: Understand that there may be special circumstances in which additional medication is needed and give the medication as ordered. Ask the patient if the patient has been receiving the dose of medications as ordered. Check with the nurse from the previous shift to see if the medication was given as ordered. Discuss the question about the drug with the physician who ordered it and record the results of the discussion. The nurse is ethically and legally obligated to question orders that appear incorrect in order to protect the patient from harm. Answer 1 is incorrect because, although the ordered dose may be appropriate, the nurse may not assume so without questioning the order first. Answer 2 is incorrect because the patient is not an appropriate source to validate a medication order. Answer 3 is incorrect because the actions of nurses on previous shifts do not remove the obligation to question the order, unless there is a clear note that the order has been questioned and the doctor, using medical judgment, has validated the dose. Test taking tip As a patient advocate, the nurse is obligated to protect the patient from harm even if the nurse is exposed to anger or frustration on the part of other health care practitioners. Always select the choice that minimizes the harm to the patient The nurse is supervising the actions of a certified nursing assistant in providing care to three newborns. The nursing assistant erroneously gives a formula feeding to a newborn who is on water feedings only. The nurse is liable for the mistake of the nursing assistant: Always, because nurses who supervise less-trained individuals are responsible for their mistakes. If the nurse failed to determine whether the nursing assistant was competent to take care of the patient. Only if the nurse agreed that the newborn could be fed formula. Always, as a representative of the institution. The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as a legal obligation to provide adequate supervision. Answer 1 is incorrect because competent individuals are responsible for the consequences of their own behavior. The nurse would not be liable unless the nurse contributed to the mistake or negligence. Answer 3 is incorrect because the nurse could be liable if the nurse failed to provide adequate supervision or failed to determine that the nursing assistant was competent to perform the assignment. Answer 4 is incorrect because the nurse is not the employer of the nursing assistant. It is the employer who is liable for the actions of employees. Eliminate options that impose absolutes such as "always" or "never." The nurse is in charge of the newborn nursery. A postpartum mother notifies the nursery that the wrong baby was brought to her hospital room. The nurse determines that two babies were placed in the wrong cribs. The most appropriate action by the nurse would be to: Record the event in an incident/variance report and notify the nursing supervisor. Reassure both mothers, report to the charge nurse, and do not record. Determine who is responsible for the mistake and terminate his or her employment. Record detailed notes of the event on the mother's medical record. Every incident that exposes a patient to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problem and permit the institution to prevent the problem from happening again. Answer 2 is incorrect because the harm to future patients is not prevented, as would be the case it an incident report was filed. Answer 3 is incorrect because it is usually not the role of the nurse alone to terminate employment, and termination of employment may not be indicated by this incident. Answer 4 is incorrect because recording the event on the medical record does not adequately put the hospital on notice of potential harm to patients. The duty to protect the patient from harm (to act as patient advocate) almost always involves extensive and appropriate reporting One of the ethical obligations for nursing is accountability. Accountability means that the staff nurse is responsible for: The behavior of patients who are noncompliant. The consequences of his or her actions, even mistakes in judgment. The behavior of other staff members who are negligent in their nursing care. The consequences of an administration decision to decrease nursing staff. Accountability means responsibility for nursing actions and the consequences of those actions even if an honest mistake in judgment is made. Answer 1 is incorrect because the patient has the right to consent to or refuse treatment and the nurse is not responsible for making the patient compliant. Answer 3 is incorrect because the nurse would only be accountable for the actions of other staff members if the behavior of the nurse contributed to the negligence and negative consequences. Answer 4 is incorrect because, although the nurse may be responsible for providing correct assessments of the need for nurses, the administrative decision is not within the role of the staff nurse. Nurses are always responsible for the positive and negative consequences of their own behavior. Responsibility for the actions of other staff is a function of the position of the nurse, as well as the potential for harm to the patient The nurse in the labor and delivery unit administered a dose of terbutaline to a patient