Chapter 32: Forensic Psychiatric Nursing My Nursing Test Banks

Chapter 32: Forensic Psychiatric Nursing

MULTIPLE CHOICE

1. A person diagnosed with bipolar disorder ran out of money, did not refill a lithium prescription, and then relapsed. After assaulting several people in the community, this person was convicted and sentenced. Prior to parole, which outcome has priority for the correctional nurse to achieve? The person:

a.

agrees in writing to continue lithium therapy.

b.

is reestablished on an appropriate dose of lithium.

c.

lists community resources for prescription assistance.

d.

agrees to a follow-up appointment in an outpatient clinic.

ANS: C

To increase medication adherence, reduce the risk of relapse, and prevent further criminal activity due to mental illness, the persons awareness of community resources for medication refills and medication-related services is the most important outcome. Agreeing to take lithium, being reestablished on medication in the jail, and agreeing to follow-up mental health care are important, but none of these will address the primary reason for the criminal behavior: the relapse caused by inability to access medication in the community.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 604-606 TOP: Nursing Process: Outcomes Identification

MSC: Client Needs: Health Promotion and Maintenance

2. An inmate was diagnosed with posttraumatic stress disorder (PTSD) caused by severe sexual abuse. One day this inmate sees a person with characteristics similar to the perpetrator, has a flashback, and then attacks the person. Correctional officers place the inmate in restraint. The correctional nurse should anticipate that the inmate would react to restraint by:

a.

committing to counseling to reduce the incidence of flashbacks.

b.

becoming less likely to assault others during future flashbacks.

c.

gradually calming and returning from the flashback to reality.

d.

becoming more frightened, agitated, and combative.

ANS: D

The correctional nurse recognizes that events occurring in the present reality are likely to be incorporated into a flashback, leading the inmate to become more frightened and desperate to escape. Even if no longer experiencing a flashback, persons will likely reexperience their original trauma if restrained, including the emotions experienced during that trauma, leading to increased fearfulness and resistance to the jail restraints. Restraints are not likely to calm the individual or reduce aggressiveness but instead increase the sense of helplessness and desperation.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 604-606 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

3. An inmate was diagnosed with posttraumatic stress disorder (PTSD) caused by severe sexual abuse. One day this inmate sees a person with similar characteristics to the perpetrator, has a flashback, and then attacks the person. Correctional officers place the inmate in restraint. Which action by the correctional nurse is most appropriate?

a.

Plan to meet with the inmate for debriefing after release from the required period of restraint.

b.

Support use of restraints as needed to control violent outbursts and assure the safety of all inmates.

c.

Contact a supervisor authorized to make an exception to the restraint policy and explain why an alternate response is needed.

d.

Confront the correctional officers who initiated the restraint, explain the inappropriateness of this action, and request the inmates release.

ANS: C

Nurses have advocacy responsibilities, regardless of the setting. The optimum outcome in this situation would be to minimize the duration of the restraint episode. The inmate and others are at risk of injury until the inmate is calm. The restraints will likely worsen and extend the inmates distress and agitation. Supporting the use of restraints ignores the need of select inmates for alternate responses that do not paradoxically worsen the situation instead of help it. Meeting with the patient to calm her after her release would be the second most helpful response, but it does not shorten the duration of the patients restraint. Confronting the officers is unlikely to be successful, since they are following proper procedures; accusing them of improper actions will likely increase defensiveness rather than expedite the inmates release from restraint.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 604-606 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

4. The correctional nurse assesses a new prisoner beginning incarceration after committing a sex crime. The prisoner speaks in a low voice and tearfully tells the nurse, My life might as well be over. There is no hope I will ever fit into society after I get out of prison. My family disowned me. Select the nurses priority action.

a.

Advise guards to place the inmate in solitary confinement.

b.

Offer to contact the inmates family to convey these feelings of remorse.

c.

Alert the guards of the risk for suicide and implement suicide precautions.

d.

Meet with the inmate weekly to discuss these feelings and explore coping strategies.

ANS: C

The inmate is experiencing significant shame and self-loathing, facing many significant losses (freedom, status in the community, perhaps his career), separated from his support system, and evidences hopelessness. These all suggest a significant risk of suicide. The priority response would be to alert the guards of the inmates risk to self and implement suicide precautions. Safety is the primary issue; none of the other options is appropriate relative to suicide prevention.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 599 (Box 32-1) | Page 604 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

5. A correctional nurse working in a county jail assesses all new inmates who report taking psychotropic medication or have symptoms of psychiatric disorders. Because of the high volume of newly incarcerated individuals, which skill is most essential for this nurse?

a.

Documenting information that could be used as trial evidence

b.

