Hey everyone, nurse Mike here from simple nursing.com. Today we're breaking down the legal musthnos like HIPPA ethics and even tort law. All made simple for your nursing exams and ultimately the ENCLEX. Now, if you're a simple nursing member, there are several study guides we'll show throughout the video to help this legal knowledge stick. So, be sure to follow along and lock it in. All right, let's get started. Starting with HIPPA confidentiality and privacy. So, HIPPA is all about privacy of information. Knock knock. Okay. What's this? Who's there? It's HIPPA. Hippa who? Sorry, I can't tell you. That's private. You know, I can't work like this. I'm I'm done. Okay. On a serious note, HIPPA is Health Insurance Portability and Accountability Act. This is a law protecting the right to privacy for clients. It regulates how clients personal health information, for example, diagnosis, test results, and other things are used and disclosed. Now, this is vitally important on exams and the enclelex. So, pause the screen and write down those words. Nurses and health care professionals are both legally and ethically required to protect clients privacy as well as maintain confidentiality of their medical information. Guys, this is critical. Many nurses have got fired as well as their license placed on probation and even removed for violating HIPPA. So, trust me, it is no joke. These privacy rules are huge on the ENCLEX and are always tested on exams. We must protect clients information and keep it private. Now for the key points to write down. Number one, only share client info with other team members directly involved with care. Big key terms right there. Directly involved with care. Also, it's a need to know basis only. And no oversharing detailed information with non-essential personnel like transporters and secretaries. For example, oversharing too much details like specific diagnosis or lab reports with non-essential personnel like transporters and unit secretaries as mentioned before who don't necessarily need to know these details. So, a Saunders question. A charge nurse from another unit asked about the client's condition, stating, "The client's my neighbor and I want to check on her." The correct answer is, "I'm sorry, I can't tell you." Yes, the key term is the charge nurse is from another unit. This is a need to know basis. And in this case, this nurse does not need to know. Now, a hessy question. The nurse looks up the chart of a cousin. Uh-oh. who is not under the care of the nurse. What is the manager's next action? Correct answer, contact human resource department. Yes, Hessie states that there's a breach in confidentiality which can lead to termination. But HR should be contacted and they should be made aware. Now, the second key point is never discuss client info in the hallway, elevator, public area, or even outside the hospital as mentioned by ATI. Always in a secure private area at work, for example, a nurse's station or a private room. Key point number three is do not access charts or information that is not needed directly for work. Trust me, this was always tested on the big Enclelex question banks. So if it's not needed directly for your job, don't access the information. Now the next one here is computer charting. No password sharing. This is huge. Not even with the supervisor, charge nurse, director, or even manager. We can't share our passwords. And number two here is log off when stepping away. and even a big key term, log off your co-workers if they leave the computer in the hall unattended. ATI mentioned this a lot. About 45% of students got this question wrong. So remember, our number one goal is to protect the client's info. So ATI had a question. A nurse has shared his computer username and password with the student nurse. Possible consequences. Correct answer. The nurse can be prosecuted as a criminal. Seriously though, you can go to jail. Oh no, HIPPA is real and it don't take no mess. Key point number five, no taking information home. Always dispose of report sheets in a secure shredder as mentioned by ATI and Kaplan. And even old medical records are kept in a locked file cabinet in the department as mentioned by Hessie. Now they're mostly online but they are secured nowadays. Now number six is information releases. So yes the client has a right to receive a copy of their own healthcare records. But no, we can't share information with family or a friend without the client's permission. The key terms there are without the client's permission. So a big big exam tip as well as enclelex tip. Test questions love to ask questions about a client's spouse asking for more information. You must first get permission from the client. Trust me, it's always tested. So, ATI had a question here. Husband requests lab results for his wife. How should the nurse respond? Let me check if you have permission. And question two, a 19-year-old female asks for a prescription of oral contraception. She is under her parents' insurance but doesn't want her parents to know about it. Oh man, this is some Jerry Springer type stuff. According to HIPPA, which of the following should the provider tell the patient? Correct answer, the client's parents may not view the medical record, but may learn about it from their insurance bill receipts. Now, this is because the client is over 18 and considered a legal adult. So parents cannot view her medical record without her permission. And lastly, number seven, we have to report any breach of confidentiality. So violation examples include talking to a client's condition in a hallway, elevator, or even cafeteria. ATI loves to use the term cafeteria. So always go to a private room or nurse's station. And even stop co-workers midway through and tell them, "This is not appropriate. Let's go to a private area. Another big example is taking home a client's report sheet. This is medical information. It must be shredded at the end of the shift. You can't take this information home. And another example, sharing information with a client's roommate. For example, your roommate is going for a gallbladder test. No, this is oversharing. We can't do that. So, just say your roommate's going for a normal test or just say your roommate's going to be back soon. No oversharing info. And lastly, sharing info with the client's spouse or legal guardian. Key terms here, without permission. We can't