without checking the patient's pulse. The standard that would be used to determine if the nurse was negligent is: The actions of a reasonably prudent nurse with similar education and experience. The statements in the drug literature about administration of terbutaline. The actions of a clinical nurse specialist who is a recognized expert in the field. The orders of the patient's physician. The standard of care is determined by the average degree of skill, care, and diligence exercised by nurses in similar circumstances. Answer 2 is incorrect because the drug literature, although informative, cannot recognize all of the circumstances that might be involved in a particular patient situation. Answer 3 is incorrect because the clinical specialist/ expert may not be a nurse with similar education and experience and would be held to a higher standard of rare. Answer4 is incorrect because the nurse's role is not limited to the direction or order of a physician. Liability/accountability/responsibility is determined by a nursing standard; and levels of education and experience influence the standard of behavior expected of individual nurses A nurse is regularly assigned to the newborn nursery. On a particular shift, two of the regularly assigned staff members are on sick time and no new staff is available for assistance. The nurse should: Provide nursing care only to those patients regularly assigned. Prioritize care so that all patients receive reasonably safe care. Refuse the nursing assignment because the increased number of patients makes it unsafe. Take all of the babies out to their mothers to take care of them. In the case of unusual circumstances, a test of reasonableness is applied. The nurse is expected to be flexible enough to prioritize care, and the minimal level of accept able care is patient 2 Answer 1 is incorrect because providing customary or ideal care to some patients and leaving others without care would not meet the test of reasonableness. Answer 3 is incorrect because refusing the assignment would expose the patients to harm from abandonment. Answer 4 is incorrect because care by family members does not obviate the need for nursing care or attendance by the nurse. The option that includes patient safety without abandonment is usually correct. Options including abandonment are rarely correct. Note that the key word in Answer 2 is "prioritize," which is a key concept The nurse on the labor and delivery unit is assigned to a primigravida in transition complicated by hypertension. A new patient, also in active labor, is admitted to the unit, and the nurse manager informs the nurse that the nurse will be assigned to the new patient as well. The nurse feels that the first patient requires one-to-one care. The nurse should first: Accept the new assignment and provide the best care possible. Accept the new assignment and complete an incident report describing a shortage of nursing staff. Report the incident to the nursing supervisor and request to be floated. Report the nursing assessment of the patient in transitional labor to the nurse manager and discuss misgivings about the new assignment. The nurse is obligated to inform the nurse manager about changes in the condition of the patient, which may change the decision made by the nurse manager. Answer 1 is incorrect because the nurse has an obligation to protect the patient from harm, which requires the nurse to inform the nurse manager about the changing status of the patient. Answer 2 is incorrect because an incident report does not protect the first patient from harm, although an incident report may be indicated to prevent future harm. Answer 3 is incorrect because, by abandoning the first patient, the nurse exposes the patient to harm and does not protect the patient from harm. Being floated may protect the nurse from harm, but it does not assist the patient. Note the key word "first" in the stem. Answers that involve a reasonable and flexible approach to care with adequate reporting are often correct During a home visit to a new mother with a 1-week-old baby, the nurse observes that the baby appears anxious and distressed and is difficult to console when crying. The fontanels are slightly sunken. The baby has one to two wet diapers per day. The urine is yellow in the diaper. The mother states that the baby has a hard time latching on to the breast nipple but she has not offered supplements because she is determined to breastfeed. The most appropriate case management decision by the nurse would be to: Refer the baby in for a medical evaluation today. Refer the mother to Women, Infants, and Children (W1C) for formula supplements. Refer the mother to Nursing Mother's Council for breastfeeding support. Schedule a repeat home visit in 1 week. The infant shows significant signs of dehydration, which requires immediate care. Answer 2 is incorrect because it fails to deal with the immediate life-threatening situation. Answer 3 is incorrect because it fails to deal with the immediate life- threatening situation. Answer 4 is incorrect because it fails to deal with the immediate life-threatening situation. When all the options appear correct, check the question again to determine if there is some key word or phrase that must be interpreted. In this case, all of the options make