Quickly and skillfully assessing risks for suicide and violence

c.

Having a comprehensive understanding of community resources

d.

Counseling inmates to promote successful adaptation to incarceration

ANS: B

Newly incarcerated prisoners are often in crisis and may be suicidal. Others may be mentally ill and experiencing relapse. Therefore, being able to quickly and skillfully assess for risk of suicide and violence is an essential skill for the correctional nurse. Documenting potential evidence may occur but is not typically the primary or priority role of a correctional nurse. Community resources and counseling are helpful but would not be a priority compared to risk assessment and reduction.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 603-605 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

6. A psychiatric clinical nurse specialist works with a defendant as a competency evaluator. A staff member asks, Why are you spending so much time with that defendant? You spend one-to-one time and write volumes. Usually, we give defendants some medication and return them to court. Select the clinical nurse specialists most appropriate response.

a.

My role is to be an advocate for the defendant, so I have to know him well and build a trusting relationship.

b.

My focus is providing intensive psychotherapy to ensure the defendant becomes competent before returning to court.

c.

The specialized assessments I make on behalf of the court require very lengthy and detailed interviews, so it takes a lot of time.

d.

I spend the time observing, assessing, and documenting competency, writing a report, and preparing expert testimony for the court.

ANS: D

The competency evaluator has to determine the patients current competence to act on his own behalf during his trial; without competency, the inmate cannot stand trial. Determining competency goes well beyond the mental status, functional, and risk assessments most psychiatric nurses are accustomed to and are very complex and time-consuming. A complete formal report is prepared for the court and all pertinent details addressed in anticipation of questioning by officers of the court. The evaluator represents the court, not the patient. Interviews of the inmate are only a portion of the evaluators work. Evaluators help the court determine competency but do not intervene to increase the patients competency.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 601-602 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

7. During arraignment, a defendant behaves bizarrely, fails to respond to the judges questions, and shouts obscenities. The judge orders an evaluation by a forensic nurse examiner. Which information provided by the examiner will be most important to the court at this time?

a.

The defendants mental state at the time of the crime

b.

The defendants competence to proceed with trial

c.

The cause of the defendants courtroom behavior

d.

The defendants history and cognitive abilities

ANS: B

Competence to proceed refers to ones capacity to assist the attorney and understand legal proceedings. In the United States, no one is tried unless deemed competent. An incompetent individual is remanded to a locked facility for treatment to regain competency. The court will desire a full assessment of the patients present mental state related to his ability to assist in his own defense, but at this time, the court is not interested in his state of mind at the time of the original crime nor his history.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 602 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

8. A psychiatric forensic nurse examiner was asked by a defendants attorney to determine the defendants legal sanity. What is the priority task of the nurse examiner?

a.

Determine if the defendant understands the charges and can assist the attorney with the defense.

b.

Complete a risk assessment to determine if the defendant is a danger to self or others.

c.

Reconstruct the defendants mental state and motives at the time of the crime.

d.

Collect and compile evidence to determine whether a crime occurred.

ANS: C

Legal sanity is determined for the specific time of the alleged crime, so reconstructing the defendants mental state, motivation, thinking, and other elements of functioning at the time of the alleged crime is essential to making the determination. The defendants ability to understand the charges and assist in his defense is pertinent to an evaluation of competency. Unless the court has specifically asked for a risk assessment (which would be unusual), the risk assessment is the responsibility of clinical staff caring for the patient, not the forensic nurse examiner. Police collect evidence about the crime, and the prosecutor compiles it. A forensic nurse examiner does not participate in evidence collection other than that related to the assessment of the patients state of mind at the time of the alleged crime.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 603 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

9. Select the best question for a psychiatric forensic nurse examiner to ask when assessing the legal sanity of an individual charged with a crime.

a.

Tell me about what you were thinking at the time of the alleged crime.

b.

What would you do if you heard a fire alarm going off where you live?

c.

At this time, are you having any experiences that others might think strange?

d.

Do you feel as though you would like to harm yourself or anyone else at the present time?

ANS: A

Legal sanity refers to the individuals ability to know right from wrong with reference to the act charged, the capacity to know the nature and quality of the act charged, and the capacity to form the intent to commit the crime. It is determined for the specific time of the act. The distracters apply to other parts of a mental status assessment and do not assess the patients state at the time of the alleged crime.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 601-602 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

10. In which circumstance would a psychiatric forensic nurse examiner determine it appropriate for a defendant and attorney to consider the insanity defense? At the time of the crime, the defendant:

a.

shot a drug dealer who tried to overcharge for cocaine.

b.

acted on auditory hallucinations of the voice of God commanding, Kill the children.

c.

tampered with the brakes on his wifes car after discovering she had an extramarital affair.

d.

was frightened because of a home robbery the preceding night, assumed a family member was another burglar, and shot him.

