Kindly answer the following questions by APPLYING CRITICAL JUDGMENT.
1. You are a community psychiatric-mental health nurse working at a local mental health center. A single, 45-year-old patient reports that his thoughts seem to be “all tangled up.” He states that he does not know how much longer he can go on, but he makes no direct reference to suicidal intent. He is disheveled and has been sleeping poorly at shelters. He becomes agitated when you suggest that it might be helpful for you to contact his family. He refuses to sign any release-of-information forms. He admits to recent hospitalization at the local veterans’ hospital and reports previous treatment at a dual-diagnosis facility even though he denies substance misuse. In addition to his mental health problems, he says that he has tested positive for human immunodeficiency virus and should be taking multiple medications that he cannot name.
A. What are your biopsychosocial and spiritual concerns about this patient?
B. What is the highest-priority problem to address before he leaves the clinic today?
C. Do you feel that you need to consult with any other members of the multidisciplinary team today about this patient?
D. In your role as case manager, what systems of care will you need to coordinate to provide quality care for this patient?
E. How will you start to develop trust with the patient to gain his cooperation with the treatment plan?
2. Two nurses, Joe and Beth, have worked on the psychiatric unit for 2 years. During the past 6 months, Beth has confided to Joe that she has been experiencing a particularly difficult marital situation. Joe has observed that over those 6 months, Beth has become increasingly irritable and difficult to work with. He notices that tranquilizers are frequently missing from the unit dose cart on the evening shift. He complains to the pharmacy and is informed that the drugs were stocked as ordered. Several patients state that they have not been receiving their usual drugs. Joe finds that Beth has recorded that the drugs have been given as ordered. He also notices that Beth is diverting the drugs.
A. What action, if any, should Joe take?
B. Should Joe confront Beth with his suspicions?
C. If Beth admits that she has been diverting the drugs, should Joe’s next step be to report Beth to the supervisor or to the Board of Nursing?
D. Should Joe make his concern known to the nursing supervisor directly by identifying Beth, or should he state his concerns in general terms?
E. Legally, must Joe report his suspicions to the Board of Nursing? To the police?
F. Does the fact that harm to the patients is limited to increased agitation affect your responses?
3. A 40-year-old man who is admitted to the emergency department for a severe nosebleed has both nares packed. Because of his history of alcoholism and the probability of ensuing delirium tremens, the patient is transferred to the psychiatric unit. He is admitted to a private room, placed in restraints, and checked by a nurse every hour per physician’s orders. While unattended, the patient suffocates, apparently by inhaling the nasal packing, which had become dislodged from the nares. On the next 1-hour check, the nurse finds the patient without pulse or respiration. A state statute requires that a restrained patient on a psychiatric unit be assessed by a nurse every hour for safety, comfort, and physical needs.
A. If standards are not otherwise specified, do statutory requirements set forth minimal or maximal standards?
B. Does the nurse’s compliance with the state statute relieve him or her of liability in the patient’s death?
C. Does the nurse’s compliance with the physician’s orders relieve him or her of liability in the patient’s death?
D. Was the order for the restraint appropriate for this type of patient?
E. What factors did you consider in making your determination?
F. Was the frequency of rounds for assessment of patient needs appropriate in this situation?
G. Did the nurse’s conduct meet the standard of care for psychiatric nurses? Why or why not?
H. What nursing action should the nurse have taken to protect the patient from harm?
4. Assume that there are no mandatory reporting laws for impaired or incompetent colleagues in the following clinical situation. In a private psychiatric unit in California, a 15-year-old boy is admitted at the request of his parents because of violent, explosive behavior that seems to stem from his father’s recent remarriage after his parents’ divorce. A few days after admission, while in group therapy, he has an explosive reaction to a discussion about weekend passes for Mother’s Day. He screams that he has been abandoned and that nobody cares about him. Several weeks later, on the day before his discharge, he elicits from the nurse a promise to keep his plan to kill his mother confidential. Consider the American Nurses Association’s (ANA) Code of Ethics for Nurses on patient confidentiality, the principles of psychiatric nursing, the statutes on privileged communications, and the duty to warn third parties in answering the following questions.
A. Did the nurse use appropriate judgment in promising confidentiality?
B. Does the nurse have a legal duty to warn the patient’s mother of her son’s threat?
C. Is the duty owed to the patient’s father and stepmother?
D. Would a change in the admission status from voluntary to involuntary protect the patient’s mother without violating the patient’s confidentiality?
E. Would your response be different depending on the state in which the incident occurred? Why or why not?
F. What nursing action, if any, should the nurse take after the disclosure by the patient?
5. A 37-year-old Hispanic man arrived by ambulance from a supermarket, where he had fallen. He remains lethargic. On his arrival to the emergency department (ED), his breath smelled “fruity.” He appears confused and anxious, saying that “they put the ‘evil eye’ on me, they want me to die, they are drying out my body … it’s draining me dry … they are yelling, they are yelling … no, no I’m not bad … oh God, don’t let them get me.” When his mother arrives in the ED, she tells the staff, through the use of an interpreter, that Pedro is a severe diabetic and has a diagnosis of paranoid schizophrenia, and this happens when he does not take his medications. In a group or in collaboration with a classmate, respond to the following:
A. A number of nursing diagnoses are possible in this scenario. Formulate in writing at least two nursing diagnoses (problems) given the preceding information, and include “related to” and “as evidenced by.”
B. For each of your nursing diagnoses, list one long-term outcome (e.g., the problem, what should change). Include a time frame, desired change, and three criteria that will help you evaluate if the outcome has been met, not met, or partially met.
C. For each long-term outcome, list two short-term outcomes (goals) (the steps that need to be taken in order for the goal to be accomplished), including time frame, desired outcomes, and evaluation criteria.
D. What are the four basic principles for planning nursing interventions?
E. What specific needs might you take into account when planning nursing care for Mr. Gonzales?
F. Using informatics, evaluate optimal outcomes for Mr. Gonzalez at your current health care setting, or use the charting method employed by the institution.
G. Give an example of the QSEN competencies you might stress when planning care for Mr. Gonzalez.