sense, but, to find the right one, it is necessary to recognize that the baby might have a life-threatening problem The nurse on the postpartum unit is giving medications at 10:00 a.m. The nurse enters the room of a patient, calls the patient by name, checks the name band for accuracy, and administers an oral vitamin. After the patient swallows the pill, she states that another nurse has also given her this same pill just 1 hour ago. The nurse checks the medication record and finds that another nurse has signed off the drug entry. The most appropriate action by the nurse is to: Report the first nurse to the nurse manager for not informing the medication nurse that a drug had been given. Submit an incident report describing the circumstances of the medication error. Do nothing because the patient was not harmed by the second vitamin. Notify the patient's physician and ask for advice. It is the legal and ethical obligation of the nurse to report incidents such as medication errors that expose a patient to harm. Failing to check the medication record to see if a drug had been given is a form of medication error. Answer 1 is incorrect because it fails to discharge the legal and ethical obligation of the nurse to report a medication error. Answer 3 is incorrect because actual harm to the patient is not a prerequisite for filing an incident report, and failure to report the incident does nothing to prevent future incidents. Answer 4 is incorrect because it is not the legal and ethical obligation of the physician to inform the nurse about the need to report a medication error. Incidents involving harm to the patient involve a strong obligation to report them adequately, even if it puts the nurse in the position of experiencing negative consequences, and even if the patient is unharmed. It is only necessary to have the potential for harm What should be included in the nurse's response when the patient asks for factual information about becoming an organ donor? A donor can be any age. Verbal consent would be sufficient. Family members must also give their consent. There are some contraindications for being an organ donor. The only factually correct answer would include information about contraindications (e.g., HIV-positive status and a person with metastatic cancer). Answers 1, 2, and 3 have incorrect information: (1) a donor must be at least 18 years of age; (2) Knowledge about the Uniform Anatomical Gift Act will identify the only correct option and eliminate the other three options A terminally ill patient tells the nurse during a home health care visit that he does not want CPR when the time comes. What should be the nurse's next action? Document the request in the health care plan. Talk to the family about this request. Obtain an order from the MD. Share this information with other members of the home health care team. A Do Not Resuscitate (DNR) order is required. Answers 1, 2, and 4 are also appropriate, but not as great a priority as notifying the MD, who must provide a written order. Prioritization is required. Note the key words "next action." Which is an accurate statement regarding the role of a nurse as a patient advocate? A nurse helps patients gain greater independence and self-determination. A nurse measures the risk and benefits of various health situations while factoring in cost. A nurse has the moral obligation to prevent harm and do good for patients. A nurse may override patients' wishes for their own good. An advocate role encourages freedom of choice, includes speaking out for the patient, and supports the patient's best interests. Answer 2 is the definition of cost-benefit analysis. Answer 3 is an ethical principle. Answer 4 is a liberty-limiting principle, called paternalism, that does not allow patients' preferences. Key word is role, not ethical principle (3, 4). Cost-benefit analysis is a course of action, not a role Which assignment would the RN give to a nursing assistant? Assisting a recently admitted post-cerebrovascular accident patient to eat. Admitting a patient to the unit who is being transferred from ICU. Taking vital signs on a postoperative patient whose blood transfusion is about to end. Irrigating a Foley catheter that is not draining well. This is a routine function, when the danger of a transfusion reaction is not likely to occur at the conclusion of this treatment. Answer 1 requires the assessment by a licensed professional for potential for aspiration in a newly admitted patient who has had a stroke. Answer 2 requires assessment of status at admission and is the role of the RN. Answer 4 may be assigned to an LVN/LPN, not a nursing assistant. The key concept is "assessment." Any activity that requires assessment is carried out by an RN, with knowledge, ability, and skills, not a nursing assistant In providing an orientation for the new graduate nurse on case management, which characteristic should be included in the discussion about what is case management? Main focus is comprehensive coordination of patient care, avoid unnecessary duplication of services, improve resource utilization, and decrease cost. Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems. Main purpose is to identify expected patient, family, and staff performance against the timeline for patients with the same diagnosis. Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care. There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations, and continually monitor progress over time. Answer 2 describes variance analysis. Answer 3 states the purpose of a care map. Answer 4 is the description of a case management tool, the critical path. The other options define different tools of case management, not the concept itself What level of prevention is the nurse's goal in the community following an earthquake? Primary level of prevention. Secondary level of prevention. Tertiary level of prevention. Quaternary level of prevention. The nurse's goal is to reduce the extent of injury, death, and damage after this crisis (e.g., by providing housing for survivors, obtaining physical care, providing counseling and support for families). Answer 1 would involve prevention of the crisis from happening (which is not realistic in a natural disaster). Answer 2 involves reduction of intensity and dura tion (which is also unrealistic). Answer 4 is nonexistent as a level of prevention. Picture the aftermath of an earthquake and apply knowledge of levels of prevention used by nurses in disasters Which situation would be an example of professional mal practice by a nurse? An infant is injured as a result of incorrect information provided to the parents by the nurse on the use of a child safety restraint in the car. The nurse inadvertently throws away the container holding the patient's dentures. A patient is ambulating in the hall and slips on a recently mopped floor, causing injury to his leg. A visitor who is sitting by the patient's bed is hit by a falling IV pole while the nurse is changing the IV tubing, and requires stitches for a laceration. The definition of malpractice is the "incorrect or negligent treatment of a patient." Included would be incorrect instructions that resulted in injury. Answers 2 and 3 are careless and would likely require the hospital to compensate the patient for the loss or injury. Answer 4 is an accident, not malpractice or negligence. Think of the meaning of the word malpractice—"bad practice." Which situation puts the patient at risk because of the nurse's action? The nurse manager has requested a social worker see the following patients. Which one requires assistance first? A 30-year-old woman, who is homeless, newly diagnosed with diabetes. A 70-year-old man with heart failure and no insurance coverage. A 55-year-old man, with a history of a recent myocardial infarction, who is in the midst of a divorce. A 60-year-old woman, post-cerebrovascular accident, who has been living alone. Although all of the patients need social service and discharge assistance, the newly diagnosed diabetic is at greatest risk for complications from the condition and the potential for poor management. Proper diet and safe medication administration would be difficult for a person who is home less. Answers 2, 3, and 4 do not pose the most immediate risk to the patient. Note the pattern in the responses: three options are concerned with cardiovascular conditions, one with diabetes. Choose the one that is different (1). Two of the conditions are past history; the best option states "newly diagnosed." In which one of the following patient situations would it be inappropriate for the RN to delegate the care to the nursing assistant? A postoperative patient who is stable needs to ambulate. Routine temperature check that must be done for a patient at end of shift. A confused elderly woman who needs assistance with eating. Patient in soft restraints who is very agitated and crying. The RN cannot delegate the responsibility for assessment and evaluation of patients. The status of the patient in restraints requires further assessment to determine if there are additional causes for the behavior. Answers 1, 2, and 3 are implementation of the nursing care plan, not assessment. The first step in the nursing process, assessment, cannot be delegated by the RN When checking the IV solution at the beginning of the shift, it was discovered that an incorrect solution was running. After changing the solution to the correct order, an appropriate nursing action would be to: Report the discovery of the error to the supervisor. Document the error and correction in the medical record. Fill out an incident report according to hospital policy. Assure the patient that the error had no adverse effects. A quality assurance report or incident report should be completed and submitted according to hospital policy. The report would indicate that the MD was notified, the status of the patient, and any orders as a result of the error. The supervisor (Answer 1) should be notified, but not before completing the incident report. It is also most important to notify the MD before completing the report. Incidents are not usually documented in the patient (medical) record (Answer 2). If unsure of hospital policy, hospital risk management should be consulted. Open communication with patients is important (Answer 4); however, unless there was an adverse effect that required additional treatment or a change in treatment, it is unlikely that the physician will inform the patient. When two options are correct, select the one that encompasses the other. The incident report (Answer 3) also serves to inform the supervisor (Answer 1)