ANS: B

The defendant, demonstrating symptoms of psychosis and acting on the direction of command hallucinations, could use the defense of legal insanity because he was unable to recognize his action as wrong due to a psychiatric illness. The other options suggest the defendant knew right from wrong, had the capacity to know the nature and quality of the act, and had the capacity to form intent to commit the crime.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 601-602 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

11. A nurse testifies about care provided to a patient in the 8 hours before a successful suicide. The nurse responds to questions about observations regarding the patients behavior as well as interventions performed and documented during the shift. In what capacity was this nurse testifying?

a.

Forensic nurse examiner

c.

Fact witness

b.

Expert witness

d.

Consultant

ANS: C

A fact witness testifies regarding first-hand experience only; that is, the facts the witness possesses because of personal experience with the situation under review. Forensic nurse examiners conduct court-ordered examinations and provide written reports and court testimony regarding the findings of the examinations, but they do not give direct patient care. Consultants are neutral experts who educate or advise the court or its officers on technical matters such as standards of nursing care. An expert witness shares professional expertise about the defendant or elements of the crime and testifies on behalf of the prosecution or defendant.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 602 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

12. The highest degree of credibility is required by a nurse who provides testimony before the court as a(n):

a.

fact witness.

c.

correctional nurse.

b.

expert witness.

d.

critical care nurse.

ANS: B

An expert witness is recognized by the court as having a higher level of skill or expertise in a specific area. In addition to testifying about involvement with the individual and documentation of the interactions, an expert witness is permitted by the court to give a professional opinion. A fact witness may testify only regarding what was seen, heard, performed, or documented regarding first-hand nursing care. Correctional and critical care nurses may testify as fact witnesses.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 602-603 (Box 32-3) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

13. The psychiatric forensic nurse provides this description of work responsibilities: I use knowledge of psychopathology as I investigate and reconstruct crimes and then try to understand a criminals reasoning process. This allows me to compile information on what type of individual would have most likely committed the crime. The work the nurse describes is that of a:

a.

competency therapist.

c.

forensic examiner.

b.

hostage negotiator.

d.

criminal profiler.

ANS: D

Criminal profilers attempt to provide law enforcement with specific information and the type of individual who would have committed a certain crime. Profilers use behavioral and psychological indicators left at violent crime scenes and apply their understanding of psychopathology, attempt to reconstruct the crime, formulate hypotheses, and develop a profile, which is then tested against known data. The distracters refer to roles the psychiatric forensic nurse may fill, but none of these roles fits the description given in the scenario.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 603 TOP: Nursing Process: Implementation MSC: Client Needs: N/A

14. A correctional nurse plans a health education series for prison inmates. Which topic is most important for the nurse to include in this series?

a.

Sleep hygiene

c.

Social skills training

b.

Personal grooming

d.

Assertive communication

ANS: A

The most common mental health symptoms experienced by inmates are insomnia and hypersomnia; therefore, sleep hygiene would address these needs. Sleep is a basic physiological need that must be met before higher needs are addressed.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 604 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

15. Health problems most commonly encountered by correctional nurses are:

a.

routine infections and minor trauma.

b.

chronic medical and psychiatric disorders.

c.

similar to the non-incarcerated population.

d.

injuries acquired during arrest or incarceration.

ANS: B

Correctional nurses provide care for inmates who have disproportionately high rates of mental illness, substance abuse, tuberculosis, AIDS, hepatitis, diabetes, and other chronic disorders and infections. The health problems of inmates are more complex and chronic, not similar to their non-incarcerated peers. Trauma is an important issue that affects inmate health, but it is not the primary health issue for this population as a whole.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 603 TOP: Nursing Process: Implementation

MSC: Client Needs: Physiological Integrity

16. A guard tells an inmate diagnosed with schizophrenia to ask the desk officer for a mop and bucket, then get some water from the shower area and mop the kitchen and hall. The inmate does not comply. The guard becomes angry and cancels the inmates recreation time. Which action by the correctional nurse is most appropriate?

a.

Document the inmates response as indicative of resistance and psychopathology.

b.

Do not intervene. Intervention is not part of a correctional nurses scope of practice.

c.

Confer with the prison psychiatrist regarding reevaluation of this inmates antipsychotic medication regime.

d.

Explain to the guard that this inmate has difficulty following multiple instructions. Suggest stating one idea at a time.