be like, "Yep, your wife is pregnant." Or even more exciting, "Your daughter is super pregnant." No, no, no. We must keep that information private. So, don't let the enclelex trick you with these nonviolations. For example, censoring visitor conversations in the waiting room talking about their loved one is a nonviolation, as well as a nosy client's roommate who overhars report details through the room's curtain. Now, this is a nonviolation. And even writing the last name of a client on the whiteboard or calling out the full name in a waiting room, again, not a violation. And the last two here, telling a visitor to wear a mask because the client's on isolation precautions. As long as the diagnosis or details are not shared, you're in the safe zone. And the last one here, general discussions about cures for a disease like HIV doesn't disclose a client's personal info. So don't get tricked on the enlex there. Now for a top missed enclelex question to test your knowledge. Which of the following violates the health information privacy law? Option number one, calling out a client's full legal first and last name in the waiting room. Nah, this is not a violation. We're just asking for the client to come up like in triage. Now, option two here, telling the client's transporter tech that the client has stage 4 pancreatic cancer for 3 weeks and needs to be handled gently. Guys, this is a violation. So remember, no oversharing details with non-essential personnel. This transporter doesn't need to know that the client has stage 4 cancer. This is way too much information. We're definitely oversharing here. They only need to know to be gentle with this client. Now, option three here. The client overhears the nurse giving report details on the client's roommate through the room's curtain. Talk about a nosy roommate, right? Now, this is not a violation, surprisingly, since the nurse did her best. due diligence to keep it private by closing the magical curtain. Right? And we can't stop a nosy roommate in the same room now. The last two options. The new graduate nurse accessing updated medical records of a client that they took care of last week, but not currently assigned. Yes, this is a big violation. The key term there is not currently assigned. Remember, we only access info on a need to know basis in order to do our job as current duties. And the last option here, explaining the results of the client's lab values or laboratory report to the unit secretary who's organizing the client's medical record. Yes, this is a huge violation. Remember, this unit secretary doesn't need to know the details. Remember, don't overshare with oversharing these details. It's only a need to know basis. Looking for more tips and strategies for questions like the ones we just covered? Well, our simple nursing membership includes exit prep lectures and thousands of questions across all nursing school and enclelex topics. Now, a little side note to HIPPA rules. There are some exceptions. Some information must be shared even if the client doesn't consent to it. This information usually pertains to safety. For example, if the client is threatening self harm or even harm of others, well then the HCP is required to share and the HIPPA laws don't apply. Additionally, if the client discloses that they're being abused, well, then nurses are mandatory reporters, which we'll cover in detail at the very end of this video. So an ATI example, the nurse would be justified in breaking confidentiality if an older adult client discloses that their caregiver hits them. Yes, this is mandatory reporting. You are required to report this. Now, records and billing may be different. A child may have the right to privacy with their records, but if the parents are paying the insurance, they may see the line items on the bill like birth control or something else as mentioned in the example before. And lastly, inadvert sharing of data is not a violation of HIPPA. We just consider did the nurse use reasonable measures to protect the client's information. For example, conversations that are overheard, like through a client curtain, are not really considered HIPPO violations as long as the nurse used reasonable measures to protect the client's data. Okay. Now, moving on to ethical key terms. First is autonomy. Think always in control. This is the client's right to make their own healthcare decisions. For example, respecting a client's right to refuse any treatment. The next key term is advocacy. Just think advocate to protect the client's rights, health, and safety. A great example of this is reporting critical changes in the client's condition and advocating for further treatment, and more analysis. Now, some hot topics for advocacy include endof life issues, access to health care, protecting client privacy, standards of practice, questioning orders, and even informed consent. Next up is beneficence. So just think benefit, benefit the client with beneficence. It basically means doing and promoting good. So let the name help you there. A great example is calling the family of a client to tell them their loved one is critically ill and we are caring for their needs. Be sure to write those down. Huge enclelex tip. Over 60% of students got this wrong. By reassuring family members that their loved one is getting the best care available is promoting good. So, don't let the enclelex trick you here. You don't have to give too many details over the phone, like his heart is stopped, but we're doing CPR. This is actually bad and will cause panic until they come to the hospital. And never just give the responsibility to the healthcare provider and have them talk to the family. Guys, you can practice beneficence and promote good too. So, just do it. You are the nurse. The next term is fidelity. So, just think faithful with fidelity. This means to stay loyal as well as follow through. So think of the triple Fs. Fidelity is faithful and you are following through. A great example is to follow through with your responsibilities as a nurse. So an ATI question, the client reports a out of 10 pain. The nurse states she'll return with pain meds and follow through with the act. The correct answer is fidelity. Next is justice. To treat fairly and equally. A great example is provide care equally regardless of race, gender, religion or culture. So ATI key terms ensuring that time and resources