Legal and Ethical Issues
A nurse is caring for a terminally ill patient who is experiencing significant pain. The patient expresses a desire to receive pain medication but is concerned about potential side effects and their impact on alertness. According to the principle of beneficence, which of the following actions should the nurse take?
A. Administer the pain medication as prescribed and educate the patient about managing side effects.
B. Withhold the medication to prevent any potential side effects.
C. Encourage the patient to use non-pharmacological methods for pain relief only.
D. Inform the patient that they may not receive any pain medication if they are not alert.
Correct Answer:
A. Administer the pain medication as prescribed and educate the patient about managing side effects.
Rationale:
A nurse is caring for a patient diagnosed with an impulse control disorder. Which of the following manifestations should the nurse expect to observe in this patient?
A. Excessive worry about daily activities and responsibilities.
B. Recurrent episodes of aggressive behavior or property destruction.
C. Obsessive thoughts about cleanliness and order.
D. Persistent feelings of sadness and hopelessness.
Correct Answer:
B. Recurrent episodes of aggressive behavior or property destruction.
Rationale:
A 30-year-old female patient is brought to the clinic by her partner, who reports that she has lost interest in activities she once enjoyed, has been sleeping excessively, and expresses feelings of worthlessness. During the assessment, the nurse notes that the patient has a flat affect and difficulty concentrating. Which of the following nursing diagnoses is the priority for this patient?
A. Risk for self-harm
B. Ineffective coping
C. Impaired social interaction
D. Disturbed sleep pattern
A. Risk for self-harm
Rationale: In patients with Major Depressive Disorder, the risk for self-harm is a significant concern due to potential suicidal ideation. While ineffective coping, impaired social interaction, and disturbed sleep patterns are relevant, ensuring the patient's safety is the top priority.
The nurse is reviewing the history of a client who has recently been diagnosed with generalized anxiety disorder (GAD). Which of the following risk factors should the nurse identify as modifiable and nonmodifiable?
Modifiable
B. Recent life stressors, such as job loss (modifiable)
D. Substance abuse (modifiable)
Non Modifable
A. Family history of anxiety disorders (nonmodifiable)
C. Childhood trauma (nonmodifiable)
Rationale:
A nurse is working in a community health clinic that serves a diverse population. The clinic has a limited supply of a new, highly effective medication for managing a chronic condition. The nurse must decide how to allocate the medication fairly among patients who need it. Which action by the nurse best demonstrates the principle of justice?
A. Giving the medication to the patients who are most likely to adhere to the treatment plan.
B. Distributing the medication on a first-come, first-served basis to ensure fairness.
C. Prioritizing the medication for patients who are most at risk for severe complications without it.
D. Alternating distribution between patients of different socioeconomic backgrounds to ensure diversity.
C.
Prioritizing the medication for patients who are most at risk for severe complications without it.
Rationale:
The principle of justice in nursing ethics involves distributing resources fairly and equitably, taking into account the needs of all patients. Prioritizing patients who are most at risk for severe complications
Which action by a nurse best exemplifies the ethical principle of non-maleficence?
A. Administering pain medication as prescribed to a patient in severe pain.
B. Respecting a patient’s decision to refuse treatment even if the nurse believes it would benefit the patient.
C. Ensuring that a patient has all the necessary information to make an informed decision about their care.
D. Double-checking a medication dosage before administration to prevent potential harm to the patient.
D. Double-checking a medication dosage before administration to prevent potential harm to the patient.
Rationale
Non-maleficence is the ethical principle of "do no harm."
A nurse is working in a psychiatric unit and has four clients with varying mental health conditions. The nurse must prioritize care based on the patients’ immediate needs. The clients include:
Which patient should the nurse prioritize for immediate intervention?
A) The 16-year-old with Oppositional Defiant Disorder (ODD).
B) The 25-year-old engaging in non-suicidal self-harm.
C) The 32-year-old experiencing mania.
D) The 19-year-old with Intermittent Explosive Disorder (IED).
Correct Answer: D) The 19-year-old with Intermittent Explosive Disorder (IED).
Rationale: The patient with IED (D) requires immediate intervention due to the acute risk of harm to themselves or others following an aggressive outburst. Ensuring safety for all clients is the highest priority in this scenario. While the other patients also need attention and interventions, the immediate concern for the patient with IED takes precedence due to the potential for violence and safety risks. The nurse must first stabilize the situation before addressing the other clients' needs.
