SUMMARY MODULE 3 CHAPTER 5,12 & 39
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SUMMARY CHAPTER 5
■
Ethics is a branch of philosophy that addresses methods for determining the rightness or wrongness of
one’s actions.
■
Bioethics is the term applied to these principles when they refer to concepts within the scopes of
medicine, nursing, and allied health.
■
Moral behavior is conduct that results from serious critical thinking about how individuals ought to
treat others.
■
Values are personal beliefs about what is important or desirable.
■
Rights are expectations to which an individual is entitled either by established laws, policies, or ethical
principles.
■
The ethical theory of utilitarianism is based on the premise that what is right and good is that which
produces the most happiness for the most people.
■
The ethical theory of Kantianism suggests that actions are bound by a sense of duty and that ethical
decisions are made out of respect for moral law.
■
The code 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.
■
The moral precept of the natural law theory is “do good and avoid evil.” Good is viewed as that which
is inscribed by God into the nature of things. Evil acts are never condoned, even if they are intended to
advance the noblest of ends.
■
Ethical egoism espouses that what is right and good is what is best for the individual making the
decision.
■
Ethical principles include autonomy, beneficence, nonmaleficence, veracity, and justice.
■
An ethical dilemma is a situation that requires an individual to decide between two equally
unfavorable alternatives.
■
Ethical issues may arise in psychiatric-mental health nursing around the client’s right to refuse
medication and right to the least restrictive treatment alternative.
■
Statutory laws are those that have been enacted by legislative bodies, and common laws are derived
from decisions made in previous cases. Both types of laws have civil and criminal components.
■
Civil law protects the privacy and property rights of individuals and businesses, and criminal law
provides protection from conduct deemed injurious to the public welfare.
■
Legal issues in psychiatric-mental health nursing center around confidentiality and the right to privacy,
informed consent, restraints and seclusion, and commitment issues.
■
Nurses are accountable for their own actions in relation to legal issues, and violation can result in
malpractice lawsuits against the physician, the hospital, and the nurse.
■
Developing and maintaining a good interpersonal relationship with the client and his or her family
appears to be a positive factor when the question of malpractice is being considered.
Review Questions
1. The nurse decides to go against family wishes and tell the client of his terminal status because that
is what she would want if she were the client. Which of the following ethical theories is considered in
this decision?
a. Kantianism
b. Christian ethics
c. Natural law theories
d. Ethical egoism
2
. The nurse decides to respect family wishes and not tell the client of his terminal status because that
would bring the most happiness to the most people. Which of the following ethical theories is
considered in this decision?
a. Utilitarianism
b. Kantianism
c. Christian ethics
d. Ethical egoism
3
. The nurse decides to tell the client of his terminal status because she believes it is her duty to do so.
Which of the following ethical theories is considered in this decision?
a. Natural law theories
b. Ethical egoism
c. Kantianism
d. Utilitarianism
4
. The nurse assists the physician with electroconvulsive therapy on a client who has refused to give
consent. With which of the following legal actions might the nurse be charged because of this nursing
action?
a. Assault
b. Battery
c. False imprisonment
d. Breach of confidentiality
5
. A competent, voluntary client has stated he wants to leave the hospital. The nurse hides his clothes
to keep him from leaving. With which of the following legal actions might the nurse be charged
because of this nursing action?
a. Assault
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b. Battery
c. False imprisonment
d. Breach of confidentiality
6. Joe is very restless and is pacing the room. The nurse says to Joe, “If you don’t sit down in the chair
and be still, I’m going to put you in restraints!” With which of the following legal actions might the
nurse be charged because of this nursing action?
a. Defamation of character
b. Battery
c. Breach of confidentiality
d. Assault
Clinical Judgment Questions
7.
A nurse reports to the supervisor that a depressed client is refusing medication to treat his heart
condition and states he “would rather just die.” The nurse is not sure how to intervene because,
although clients have a right to refuse medication, this client may be so depressed that his behavior
represents risk for suicide. Which of these actions by the supervisor is a priority?
a. Tell the nurse that medication will have to be given forcibly if the client continues to refuse
medication.
b. Instruct the nurse that, because the client is elderly, he is unable to make this decision and medication
will need to be secretly mixed in his food.
c. Educate the nurse that the physician has the final say so the nurse should ask the physician what to
do.
d. Activate appropriate hospital resources, such as an ethics committee, so this issue can be explored
further.