are distributed equitably to clients. And now for the last two terms, non-maleficence or just think nonmal intent. So mal is Latin for bad. So just think no mal or basically no bad. The definition is to avoid causing harm. A great example is double-checking a drug dosage with another nurse to avoid a medication error. And the last key term is verocity. Just think very honest with verity. The definition is to tell the truth. An example is a med error with no adverse effects but still reporting it. This is very honest and was a direct question from ATI. Now, switching gears to ethical principles, let's talk about tors, which are wrongful acts or violations of rights that can lead to legal liability. A big key point to know is that the burden of proof lies with the accuser and not the accused. So, first up is unintentional tors. This is unended or accidents that cause harm. Be it injury, property damage or even financial loss. An example is negligence, which is the failure to provide adequate care. Be sure to write that down. Failure to provide adequate care in which another reasonable or prudent co-orker would do similar in that same situation. The key terms here are co-workers or other staff personnel in the same role. So, ATI mentions these key terms. Practice that is below standard of care would be negligent. and a nurse that did not wash their hands prior to inserting a fully catheter. Again, negligent. And the nurse identifies the absence of peripheral pulse in a client's cast extremity in the early morning. The nurse reports it to the HCP in the early afternoon. Wow, that is way later. Definitely negligent. And over to Aandre's question. If informed consent is withheld from a client, healthcare providers could be found guilty of negligence. This question was actually about withholding a diagnosis of cancer because the client's child said, "I don't think my parent can handle the cancer diagnosis." But guys, it doesn't matter. The client has the right to know. And withholding info, you can be guilty of negligence. The next key term is malpractice. defined as illegal, improper, or negligent actions by a licensed professional. For example, doctors, RNs, LPNs, or really anyone with a license, and it results with provable damage to the patient. This is malpractice. A great example is the RN failed to check the dosage on a medication vial, which harmed the client. The big key term there is it harmed the client. And lastly, abandonment. This is desertion of a client by anyone who has assumed the responsibility of care. So for example, if you get report from another nurse and you assume care, you can't just leave the floor or go home. You must always give report to another nurse to assume that care. If you guys leave without giving reports, you're going to face legal consequences of abandonment. Now moving on to intentional tors. These are willful acts that violate a client's rights. So the memory trick here for assault and battery. Think of the A's and the B's. A for assault is a threat. Before B for battery, which is actual harm. So let's go into assault. Remember assault is the threat of harm. So think of assult, you are being assulted with your words. So any threat made toward a client that threatens harm. A great example is I'm going to restrain you to the bed if you keep on getting up. Or another example is threatening to place an NG tube in a client who refuses to eat. Now, as far as battery, this is the act of harm. So, think battery is like a baseball bat beating up the client and causing harm. The definition is a physical act that causes harm or unconenting contact that causes harm. For example, performing a procedure without consent or giving a medication that the client refuses unless they're altered, of course, and can't make decisions for themselves. Now, for an assault and battery example is chemically restraining a patient who is competent and able to make their own decisions. This is a great example. We can't just drug up a patient and put them under a chemical sedation without their consent. Now the next key term is false imprisonment. For example, using physical restraints, seclusion, and even a chemical restraint to keep someone against their will. Now, a little side note, this does not include clients on the psychiatric or a suicide hold. For example, using restraints on a competent client to prevent them from leaving the healthcare facility. Guys, if the client is competent and not on a suicide hold, they can leave AMA or against medical advice. Now, the next term for intentional tors is invasion of privacy. As mentioned before, this is violating confidentiality rights. We're basically violating HIPPA here, like sharing client information to a family member without the client's consent. The next one here is defamation of character. This one is huge, so please be sure to write this down. making rude, insulting remarks that harms a client's reputation. Now, these include both written and spoken and can even also pertain to co-workers. So, write this down. Liel is written defamation of character. So, think of it like a book. The memory trick for liel, think library. And S is for slander. Just think S for spoken. So, yes, this is when you go to the breakroom and gossip. You guys, you can get into legal trouble of slander if you're gossiping about another co-worker or even a client. Now, for two ATI questions. Question one. Two nurses are sitting in the lounge and hear a co-orker state that she believes a married HCP is involved in a relationship with a client. So scandalous. The answer here is slander. Guys, you can't speak gossip. You can get into legal trouble here. And question two here, a nurse applies restraints without a prescription. Uhoh. To a client who threatens to leave AMA, what are the intentional tors? Select all that apply. Okay, so looking at the list here, take a moment to choose the best option. So we have malpractice, negligence, battery, as well as false imprisonment. So remember intentional tors are intentional willful acts of harm here. So the correct answer is battery since restraints were applied basically beating up the client here. And the second answer is false imprisonment keeping a client against their will. Both of these are intentional. Now as a last and final note for the ethics of care. The ANA, the American Nurses Association, establishes the ethical standards