A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

The client was placed on one-to-one continuous observation for a history of aggressive behavior

Physical restraints were used to prevent harm to self

The client’s belongings were searched at admission

A lack of documentation of benefits of treatment and treatment options

Answer and Explanation

The Correct Answer is D

Choice A reason: One-to-one observation for aggressive behavior is a standard safety measure to prevent harm, aligning with the right to safe care. It does not violate client rights when justified by clinical need, as it prioritizes protection without restricting autonomy unnecessarily, making it an appropriate intervention.

Choice B reason: Using physical restraints to prevent self-harm is permissible when less restrictive measures fail, aligning with the right to safety. If properly documented and justified, it does not violate rights, as mental health laws allow restraints for imminent danger, making this action compliant with client rights.

Choice C reason: Searching belongings at admission is standard in psychiatric settings to ensure safety (e.g., removing contraband). This practice, when conducted respectfully and per policy, does not violate client rights, as it prioritizes a safe therapeutic environment for all patients and staff on the unit.

Choice D reason: Lack of documentation of treatment benefits and options violates the right to informed consent. Clients must be informed about treatment rationale and alternatives to make autonomous decisions. Failure to document this breaches legal and ethical standards, undermining the client’s ability to participate in their care, making it a rights violation.

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Correct Answer is B

Explanation

Choice A reason: Violating a nurse’s boundaries, such as inappropriate behavior, does not legally mandate breaching confidentiality. Ethical responses involve setting boundaries or reporting within the care team, but confidentiality is protected unless harm to others is threatened, making this situation insufficient for a legal breach.

Choice B reason: Nurses are legally obligated to breach confidentiality when a client makes credible threats to harm an identifiable third party (Tarasoff duty). This protects potential victims by ensuring warnings or interventions occur, balancing patient confidentiality with public safety, as harm prevention takes precedence in mental health law.

Choice C reason: Client aggression does not automatically warrant breaching confidentiality unless it involves specific threats to identifiable individuals. Aggression is managed within the care setting, and confidentiality is maintained unless legal criteria, like imminent harm to others, are met, making this option incorrect.

Choice D reason: Disagreement with the nurse does not justify breaching confidentiality. Ethical care respects client autonomy, and confidentiality is protected unless legal exceptions, like threats or court orders, apply. Disagreement is managed through therapeutic communication, not by disclosing private information, making this an invalid reason for breach.

A. Restrain the client and give the medication intramuscularly B. Inform the client that refusing the medication means not getting any better C. Accept the client’s decision and continue to maintain safety D. Obtain a discharge order for nonadherence to the medication regimen

Correct Answer is C

Explanation

Choice A reason: Restraining and forcibly administering medication violates patient autonomy and ethical principles, potentially escalating agitation in psychosis. It risks physical harm and legal issues, as forced medication requires specific legal orders (e.g., involuntary commitment). Non-invasive approaches like negotiation or assessing refusal reasons are safer and more ethical.

Choice B reason: Stating that refusal prevents improvement is coercive and undermines autonomy. It fails to explore reasons for refusal, such as side effect concerns or psychosis-related mistrust, which are common in severe psychosis. This approach may damage trust and hinder therapeutic alliance, making it inappropriate as an initial action.

Choice C reason: Accepting the client’s refusal respects autonomy while prioritizing safety, critical in psychosis where agitation is common. This allows exploration of refusal reasons (e.g., paranoia) and alternative interventions, maintaining a therapeutic environment. Monitoring ensures no immediate harm, making this the most ethical and safe initial response.

Choice D reason: Obtaining a discharge order for nonadherence is premature and inappropriate, as refusal does not warrant immediate discharge. Psychosis requires ongoing assessment and management, and discharge could exacerbate symptoms or risk harm, making this action contrary to the goal of stabilizing the client’s mental health.

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A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When is a nurse legally obligated to breach confidentiality?

Correct Answer is B

Explanation

The healthcare provider prescribes haloperidol 10 mg for a client with severe psychosis, but the client refuses the medication. Which initial nursing action is appropriate?

Correct Answer is C

Explanation

The client feels that the client’s rights have been violated. Placing a client in restraints before using other methods of intervention violates which of the client’s rights?

A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?

Which statement by a nurse may undermine a patient’s feelings and belittle the patient’s concerns?

Which significant change in the treatment of people with mental illness occurred in the 1950s?

A client is fearful and reluctant to talk after a traumatic event. Which technique will the nurse employ that is most effective when trying to engage the client in interaction?

The nurse is caring for a client who is in the oliguric phase of acute kidney injury (AKI). During this phase of AKI, the nurse might anticipate which of the following findings?