ANS: D

Correctional nurses, like most direct-care nurses outside of corrections, have a professional responsibility to advocate for inmates regarding needed care. A psychiatric nurse would have an understanding of schizophrenia and recognize that the inmates ability to process multistep instructions was impaired. Advocacy for the inmate is evident by educating the guard so he would not misperceive the reason the inmate did not respond. Documentation is needed for all nursing activities. Involving the psychiatrist might be of some value but is at best a passive form of advocacy, and again, as worded here, suggests that the nurse does not understand how schizophrenia contributed to the inmates not responding to complex instructions.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 604-605 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

17. Which treatment setting would necessitate the most restrictive care environment?

a.

Partial hospitalization program

c.

Forensic hospital

b.

Geropsychiatric unit

d.

Group home

ANS: C

Patients in forensic hospitals have mental illness as well as conviction or charges for criminal activity. These settings must be therapeutic but also confine patients from society. Rules, regulations, and restrictions have similarities to prisons.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 598 | Page 603 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

18. Which statement about the practice of correctional nursing is accurate?

a.

Because the majority of inmates are younger than 40 years of age, most have lower rates of chronic illnesses than the general population.

b.

Correctional nurses work primarily with medically ill persons rather than persons with psychiatric or substance abuse disorders.

c.

More persons diagnosed with mental illness receive treatment services in prisons than in inpatient psychiatric facilities.

d.

Correctional nurses commonly provide holistic and comprehensive care for the incarcerated population.

ANS: C

When compared to the rates in the general population (11% of whom have a mental health problem, with approximately 55,000 individuals hospitalized at an inpatient psychiatric hospital on any given day), correctional facilities carry a disproportionate share of the burden for the provision of mental health services. Rates of chronic illness are higher among inmates than in the general population due to factors such as higher rates of poverty, lower educational status, higher rates of trauma, institutional living when incarcerated, reduced access to health care, poor health habits, and higher rates of high-risk behaviors such as IV drug abuse. Correctional settings provide adequate care of inmates, but it is rarely holistic or comprehensive.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 603-604 TOP: Nursing Process: N/A

MSC: Client Needs: Safe, Effective Care Environment

19. Which credential would be expected of an expert witness in the area of forensic psychiatric nursing?

a.

3 years of experience in an inpatient psychiatric facility

b.

10 years of experience in community health nursing

c.

Educational preparation of an associate degree in nursing

d.

Publication of three articles in peer-reviewed psychiatric nursing journals

ANS: D

To establish credibility as an expert witness and have ones opinion given equal weight to that of other professionals in court, the forensic nurse specialist must have current clinical expertise, trustworthiness, and a professional presentation style. The expert witness is an authority in a specialty area. If the expert has conducted research and published in the area, it is an added strength. Expert testimony is based on evidence-based practice. Forensic nurses with advanced degrees are more likely to be called upon as expert witnesses.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 602-603 (Box 32-3) TOP: Nursing Process: N/A

MSC: Client Needs: Safe, Effective Care Environment

MULTIPLE RESPONSE

1. A psychiatric forensic nurse assigned to a hostage negotiation tactical team is deployed when an individual takes several hostages. Which tasks apply to the nurses role on the team? Select all that apply.

a.

Assess released hostages.

b.

Negotiate with the perpetrator.

c.

Direct strategies for police deployment.

d.

Assess the mental status of the perpetrator.

e.

Suggest communication techniques to a negotiator.

ANS: A, D, E

The forensic nurse assigned to a hostage tactical team serves to assist the team and provide them with clinical information and assessments consistent with the nurses training and experience. This nurse does not negotiate with the perpetrator or direct actions of police officers. Assistance can include assessing the perpetrator, assisting the freed hostages, educating police officers on mental health-related topics, assessing the stress level of the negotiator, suggesting techniques that might be appropriate (particularly when the perpetrator is mentally ill), and serving as a go-between with local mental health agencies.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 603 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

2. Which characteristics best qualify a nurse for employment as a forensic psychiatric nurse? Select all that apply.

a.

Incorporation of street smarts into clinical practice

b.

Comfortable in a variety of practice settings

c.

Desire to punish perpetrators of crime

d.

Able to think clearly under stress

e.

Autonomous and self-sufficient

f.

Critical care skills

ANS: A, B, D, E

Forensic nursing requires the ability to address the issues and provide care in a truly neutral manner. All forensic nurses, whatever their specific title or responsibilities, must therefore be objective and not be motivated by any personal beliefs about what should or should not happen to patients involved in the criminal justice system. Street smarts can be a desirable trait in working with perpetrators, especially in hostage negotiation situations. Forensic nurses practice in a wide variety of nontraditional settings. While forensic nurses are often members of teams, autonomy and self-sufficiency are important traits. Forensic nurses do not need critical care skills.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 603 TOP: Nursing Process: N/A MSC: Client Needs: N/A

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