for the nursing profession. And an ethics committee is a healthcare team that provides guidance in the face of an ethical dilemma. They help assist in mediation between client, family, and treatment team and also provide recommendations, but does not impose decisions. And lastly, standards of practice. The reasonable nurse test is used to determine the standard of care. So basically, what would a prudent nurse do in the same circumstances? And another question here, what would a similar nurse in the same area with the same training and background do? Now, moving on to informed consent. Informed consent is required before invasive procedures and even surgery. So, write this down. This confirms a client's voluntary decision to undergo the procedure where the provider explains reasons for the intervention, benefits and risks involved with treatment or without treatment as well as alternative treatment options. And performing a procedure without consent is illegal. This is what's called battery. So remember, battery is basically beating up the patient. Now when it comes to charges brought in a legal case, they can be either civil or criminal. So for civil, this is crimes against an individual. And for criminal, crimes against the state, which is often more serious. In terms of rules for informed consent, who can actually give informed consent? Well, state laws determine who can give this consent. And consent must be given by a competent adult. So, a parent or guardian of a minor, a legal guardian or court specified representative, as well as a healthc care surrogate, basically a power of attorney or a proxy or a spouse or closest available relative. And this is determined by state laws. And lastly, emancipated minors can give their own consent. Now, what if a client is confused or has an altered level of consciousness, what's known as ALOC? This means that they're not competent to provide consent since they don't know who they are or they're not aware to person, place, time or date. They are basically confused. Now, some key terms to identify alter level of consciousness. So, unconscious clients, mental health clients with bipolar or schizophrenia during episodes, impaired with alcohol or drugs, dementia, and even delirium. These clients need a guardian to make decisions. So ATI mentions clients who are admitted involuntarily have the right to informed consent. For example, this is common with clients admitted to the mental health unit as mentioned before as long as they remain competent. They have the right to consent for procedures. And Saunders mentions a client needs emergency surgery, but they cannot sign the operative consent form because of sedation. The nurse should take which priority action? Obtain telephone consent from a family member witnessed by two authorized individuals. So this is best for emergency life-saving interventions. Now in terms of minors less than 18 years old, they require parent consent or parental consent. The exceptions include minors who are pregnant, married, emancipated, who have substance abuse, STI, and even members of the military, or minors who are parents. So, ATI mentions informed consent can be provided by which of the following clients? A pregnant 16-year-old client at 36 weeks gestation with painful vaginal bleeding? Yes, this minor is pregnant. and Saunders, a 14-year-old prescribed an antiscychotic medication without parental consent obtained. Do not give the medication and document the reason. Yes, don't be tricked here. There must be a signed consent form from a guardian before a minor is treated as long as it's not an emergency situation. And in this case, it's not. Obviously, the parents should be contacted and the consent form must be signed or declined. Now, in terms of language, non-English speakers cannot consent without big key term here, a medical interpreter to translate. The key term is medical interpreter. And it's always tested here, not the family member as an interpreter or a friend. It must be a medical interpreter. There are bad stories out there of a woman who wanted to have kids and accidentally got a full hyctomy because her son interpreted the wrong info. Oh no. So remember, it must be a medical interpreter. So once again, a client who does not speak English cannot consent without a medical interpreter available to translate. Now for informed consent roles and goals. First up is the provider. Often the surgeon, not the nurse here. So remember these key points here. Number one responsibility for the provider is to obtain informed consent. It is not the nurse's responsibility. So write that down. It's the nurse's job to witness, not to obtain. Remember, it's all about the key words here. Nurses do not obtain. It's also the provider's responsibility to explain the procedures, including the benefits, risks, and alternatives to the procedure. And number three is answer all the client's questions. Again, only the provider can do this, not the nurse. Please be sure to write that down. So, don't get tricked on exams. For example, if the client is having a gallbladder removed and wants to talk about diet after the surgery, then this is the RN's role. But if they want to know specifics about the surgery risks, well, that information must be given by the surgeon or the provider. Next, it's the provider's responsibility to explain the right to refuse surgery. And the client indicates understanding of the info and gives voluntary consent. So, a big enclelex tip here. Be sure to write this one down. There was a case. If any issue arises during surgery and needing additional surgery, always call the client's medical power of attorney or legal guardian or even next of kin to provide consent for additional procedures. Nearly 50% of students got this wrong. So, if the surgeon can't reach the family to give consent and it's in the client's best interest to have a more in-depth or thorough surgery rather than go through the physical or financial strain of a second surgery. So, phone consent requires two witnesses. Now, if it's a life-saving intervention, the provider will decide what is best for the client based on the client's code status and advanced directives. Okay. Now, switching over to nurses. These key points love to come up on select all that apply questions. So, please be sure to write these down. These are seven enclelex tips. Number one is witness