8
. A client on the psychiatric unit begins yelling out loud that no one is listening to him and that he is
going to “blow up” soon. The orderly asks the nurse if he should go ahead and put the client in
restraints for the safety of others. Which of these responses by the nurse is most appropriate?
a. Educate the orderly that restraints may never be initiated without a physician’s order.
b. Instruct the orderly that it would be best to see if the client can be assisted to calm down by listening
to his concerns.
c. Instruct the orderly to put the client in restraints but make sure to assess the client every 15 minutes
for issues regarding circulation, nutrition, respiration, hydration, and elimination.
d. Instruct the orderly to get others to assist him in restraining the client but be aware restraints should
be discontinued at the earliest possible time regardless of when a physician’s order is scheduled to
expire.
9
. The nurse collects the following information during the admission assessment. For which of these
pieces of data should the nurse take additional action to ensure that “duty to warn” laws are
followed?
a. The client threatens violence toward another individual.
b. The client states he wants to kill everyone that has demons.
c. The client is having command hallucinations.
d. The client reveals paranoid delusions about another individual.
10
. Which of these actions by the nurse demonstrates an application of the QSEN competency related
to informatics?
a. Learns how to effectively communicate information using electronic health records
b. Provides a verbal report of client behavioral issues at shift change
c. Asks the supervisor for guidelines on how to prevent lawsuits
d. Reads journals to learn information about new treatments and approaches to nursing care
Summary CHAPTER 11
■
In psychiatry, milieu therapy (or a therapeutic community) constitutes a manipulation of the
environment to create behavioral changes and to improve the psychological health and functioning of
the individual.
■
The goal of a therapeutic community is for the patient to learn adaptive coping, interaction, and
relationship skills that can be generalized to other aspects of his or her life.
■
The community environment itself serves as the primary tool of therapy.
■
According to Skinner (1979), a therapeutic community is based on seven basic assumptions:
1. The health in each individual is to be realized and encouraged to grow.
2. Every interaction is an opportunity for therapeutic intervention.
3. The patient owns his or her own environment.
4. Each patient owns his or her behavior.
5. Peer pressure is a useful and powerful tool.
6. Inappropriate behaviors are dealt with as they occur.
7. Restrictions and punishment are to be avoided.
■
Because the goals of milieu therapy relate to helping patients learn to generalize that which is learned
to other aspects of their lives, the conditions that promote a therapeutic community in the psychiatric
setting are similar to the types of conditions that exist in real-life situations. Conditions that promote a
therapeutic community include the following:
■
The fulfillment of basic physiological needs
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■
Physical facilities that are conducive to the achievement of the goals of therapy
■
The existence of a democratic form of self-government
■
The assignment of responsibilities according to patient capabilities
■
A structured program of social and work-related activities
■
The inclusion of the community and family in the program of therapy in an effort to facilitate
discharge from treatment
■
The program of therapy on the milieu unit is conducted by the interdisciplinary team (IDT).
■
The team centers on the patient and includes some or all of the following professionals (and
potentially others): psychiatrist, clinical psychologist, psychiatric clinical nurse specialist or nurse
practitioner, psychiatric nurse, mental health technician, psychiatric social worker, occupational
therapist, recreational therapist, art therapist, music therapist, dietitian, and chaplain.
■
Nurses play a crucial role in the management of a therapeutic milieu. They are involved in the
assessment, diagnosis, outcome identification, planning, implementation, and evaluation of all
treatment programs.
■
Six principles for establishing therapeutic milieu as a practice model for nurses in any health-care
setting are contagious calmness, respect for inherent human dignity, caring for self and others,
intellectual engagement, caritas, and maintaining safe and restorative physical surroundings (Meehan,
2019).
■
Nurses have significant input into the IDT plans, which are developed for all patients. They are
responsible for ensuring that patients’ basic needs are fulfilled; assessing physical and psychosocial
status; administering medication; helping the patient develop trusting relationships; setting limits on
unacceptable behaviors; educating patients; and, ultimately, helping patients, within the limits of their
capability, to become productive members of society.
Review Questions
1.
Which of the following are basic assumptions of milieu therapy? (Select all that apply.)
a. The person owns his or her own environment.
b. Each person owns his or her behavior.
c. Peer pressure is a useful and powerful tool.
d. Inappropriate behaviors are punished immediately.
2.
On the milieu unit, duties of the staff psychiatric nurse include which of the following? (Select all
that apply.)
a. Medication administration
b. Client teaching
c. Medical diagnosis
d. Reality orientation
e. Relationship development
f. Group therapy
3
. Which of the following activities would be a responsibility of the clinical psychologist member of the
IDT?
a. Locates halfway house and arranges living conditions for client being discharged from the hospital
b. Manages the therapeutic milieu on a 24-hour basis
c. Administers and evaluates psychological tests that assist in diagnosis
d. Conducts psychotherapy and administers electroconvulsive therapy treatments
4.