A 27-year-old female patient is admitted to the psychiatric unit following a suicide attempt by overdose. During the initial assessment, the nurse notes that the patient expresses feelings of hopelessness and despair. She states, "I just don't see the point in living anymore." Which of the following actions should the nurse prioritize to ensure the patient’s safety?
A. Contact the patient's family to inform them of her condition.
B. Place the patient in a private room to allow her to rest quietly.
C. Perform a detailed assessment of the patient's suicide risk, including intent, plan, and means.
D. Encourage the patient to participate in group therapy sessions to express her feelings.
Correct Answer: C. Perform a detailed assessment of the patient's suicide risk, including intent, plan, and means
Rationale:
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? Select all that apply
A. Excessive worry for 6 months
B. Impulsive decision making
C. Delayed reflexes
D. Restlessness
E. Sleep Disturbances
Correct Answer
A.
D.
E.
A 32-year-old patient with schizophrenia has been prescribed clozapine. During a follow-up visit, the nurse reviews the patient’s laboratory results and current symptoms. Which of the following findings would be of most concern to the nurse as a potential adverse reaction to clozapine?
A. Heart rate of 82 beats per minute
B. Neutrophil count of 1,000 cells/mm³
C. Mild hand tremors
D. Weight gain of 2 pounds in one month
Correct Answer: B. Neutrophil count of 1,000 cells/mm³
Clozapine is associated with several potential adverse reactions, the most serious of which is agranulocytosis, a condition characterized by a dangerously low number of neutrophils (a type of white blood cell). A neutrophil count of 1,000 cells/mm³ is significantly below the normal range and indicates neutropenia, which can progress to agranulocytosis. This condition requires immediate medical attention and possibly discontinuation of the drug.
A nurse is working on a psychiatric unit and is tasked with creating a therapeutic milieu for clients. Which of the following actions should the nurse prioritize to ensure a supportive environment?
A. Allow clients to choose their daily activities and schedules without any structure.
B. Facilitate structured group activities that encourage social interaction and communication.
C. Maintain strict rules and regulations without providing rationale to clients.
D. Isolate clients who exhibit disruptive behavior to maintain order on the unit.
Correct Answer:
B. Facilitate structured group activities that encourage social interaction and communication.
Rationale:
A nurse is assessing a child who is suspected of having Oppositional Defiant Disorder (ODD). Which of the following manifestations are consistent with ODD? (Select all that apply)
A) Frequent outbursts of uncontrolled anger
B) Arguing with authority figures or adults
C) Delinquent behavior
D) Blaming others for their mistakes
E) Questioning and refusing to comply with rules
F) Persistent sad or depressed mood
A) Frequent outbursts of uncontrolled anger; B) Arguing with authority figures or adults; D) Blaming others for their mistakes; E) Questioning and refusing to comply with rules
Rationale : Oppositional Defiant Disorder (ODD) is characterized by a frequent and persistent pattern of anger, hostility, irritable mood, disobedience, and defiant behaviors. Typical symptoms include frequent outbursts of uncontrolled anger (A), arguing with authority figures or adults (B), blaming others for their mistakes (D), and questioning and refusing to comply with rules (E). Delinquent behavior (C) is not typical of ODD, as ODD behaviors are more about problematic interactions with authority figures and others rather than engaging in criminal activities.
A 17-year-old female patient is admitted to a psychiatric unit after her mother discovered her with several fresh cuts on her forearms. During the initial assessment, the nurse notes that the patient appears withdrawn and avoids eye contact. She expresses feelings of hopelessness and mentions, "I just want to feel something." Which of the following nursing interventions should the nurse prioritize for this patient?
A. Encourage the patient to talk about her feelings in detail.
B. Establish a safety plan to prevent further self-harm.
C. Administer prescribed antidepressant medication immediately.
D. Assign the patient to a room alone to promote privacy.
B. Establish a safety plan to prevent further self-harm.
Rationale:
Establishing a safety plan is critical to ensuring the patient's immediate safety and preventing further self-harm. While encouraging the patient to express her feelings is important (Option A), it should occur after ensuring safety.