the consent. Remember, nurses are not responsible for obtaining informed consent. Stay away from that word obtaining. This is the provider, the HCP's primary responsibility. Remember, it's all about the key words here. Many students get this wrong on exams. Number two is document in the medical record the date and time the signatures are obtained. And the key word again is obtained. And number three is verify that the client is competent and voluntarily signing. This is huge. We must make sure the client is competent. So ATI mentions a client must have the capacity to make decisions. Again, we don't want our client on seditive medications not knowing what they're signing. This is a big legal implication and a client's safety risk. And another question, a client who has a history of dementia but is alert and oriented times four. Who gives the consent? Well, don't be tricked here. It would be the client. In cases of actual dementia or delirium, when the client is not alert and oriented, then the POA would kick in here. It's all about if the client is incapacitated or altered, unable to make their own decisions. Now, four is for advocate. So, we assess the client and confirm they received and understands the info. So, ATI mentions determine the client's level of understanding about the procedure. In the role of the client advocate, the nurse is responsible for ensuring the client understands the information provided by the surgeon and must notify the surgeon if the client has any questions about the specific surgery. Now moving on to number five. What about client questions? So ordinary questions like diet, exercise, breathing after surgery, this is general care teaching and can be provided by the nurse just not specifics about the surgery or the procedure. We always contact the HCP if the client does not have correct understanding about the procedure itself. Be very careful here. We see a lot of students get these wrong. Don't answer new questions directly tied to the surgery. only assess and confirm understanding. If the client still doesn't understand, then speak up. This is advocacy. So, advocate by calling the provider and have them educating the client again. You are the nurse and you will be held legally responsible for giving wrong info. So, don't do it or girl, don't do it. Now, number six is what to avoid the big no no list. So, no educating about the procedure if there's a misunderstanding as mentioned before. Remember, only the provider can do this and no explaining the right to refuse surgery. Once again, only the provider can do this. Lots of students got this wrong. And last but not least, number seven. What if the client changes their mind? Well, we notify the provider first. Write this down. Do not try to talk the client into a surgery. Only the provider can explain the details involved in the procedure or the surgery and answer the client's concerns. So ATI question here. I've changed my mind. I don't want to have this surgery. The nurse's response. I will notify the provider about your decision. Yes, guys, don't get tricked here. It's not your responsibility to educate the client about any details of the procedure or surgery. Always tell the surgeon. Now for a top missed enclelex question. While the nurse is obtaining the client's signature before surgery, the client states, "I don't understand what's included in a low sodium diet after surgery. How should the nurse respond?" Okay. Option one, call the HCP immediately to come and answer the client's questions. No. Nearly 40% of students got this wrong. Only if the client had specific questions about the procedure itself do we contact the provider. Now how about option two? Teach the client about that low sodium diet. Yes. Ordinary questions about general care and teaching can be answered by the nurse. Remember the key term here is not specific details about the procedure or the surgery. Now the last two options. Place the signature on hold for now. H. No, we don't really need to do that. you can educate the client about that low sodium diet. And option four, if you chose that, then you bad. For everything you need to know to pass the ENCLEX, make sure to check out our ENCLEX review lecture series and live CRAM sessions. And now for an ATI question. A client who's about to undergo a surgical procedure doesn't fully understand the risks. Uh-oh. Which of the following is a duty of the nurse? Select all that apply. So option one, explaining the risks and benefits of the procedure. No, this is the surgeon's responsibility or the providers. Option two, witnessing the client's signature on the informed consent form. Yes, this is the nurse's responsibility. Even though the client should not sign right now, it is still one of the nurse's duties. How about the next option? Acting as an advocate to ensure the client has all the necessary information. Yes, advocacy for your client is a nursing responsibility. And have the surgeon address all the questions here. And for the last two options here, explain any alternative treatments for the condition. No. And explain the risk of refusing surgery. No. No. No. The last two options go into too much detail. It is not the nurse's responsibility for doing this. It's the surgeon's responsibility. Now, moving on to advanced directives. Be sure to write down the bolded and highlighted ones here as these are the most tested. So, key point number one, advanced directives are legal documents that outline desired medical care if the client becomes unable to verbalize their wishes. An example would be a client with a Glasgow coma scale or a GCS score less than seven. Basically, it means that the client is in a coma or a client with a brain bleed, an inter cerebral hemorrhage with aphasia. This client has a brain bleed and can't speak. Now, these two examples came up on our ENCLEX review. The second key point is documentation placement. So, we have to place this in the client's medical records and copies of this advanced directive should be given to family, friends, and everyone listed as health proxies. Now, this was a big enlex tip that over 35% of students got wrong. So, just think about it here. Let's say the client has only one copy and now rolls up into the ER with a brain bleed with no documentation on their life-saving wishes. Well, that's not smart, right? And also Kaplan stressed this. The most concerning