Which of the following activities would be a responsibility of the psychiatric clinical nurse specialist
on the IDT team?
a. Manages the therapeutic milieu on a 24-hour basis
b. Conducts group therapies and provides consultation and education to staff nurses
c. Directs a group of clients in acting out a situation that is otherwise too painful for a client to discuss
openly
d. Locates halfway house and arranges living conditions for client being discharged from the hospital
5.
A client who was sexually abused as a child is admitted to the inpatient psychiatric unit with a
diagnosis of borderline personality disorder after a suicide attempt. She has refused to talk to anyone.
Which of the following therapies might the IDT team recommend for this client? (Select all that apply.)
a. Music therapy
b. Art therapy
c. Seclusion
d. Electroconvulsive therapy
Clinical Judgment Questions
6
. In a medication education group, which of the following actions is most important for reinforcing
the therapeutic milieu?
a. Allowing each person a specific and equal amount of time to talk
b. Reviewing group rules and interpersonal behavior expectations that apply to all clients
c. Reading the medication information
d. Restricting the group to only those clients who are currently adhering to medication schedules
7
. One of the goals of a therapeutic milieu is for clients to become more independent and accept self-
responsibility. Which of the following approaches by staff best encourages the fulfillment of this goal?
a. Including client input and decisions into the treatment plan
b. Insisting that each client take a turn leading a group activity
c. Making decisions for the client regarding plans for treatment
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d. Requiring that the client bathe, dress, and attend breakfast on time each morning
8
. A client is admitted to the inpatient psychiatric unit, appears anxious, and states, “I’ve never been
on a unit like this before.” Which of these actions by the nurse is a priority for beginning to establish a
therapeutic milieu?
a. Instruct the client to remain in his room until he feels less anxious.
b. Orient the client to the physical surroundings, milieu rules, and activities.
c. Offer to medicate the client with antianxiety medication.
d. Instruct the client not to worry because he will only be on the unit for a few days.
9.
A client approaches the nurse and says, “I’m sick of the rules on this unit about not touching each
other. I’m an adult and if I want to give one of the ladies a massage, it’s my own business.” Which of
these responses best incorporates milieu therapy principles?
a. “If you don’t follow the established rules, you will be put in seclusion.”
b. “You don’t make the rules, so just do as you’re told.”
c. “Why are you on this unit?”
d. “Let me try to explain why these rules are important for everyone’s safety.”
10
. A group of clients in a long-term psychiatric hospital setting complains to the nurse that they feel
like there’s not much to do during the day. One client says, “It seems like we’re just sitting around
watching TV all day.” Which of these actions by the nurse best supports a therapeutic milieu?
a. Instruct clients that the milieu is intentionally designed to provide for relaxation and minimal
structured activities.
b. Suggest that the clients organize some games and activities for their peers.
c. Instruct these clients that they should be focusing on getting better rather than complaining.
d. Explore with clients and IDT members activities that would create more structure and support
treatment goals
Summary CHAPTER 39
■
A crisis is defined as an acute event in one’s life, perceived by the individual as distressing and in
which coping mechanisms and support systems are inadequate to manage associated anxiety.
■
All individuals experience crises at one time or another. A crisis does not necessarily indicate
psychopathology. However, individuals with psychopathology are also vulnerable to crisis and may
experience an exacerbation of psychiatric symptoms when in crisis.
■
Crises are precipitated by specific identifiable events and are determined by an individual’s perception
of the situation.
■
Crises are acute rather than chronic and generally last no more than a few weeks to a few months.
■
Crises occur when an individual is exposed to a stressor, and previous problem-solving techniques are
ineffective, causing an increase in the level of anxiety. Panic may ensue when new techniques are tried,
but resolution fails to occur.
■
Six types of crises have been identified: dispositional crises, crises of anticipated life transitions, crises
resulting from traumatic stress, maturation/developmental crises, crises reflecting psychopathology, and
psychiatric emergencies. The type of crisis determines the method of intervention selected.
■
Crisis intervention is designed to provide rapid assistance for individuals who have an urgent need.
■
The minimum therapeutic goal of crisis intervention is the psychological resolution of the individual’s
immediate crisis and restoration to at least the level of functioning that existed before the crisis period.
A maximum goal is improvement in functioning above the precrisis level.
■
Nurses regularly respond to individuals in crisis in all types of settings. The nursing process is the
vehicle by which nurses assist individuals in crisis with a short-term problem-solving approach to change.
■
A four-phase technique of crisis intervention includes assessment/analysis, planning of therapeutic
intervention, intervention, and evaluation of crisis resolution and anticipatory planning.