A nurse is caring for a client diagnosed with generalized anxiety disorder (GAD) who is being treated with medication. The healthcare provider prescribes duloxetine (Cymbalta) as part of the treatment plan. Which of the following statements by the client indicates a correct understanding of the purpose of duloxetine?
A. "This medication will help me feel more energized and less fatigued."
B. "Duloxetine will reduce my anxiety by increasing serotonin and norepinephrine levels in my brain."
C. "I should take this medication only when I'm feeling anxious."
D. "I can stop taking this medication once I feel better."
Correct Answer:
B. "Duloxetine will reduce my anxiety by increasing serotonin and norepinephrine levels in my brain."
Rationale:
A 10-year-old child is brought to the pediatric clinic for a routine check-up. The nurse notes that the child has been performing poorly in school, has frequent stomach aches, and appears anxious. Upon further questioning, the nurse learns that the child has witnessed domestic violence between their parents and that one parent has a history of substance abuse.
Which of the following ACEs should the nurse identify based on the information provided? (Select all that apply.)
A. Physical abuse
B. Witnessing domestic violence
C. Parental substance abuse
D. Emotional neglect
E. Physical neglect
Correct Answers: B. Witnessing domestic violence and C. Parental substance abuse
Rationale:
Which of the following actions by a nurse best exemplifies the principle of veracity?
A. Withholding a terminal diagnosis from a patient to avoid causing them distress.
B. Providing complete and honest information to a patient about their diagnosis and treatment options.
C. Telling a patient that a painful procedure will not hurt to ensure their cooperation.
D. Giving a patient only the positive aspects of a treatment to encourage them to agree to it.
B. Providing complete and honest information to a patient about their diagnosis and treatment options.
Rationale:
Veracity refers to the obligation of healthcare professionals to tell the truth and provide accurate information to patients. This principle supports patient autonomy by ensuring that patients have all the information they need to make informed decisions about their care.
A 22-year-old male college student is brought to the emergency department by his roommate after a severe outburst in which he destroyed furniture and threatened others. The roommate reports that these outbursts have been occurring more frequently over the past six months, with the patient becoming extremely aggressive and irritable over minor issues. The patient denies substance abuse but admits to feeling guilty and remorseful after each episode. He has no significant medical history and no current medications.
Based on this case study, which of the following interventions should the nurse prioritize to manage the patient’s condition effectively?
A. Refer the patient for cognitive-behavioral therapy (CBT) to address underlying triggers and develop coping strategies.
B. Administer a benzodiazepine as needed to manage acute episodes of aggression.
C. Place the patient in a quiet room with minimal stimuli to help reduce agitation.
D. Educate the patient about the importance of avoiding caffeine and other stimulants to decrease irritability.
Correct Answer: A. Refer the patient for cognitive-behavioral therapy (CBT) to address underlying triggers and develop coping strategies
A nurse is caring for a client diagnosed with bipolar I disorder who is currently experiencing a manic episode. The client exhibits signs of grandiosity, decreased need for sleep, and impulsivity, resulting in poor judgment. Which of the following interventions should the nurse prioritize to ensure the safety of the client and others?
A. Encourage the client to participate in group therapy sessions.
B. Set firm limits on the client's behavior and provide a structured environment.
C. Allow the client to express their feelings and thoughts freely without interruption.
D. Administer mood-stabilizing medication as prescribed and monitor for effectiveness.
Correct Answer:
B. Set firm limits on the client's behavior and provide a structured environment.
Rationale:
A 45-year-old male patient with schizophrenia is prescribed risperidone 4 mg daily. During a follow-up visit, the nurse assesses the patient for potential side effects and adherence to the medication regimen. Which of the following findings should the nurse prioritize as most concerning and requiring immediate intervention?
A. Patient reports gaining 5 pounds over the past month.
B. Patient experiences mild tremors in the hands.
C. Patient complains of a persistent sore throat and fever.
D. Patient reports feeling sleepy during the day.
Correct Answer: C. Patient complains of a persistent sore throat and fever
Rationale:
A nurse is monitoring a client diagnosed with schizophrenia who has been prescribed olanzapine (Zyprexa). Which of the following findings would the nurse identify as a potential adverse effect of this medication?