statement from a client, my living will is all made out and secured in my safety deposit box. Oh no, definitely not good. Now, key point number three, this advanced directive does not need to be notorized. It can be completed in the healthcare setting if there are two witnesses. But these witnesses should not be the nurses or HCPs directly involved in the care of the client. Some states prohibit any employees or even nurse supervisors from being a witness since they are part of the faculty of the facility. And also witnesses cannot be individuals named as healthc care proxies as stated by Saunders, ATI, Hessie and Kaplan. Now number four is a big one. What if there is no advanced directive found? Well then what do you do? Well care is based on what a reasonable person would want in a given situation. Typically full treatment or full life-saving measures. Now for a top missed and click question. A client newly diagnosed with mild Alzheimer's disease. Which action should the nurse prioritize at this time when teaching the client and family? Now, as you know, Alzheimer's disease is a progressive neurocognitive disorder resulting in memory loss and cognitive decline. Clients don't even remember who they are, where they are, or who their family is. It's very sad. So, the correct answer is encourage the client to make advanced directive decisions before cognitive abilities decline further. Yes, this is priority. Over 70% of students got this wrong. The key term in this specific question is mild Alzheimer's. So, the client can still make decisions and get that legal house in order before their brain totally declines. And Saunders enclelex review mentions advanced directives. It's separate from a final will and it's a document that describes what kind of treatment is wanted. Now moving on to types of advanced directives. First up is durable power of attorney, DPOA or just POA for short. This assigns another person or a healthcare proxy or surrogate to make medical decisions for the client if the client becomes incapacitated. Remember the key term that's most often used is healthc care proxy. This is the one who will make decisions for the client, not the spouse, not the family member, only this elected person. Now, if they happen to be the sister of the client and not the wife, well then the sister will make the final decisions because she is the POA, the power of attorney. So, big Enclelex tip, there are many types of POAs, power of attorneys like financial or medical. So, always clarify the POA that can make those healthc care decisions. Over 25% of students got this wrong. Now, for example, let's just say the client is in a coma or something. Well, the POA is the person that makes decisions. And it doesn't have to be related to the client. And this POA always trumps a spouse or even a child or a family member. They are the final decision makers. So, choose your proxy and surrogate wisely. Now, a little side note here. This proxy can be changed at any time as long as the client is fully cognitive and has their bearings about them. Another type of advanced directive is a living will. This is a signed document that outlines the wishes and desires of medical care if the client becomes incapacitated or unable to communicate as mentioned by ATI. Over 22% of students got this wrong. So, please be sure to write down the highlighted words there. A living will outlines level of interventions, life sustaining measures, for example, ventilators or tube feedings, and even code status. So, this one's really big. Be sure to write this down. A full code means full resuscitative measures. A chemical code means medications only. So, no CPR, no electric shocks, and no respirations. A DNR means do not resuscitate. So no CPR, no back valve mask for respirations and no resuscitative actions. Other key terms include and allow natural death or DNI, do not intubate. So big Enclelex tip, applying oxygen via nasal canula and even giving fluids and certain medications can be given for comfort and is not considered resuscitative efforts. Over 40% of students got this wrong. But again, if it's clearly stated, it just depends on the client's written will. So, be sure to write that down. Now, don't let the ENCLEX trick you. Advanced directives do not include financial power of attorney. Life insurance beneficiaries or even safety deposit boxes. Now, sure, those are important end of life care needs, but not considered advanced care planning. So, don't be tricked. Now, in terms of portable orders, a DNR bracelet can be used and a Pst, a physician's order for life sustaining treatment. These are medical orders that summarize the client's wishes regarding medical care. So, Hessie had a question here. The client's condition is worsening. The nurse is unsure the client's resuscitative status. Which action should the nurse take first? The key term there is first. Call the charge nurse to check advanced directives while continuing to assess the client. Yes, just because the client's condition is worsening, the nurse should remain with the client. Remember, assessment always comes first. So, continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status. Always assess and stay with the client. Now moving on to PSDA, patient self-determination act. This protects and ensures clients rights to determine endof life care. So be sure to write this down. Number one, it requires facilities to ask all admitted clients if they have advanced directives as mentioned by ATI. ATI actually mentioned this a few times and over 33% of students got this wrong. And number two, if there's no advanced directive found, well then what do you do? The law requires that the facility is able to furnish a written information outlining the client's rights, wishes, and healthcare decisions. Furthermore, you have to be asked and given in writing if you have an advanced directive when you are admitted to the facility. So, you're given the opportunity to be an active participant in your care. And in the event of your end of life care as well as life-threatening decisionmaking. Now switching gears to AMA and refusal of care. Clients have the right to refuse. So clients have the right to refuse treatment if they are competent to do so. Big key terms only if they're competent to do so. Clients also have the right to refuse medications or other therapies even if they were involuntarily