■
Through this structured method of assistance, nurses help individuals in crisis develop more adaptive
coping strategies for dealing with stressful situations in the future.
■
Nurses have many important skills that can assist individuals and communities in the wake of
traumatic events. Nursing interventions presented in this chapter were developed for the nursing
diagnoses of panic anxiety/fear, spiritual distress, risk for post-trauma syndrome, and ineffective
community coping.
Review Questions
1.
Which of the following is a correct assumption regarding the concept of crisis?
a. Crises occur only in individuals with psychopathology.
b. The stressful event that precipitates crisis is seldom identifiable.
c. A crisis situation contains the potential for psychological growth or deterioration.
d. Crises are chronic situations that recur many times during an individual’s life.
2
. Crises occur when an individual:
a. Is exposed to a precipitating stressor.
b. Perceives a stressor to be threatening.
c. Has no support systems.
d. Experiences a stressor and perceives coping strategies to be ineffective.
3.
Which of the following events would likely precipitate a crisis? (Select all that apply)
a. First-time parenthood when the parents perceive they have inadequate support and education.
b. Receiving a pay raise when the worker perceived they had to work very hard to accomplish their
financial goals.
c. A natural disaster such as a forest fire in which lives and property were lost.
d. A peer or family member dies by suicide.
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4. Which of the following is a desired outcome of working with an individual who has witnessed a
traumatic event and is now experiencing panic anxiety?
a. The individual will experience no anxiety.
b. The individual will demonstrate hope for the future.
c. The individual will identify that anxiety is at a manageable level.
d. The individual will verbalize the acceptance of self as worthy.
5. The client, a firefighter who responded to an industrial explosion, lost a coworker and close friend
when they entered a building that collapsed. The client reports that since this event, he has had
frequent nightmares and anxiety attacks. He says to the mental health worker, “I should have died, but
instead I lost my best friend!” This statement suggests that the client is experiencing:
a. Spiritual distress.
b. Night terrors.
c. Survivor’s guilt.
d. Suicidal ideation.
Clinical Judgment Questions
6. A client whose home was destroyed during a tornado expresses to the nurse that she is has been
having disabling anxiety and nightmares for the last 2 weeks following this disaster. The most
appropriate crisis intervention would be to:
a. Encourage her to recognize how lucky she is to be alive.
b. Discuss stages of grief and feelings associated with each.
c. Identify community resources that can help Amanda.
d. Suggest that she find a place to live that provides a storm shelter.
7
. A teenager tells the high school nurse that her parents are drinking alcohol every day and she
doesn’t know what to do. Her grades are starting to drop, and she complains of feeling anxious and
overwhelmed. The most appropriate nursing action in response to the client’s complaint would be to:
a. Facilitate arrangements for her to start attending Alateen meetings.
b. Help her identify the positive things in her life and recognize that her situation could be a lot worse
than it is.
c. Teach her about the effects of alcohol on the body and that it can be hereditary.
d. Refer her to a psychiatrist for private therapy to learn to cope with her home situation.
8
. A college student, who is an only child and attending school 500 miles away from his parents,
reports to the nurse practitioner at the student health center that he has been having difficulty making
decisions and will not undertake anything new without first consulting his mother. He has recently
started having anxiety attacks. Which nursing action is most appropriate in response to this client’s
maturational crisis?
a. Suggest that he move to a college closer to home.
b. Help him to explore unresolved dependency issues.
c. Help him find someone in the college town from whom he could seek assistance rather than calling his
mother regularly.
d. Recommend that the college physician prescribe an antianxiety medication for him.
9. A client is brought to the emergency department by her college roommate and appears to be
emotionless. The client reports that she was raped at a party earlier that evening. Which of these
actions by the nurse is a priority?
a. Ask the client if she would like to shower before she is examined.
b. Confront the client about her apparent lack of emotion and ask if this was consensual sex.
c. Affirm the client for seeking help and ask her to describe what happened.
d. Ask the roommate if the client is typically so emotionless.
10
. A client is admitted to the inpatient psychiatric unit after a suicide attempt. He reports that he has
a history of depression but he became acutely suicidal after he recently lost his job. Which of these
nursing actions is a priority in response to this client’s psychiatric crisis?
a. Assess why the client lost his job.
b. Ensure that the client remains safe and free from further self-injury.
c. Explore career interests and other job opportunities.
d. Assess for substance use disorder.
Summary and Key Points
■
Culture encompasses shared patterns of belief, feeling, and knowledge that guide people’s conduct
and are passed down from generation to generation.
■
Individualistic cultures value independence, personal responsibility, and freedom.