A. Increased energy and motivation
B. Weight gain and metabolic syndrome
C. Decreased appetite and weight loss
D. Insomnia and agitation
B. Weight gain and metabolic syndrome
Rationale
Olanzapine is associated with significant weight gain and can increase the risk of metabolic syndrome, including hyperglycemia and dyslipidemia.
A nurse is responsible for administering medication to patients as part of their daily care. Fidelity in nursing refers to:
A. The nurse’s obligation to respect the wishes of the patient’s family.
B. The nurse’s responsibility to provide truthful information to patients and their families.
C. The nurse’s commitment to keep promises and uphold their duties and responsibilities.
D. The nurse’s duty to avoid causing harm to patients.
C. The nurse’s commitment to keep promises and uphold their duties and responsibilities.
Rationale:
Fidelity in nursing refers to the nurse's commitment to be faithful to their promises and responsibilities. This includes maintaining trust with patients by fulfilling their duties and being reliable.
A nurse is caring for a 13-year-old patient who has been diagnosed with Conduct Disorder (CD). The patient has a history of aggressive behaviors towards peers, destruction of property, and theft. The patient also has comorbid ADHD, which exacerbates their behavioral issues. Today, the patient was involved in a physical altercation with another patient.
Which of the following should be the nurse’s priority intervention?
A) Educate the patient about the importance of following rules and respecting others.
B) Refer the patient to a mental health professional for therapy and counseling.
C) Ensure the safety of all patients and staff by separating the involved parties and de-escalating the situation.
D) Contact the patient's parents to inform them about the incident and discuss future disciplinary actions.
C) Ensure the safety of all patients and staff by separating the involved parties and de-escalating the situation
Rationale: The nurse's priority in this scenario is to ensure the immediate safety of all patients and staff, as aggressive behavior poses a direct threat.
A 34-year-old patient with a history of major depressive disorder and previous suicide attempts is admitted to the psychiatric unit after expressing suicidal ideation. The nurse assesses the patient and identifies several risk factors for the continuation of suicidal ideation. Which of the following findings would most likely indicate a high risk for continued suicidal ideation? Select all that apply.
A. The patient states, "I feel like I have no reason to live."
B. The patient reports having access to firearms at home.
C. The patient mentions feeling somewhat better after starting a new antidepressant two days ago.
D. The patient has a strong support system of family and friends.
E. The patient is experiencing severe insomnia and loss of appetite.
F. The patient actively participates in group therapy sessions.
Correct Answers: A, B, E
Rationale:
A. Expressions of hopelessness or stating that they have no reason to live are strong indicators of suicidal ideation and a high risk of suicide.
B. Access to means of suicide, such as firearms, increases the risk of a successful suicide attempt.
E. Severe insomnia and loss of appetite can indicate worsening depression, which is a risk factor for suicide.
C. Starting a new antidepressant might lead to improvement over time, but it is not a definitive indicator of immediate risk.
D. Having a strong support system is generally a protective factor against suicide.
F. Active participation in therapy can be a positive sign of engagement in the treatment process.
A client who has been prescribed diazepam (Valium) for anxiety reports feeling increasingly fatigued and has difficulty concentrating. The nurse notes that the client’s speech is slurred, and they seem disoriented to time and place.
Which of the following interventions should the nurse implement first?
A. Assess the client’s vital signs and oxygen saturation.
B. Notify the healthcare provider of the client’s symptoms.
C. Encourage the client to drink fluids and rest.
D. Administer flumazenil (Romazicon) as prescribed.
Correct Answer:
A. Assess the client’s vital signs and oxygen saturation.
Rationale:
A nurse is assessing a patient diagnosed with schizophrenia. During the assessment, the patient expresses a belief that they are being followed by government agents who are trying to harm them. The patient also insists they possess extraordinary intelligence and have been chosen for a special mission because of their exceptional abilities.
A) Persecution
B) Grandiose
C) Thought insertion
D) Thought Broadcasting
Correct Answer: A) Persecution; B) Grandiose
Rationale: The patient is exhibiting two types of delusions: persecution (A), as they believe they are being followed and targeted by government agents, and grandiose (B), as they believe they have exceptional intelligence and a special mission. Thought insertion (C) involves the belief that thoughts are being placed in one's mind by an outside force, while control (D) refers to the belief that an outside force is controlling one's thoughts or actions.