admitted. Well, except in emergency situations, of course. Now, this is correct unless it is necessary to save the client's life or safety for others. So, Saunders mentions a client refuses to take medication. What is the most therapeutic response by the nurse? Now, this is a wild answer here, so listen close. You don't have to take the medication if you don't want to. Now, the client should be assessed and educated, of course, but on the Saunders Enclelex review, that wasn't an option. And ATI mentions a client who is AO* 4 and is a Jehovah Witness and they're refusing to receive blood products. Their partner is not a Jehovah Witness and wants the client to receive the blood. Well, what should the nurse do? Correct answer is respect the client's right to refuse the treatment. Yes, the client must be informed of the risks and complications associated with the decision, but again, a competent adult can refuse treatment even if their partner doesn't agree. Now, moving on to a top-tested topic here, AMA, which means leaving against medical advice. The client can choose to leave the hospital before proper discharge, but this comes with loads of risk, especially if the client's unstable, placing them at risk for injury, readmission, and even death. So, the big question to ask is, does the client have the right to leave? Well, the answer depends on several factors. So, look at the key words here. Was the client properly educated? The key term is properly educated as to why they should stay. Now this is the number one most tested by both Kaplan and ATI. Question two is are they competent to make the decision. For example, is the client under the influence of drugs or alcohol or do they hear voices or are they mentally unstable? And lastly, do they have a legal hold like a 48 hour suicide watch? Well, obviously they're legally bound and cannot leave. So ATI question. Which of the following clients cannot be allowed to sign out AMA? A client who states the voices is telling him to kill his child. No, that client should be on a hold. Option two, a client who believes she is Marie Antinet. No, that client is altered. And option three, an intoxicated client who has been drinking heavily for 12 hours and cannot walk. So, as you can see, all these clients should stay in the hospital. Now, in terms of nursing actions for AMAs, please be sure to write down the bolded and highlighted ones here. First up, inform the client of the risks of refusal as mentioned by Kaplan and ATI. Remember, the nurse's first responsibility is to make sure the client is aware of the ramifications of their decisions to support the client's choice. So, Kaplan explains a 78-year-old client who had a bowel bleed and was basically bleeding to death inside, but they want to leave. Well, guys, this is incredible. The client is basically dying here or on the verge of dying, and she doesn't know it. So, it's your job to educate the client of all the risks, even death. Number two is notify the provider, the HCP. And number three is do not call security. Huge Enclelex tip. A lot of students chose this one for some reason. Number four is discuss the risks associated with leaving AMA. Yes, properly educate the client, especially if leaving will result in their death. Number five is have the client sign an AMA form or document the client's refusal to sign the form. Now, this was a big one for ATI and many students got this wrong. This is very important as a component of the process. And lastly, number six, remove any IV catheters or tubes. This one is huge. So, Saunders had an interesting question. A client admitted voluntarily for treatment of an anxiety disorder demands to be released. What actions should the nurse take initially? Contact the client's primary HCP. Now, in this case, due to the client's condition, it would be best to contact the primary provider. Now, finally, mandatory reporting. It is your job as a nurse to report suspected abuse, but only after a detailed assessment and full history. This goes for children, vulnerable adults, and even the elderly. Remember, nurses are required to report any suspected abuse. This is what is meant by mandatory reporting. It is a legal requirement to report the facts and circumstances that led the nurse to suspect abuse or even neglect. Now, the nurse doesn't really have to prove or provide actual proof, but anything during the assessment that gives you that gut feeling of abuse, then yes, it is mandatory to report it to the authorities for further investigation. So the top four interventions that are always tested, number one is protect the client from immediate harm. This was mentioned by many question banks. Number two, separately interview the client away from the suspected abuser. Number three, collect and prepare evidence. And lastly, number four, provide a safety plan and provide information on shelters and safe houses. Now for more key points on both child and elder abuse, let's play those segments now. Child abuse and neglect is the next topic. When child abuse is suspected, the very first thing that must be done in nursing process is assessment. So the big key terms to write down, conduct a detailed interview and physical examination. Huge enlex tip. Now, in addition to obvious injuries like bruises and physical marks, the child may show interesting behavior including overly affectionate or overly too shy and even skittish or fearful. And the second thing to assess is the parent child interaction. So for abuse, we see blaming, refusal to comfort, and even belittling from the parent and even a change in story from both the victim and the abuser. Now, these are all signs of abuse. So, abusive parents may be hostile and even uncooperative with staff, which is another key sign of abuse. So, ATI mentions a 2-year-old boy with severe dental carries or basically cavities, dry mucous membranes, and a diaper that is soaked in urine and stool. Which of the following is the next step in managing this patient? Assess caregiver interaction with the child. Yes, this must be done to assess for abuse. Now, reporting to the authorities is only done after a detailed assessment and even full history because remember in the nursing process, assessment comes before intervention. So, Hessie had two questions on this and wraps it up nicely in a sequence of interventions. In question one, the parent and a six-year-old