Which nursing intervention demonstrates false imprisonment?
An involuntary hospitalized patient with suicidal ideation runs out of the psychiatric unit. The nurse rushes after the patient and convinces the patient to return to the unit
An involuntarily hospitalized patient with homicidal ideation attempts to leave the facility. A nurse calls the security team and uses established protocols to prevent the patient from leaving.
A confused and combative patient says, "I'm getting out of here, and no one can stop me." The nurse restrains this patient without a health care providers order until the next morning at which time he obtains an order
A patient has been irritating and attention-seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you be put in seclusion"
The Correct Answer is C
Reasoning:
Choice A reason: This intervention involves verbal de-escalation and persuasion, which are non-coercive measures. Since the patient is involuntarily hospitalized due to a high risk of self-harm, the nurse has a duty to protect them. Convincing them to return does not constitute illegal confinement or false imprisonment.
Choice B reason: Preventing an involuntarily hospitalized patient with homicidal ideation from leaving is a matter of public safety and clinical necessity. Following established legal protocols to maintain the confinement of a legally committed patient does not meet the criteria for false imprisonment under psychiatric law.
Choice C reason: False imprisonment occurs when a patient is restrained without legal justification or a valid medical order. While emergency restraints can be applied, the nurse must obtain a physician's order immediately. Waiting until the next morning constitutes an unauthorized, prolonged restriction of the patient's movement and liberty.
Choice D reason: This scenario describes a verbal threat and a violation of the patient's rights through intimidation, which may be considered assault or professional misconduct. However, simply escorting a patient to their room is not false imprisonment unless they are physically locked or restrained without justification.
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Correct Answer is D
Explanation
Reasoning:
Choice A reason: The Delirium Rating Scale is a clinician-rated instrument specifically designed to measure the severity of delirium symptoms. While the patient exhibits forgetfulness, his clinical presentation of recent bereavement, anorexia, and insomnia more strongly suggests a mood disorder rather than the acute cognitive fluctuations and clouded consciousness typical of delirium.
Choice B reason: The Confusion Assessment Instrument (CAM) is a standardized evidence-based tool used specifically to identify the presence of delirium in clinical settings. It focuses on acute onset, inattention, and disorganized thinking. Cartton's symptoms of somatic complaints and sleep disturbances following significant loss are more indicative of pseudodementia related to depression.
Choice C reason: The Mini Mental Status Exam (MMSE) is a 30-point questionnaire used to measure cognitive impairment and screen for dementia. Although it assesses memory, it does not differentiate well between primary cognitive decline and cognitive deficits secondary to clinical depression, which is highly suspected given the patient's recent multiple bereavement.
Choice D reason: The Geriatric Depression Scale is the most appropriate tool because Cartton’s symptoms of forgetfulness, anorexia, insomnia, and somatic aches following the death of his wife and friend are classic indicators of geriatric depression. This scale is specifically validated for older adults to distinguish between depression and primary dementia.
Correct Answer is B
Explanation
Reasoning:
Choice A reason: Extra-large windows with street views provide excessive environmental stimuli, which can exacerbate the distractibility and psychomotor agitation characteristic of acute mania. Manic patients require a calm, controlled environment to reduce sensory overload and help decrease the intensity of their heightened internal arousal and racing thoughts.
Choice B reason: Milieu management for acute mania focuses on low-stimulus environments. Neutral colors like beige or soft grey and a lack of complex patterns or busy accessories help minimize external triggers. This physical environment supports the pharmacological goals of reducing dopamine-driven hyperactivity and allows the patient’s nervous system to rest.
Choice C reason: Bright colors and busy prints are highly stimulating and can increase the agitation and "flight of ideas" experienced by a manic patient. Such decor can lead to further behavioral dysregulation, as the patient’s brain is already struggling to filter out non-essential sensory information in a state of hyper-arousal.
Choice D reason: While deep colors are less "bright," they can still be visually heavy or stimulating depending on the saturation. In psychiatric design, the goal is "neutrality" rather than "intensity." Heavy upholstery can also pose a safety risk if the patient becomes physically aggressive or destructive during a manic peak.
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