■
Collectivist cultures place a high value on interconnectedness and inter-reliance on family, community,
and/or tribal affiliation.
■
Ethnic groups are tied together by a shared heritage.
■
Cultural groups differ in terms of communication, space, social organization, time, environmental
control, and biological variations.
■
People of many different cultures reside in the United States; some maintain traditional cultural
practices, whereas others acculturate to cultural practices (give up cultural practices or values as a result
of contact with another group) and assimilate by incorporating practices and values of the culture.
■
Disparities in both general health care and mental health care are pronounced among people of color
and low-income individuals, as well as other minority groups.
■
Cultural syndromes are clusters of physical and behavioral symptoms considered as illnesses or
“afflictions” by specific cultures that do not readily fit into the Western conventional (DSM-5) diagnostic
categories.
■
Spirituality is the human quality that gives meaning and sense of purpose to an individual’s existence.
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■
Individuals possess a number of spiritual needs that include meaning and purpose in life; faith or trust
in someone or something beyond themselves; hope; love; and forgiveness.
■
Religion is a set of beliefs, values, rites, and rituals adopted by a group of people.
■
Religion is one way in which an individual’s spirituality may be expressed.
■
Affiliation with a religious group has been shown to be a health-enhancing endeavor.
■
Nurses must consider cultural, spiritual, and religious needs when planning care for their patients.
Review Questions
1.
CLAS standards apply to all of the following except:
a. Health-care organizations.
b. Individual clinicians and health-care practitioners.
c. Manufacturers of pharmaceutical products.
d. Hospitals.
2.
When conducting a physical assessment, the nurse recognizes that biocultural variation is present
in:
a. Education level.
b. Oxygen saturation.
c. Socioeconomic status.
d. Skin color.
3
. During the assessment of a 35-year-old Asian American client, the nurse asks the client her
preferences among different group treatment options. The client indicates that she will need to
discuss this with her parents because that’s how decisions are made in her family. The most likely
rationale is that the client:
a. Ascribes to collectivist cultural values.
b. Ascribes to individualistic cultural values.
c. Has a passive dependent personality disorder.
d. Comes from an emotionally abusive family.
4.
In evaluating pharmacotherapy interventions, the nurse recognizes that:
a. All patients respond to drug therapy in the same manner.
b. Dosing and age-specific considerations are minor factors in evaluation.
c. Patients from other cultures do not recognize the value of medication as a treatment modality.
d. Environmental, cultural, and genetic factors can affect pharmacokinetics.
5
. A culturally relevant health history considers all except which one of the following?
a. Past and present modalities of self-care and self-treatments
b. Presence or absence of health insurance
c. Prevalence of disease conditions among family and relatives
d. Past and present exposure to illnesses, hazardous conditions, and toxic substances
6
. Cultural assessment in the mental health setting should identify individual preferences with regard
to which of these variable cultural dimensions?
a. Interpreters
b. Race
c. Distance
d. Political party
Clinical Judgment Questions
7.
The nurse begins to conduct a psychosocial assessment and recognizes that the client speaks very
little English and is having difficulty responding to questions. The priority nursing action is:
a. Medicate the client to reduce anxiety.
b. Contact an interpreter before conducting the assessment.
c. Ask a family member to translate questions.
d. Ask the questions in different ways.
8
. The client is an American Indian admitted to the psychiatric hospital with a diagnosis of depression.
He reports to the nurse that his problem is “ghost sickness.” Which of these should be documented by
the nurse?
a. The client reports experiencing manic symptoms.
b. The client reports preoccupation with death and the deceased.
c. The client is hallucinating.
d. The client is fabricating a nonexistent illness.
9.
A client who has come to the mental health clinic with symptoms of depression says to the nurse,
“My father is dying. I have always hated my father. He physically abused me when I was a child. We
haven’t spoken for many years. He wants to see me now, but I don’t know if I want to see him.” Which
of these nursing diagnoses is a priority?
a. Spiritual distress
b. Risk for physical injury
c. Altered mental status
d. Risk for self-harm
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10
. As a child, a client was physically abused by his father. The father is now dying and has expressed a
desire to see his son before he dies. The patient is depressed and says to the mental health nurse, “I’m
so angry! Why did God have to give me a father like this? I feel cheated of a father! I’ve always been a
good person. I deserved better. I hate God!” Which of these nursing interventions is a priority?
a. Ask the client why he thinks God gave him such an abusive father.
b. Instruct the client to set aside his feelings temporarily to meet the needs of his dying father.
c. Ask the client to describe in detail how he was physically abused.
d. Ask the client if he would be willing to talk with a chaplain.