presents to the clinic. The child weighs 35 lbs, is wearing torn and dirty clothing, and sits quietly with the parent subtle rocking motion. The nurse's next action, select all that apply. So, number one, take the child's height and vitals. Assess the child for any bruises or lacerations. Ask the accompanying parent to leave the room. Ask the child about attendance at school and stay with the child during the healthc care provers's assessment. Yes, as you see a lot of assessment. Remember this comes first before reporting abuse. Now question number two, suspected child abuse. What type of questions would help the nurse to elicit information from the person? Open-ended questions that require descriptive responses. Yes, we want to ask open-ended questions. Basically, questions that don't end in yes or no. Now, in terms of communication with the child, we want to tell them a few key terms. So, be sure to write this down. Number one, it's not your fault and you are not to blame. Number two, you are not in trouble and did the right thing. So, ATI mentions, the child reports being physically abused by his guardian. Which of the following statements should the nurse make? It is not your fault that this happened. And lastly, the third key point, which is a big ENLEX tip, is make no promises and keep no secrets. So, the nurse needs to be straightforward and telling the child and the family that is required by law to report all abuse, even suspected abuse. So Hessie mentions suspected child abuse. Report any case of suspected child abuse. Now in terms of characteristics of perpetrators, most enclelex and exam questions will talk about a nurse giving an inservice or presentation about how to spot a child abuser. So the six enclelex tips to write down for the abuser risk factors. Number one is they grew up in an environment of domestic violence. Number two is a history of alcohol or substance abuse. Number three, low self-esteem or acts impulsive. Number four, authoritarian or overly critical on the child with often unrealistic expectations. And number five, teenage parents or even a single parent at home as mentioned by ATI. And number six, a child with developmental delays. Now the interesting part is that child abusers are not easily identified as they often appear calm and controlled in public but behind closed door they have violent outbursts. So ATI mentions two questions. A nurse is teaching a group of newly licensed nurses about risk factors for child maltreatment. Which of the following risk factors should the nurse include in the teaching? Select all that apply. A parent who has a history of alcohol use disorder. A parent who often acts impulsive. A parent who believes in an authoritarian approach to raise their child and expresses unrealistic expectations of an infant. And question two in service for a group of elementary school teachers about identifying risk factors for malreatment of children. A child who lives in a single parent home. the child was born premature and has developmental delays and a toddler who has autism. Yes, as you can see, all these key terms correlate to our top six and collect tips. Now, in terms of signs of neglect, physical abuse, and even emotional abuse, we're going to look at all the top question banks and see what they have to say. So, ATI mentions two questions. Education seminar about child maltreatment. Which of the following factors would indicate neglect? Select all that apply. A child who is undernourished. A child is dirty and in poor clothing. A child has untreated dental conditions. Yes, all these things show neglect. And question two, parents do not use a child's safety seat when transporting the child indicating child neglect. and Hessie mentions which form of child maltreatment is considered the most common neglect. Now in terms of physical abuse, ATI mentions expected finding of physical abuse, burns on bilateral hands, spiral fracture of the right forearm, and a reening welt across the back. So, be sure to write down these key terms, especially spiral fracture and even reening welt. And Hessie mentions, "A child arrives to the emergency department with cigarette burns on the arm. Which type of abuse does the nurse document?" Physical abuse. And lastly, for emotional abuse, Hessie mentions, "A 4-year-old child tells the nurse, "I'm a bad boy. Daddy always says I'm not worth a second look." This is an example of emotional abuse. And question two, which statement made by the child is emotional neglect. My father does not praise me even when my teacher praises my drawings. Now, as you can see, all these answer options are pretty straightforward. But if you have an ATI and Hessie exam, I'd be sure to pay special attention on these key terms. First up is elder neglect. This is a form of abuse that happens when a caregiver fails to deliver the needs of the elderly client either emotionally, physically, or even socially. Common manifestations of neglect include poor eye contact. So the big key terms to write down is a client breaks eye contact when talking with a caregiver out of fear or even despair as well as broken assistive devices like glasses or even hearing aids as well as expired medication. Now physically for physical abuse or neglect we see weight loss dehydration and even malnutrition. For example, an elderly client losing 10 lbs in 5 weeks. Now, a big one here in the hospital setting is pressure ulcers, which is also called bed sores, as well as poor hygiene, typically seen as poor oral hygiene and even soiled clothing. So, Hessie mentions a 79year-old weighs 93 lbs and is wearing old dirty clothes diagnosed with pneumonia. Which comment by the patient suggests significant risk for abuse? Our family is poor, so my daughter gets my monthly retirement and social security checks. Uh-oh. This is a huge indicator that there's abuse. Now, caregiver role strain, CRS, is experienced when a caregiver, usually a family member, feels overwhelmed with tasks and is unable to perform their role as a primary caregiver. Often, they suffer extreme fatigue, depression, and even social isolation when caring for this client. Now, it's vital to assess for stressors and unmet needs. Big Enclelex tip. So write this down. Ask about the nature and requirements of providing daily care. These are big key terms for the enclelex review. 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