12.2 Core Workflows and Decision Points

The Consent Hierarchy

Consent is the legal backbone of every intervention. The CEN tests four flavors:

• Informed consent — a competent adult, given the diagnosis, the proposed treatment, the risks, the benefits, and the alternatives, voluntarily agrees. The physician obtains it; the nurse often witnesses the signature and confirms understanding.
• Implied (emergency) consent — when a patient is unconscious or incapacitated and a true emergency threatens life or limb, consent is presumed because a reasonable person would consent. This is the legal basis for resuscitating an unresponsive arrest patient.
• Involuntary consent — a patient held under a psychiatric hold or court order may be treated without agreement within the scope of that order.
• Surrogate/proxy consent — for minors and adults who lack capacity, a parent, legal guardian, healthcare power of attorney, or next of kin decides.

A core distinction: competence is a legal determination, while capacity is a clinical judgment that a patient can understand and weigh the decision right now. An intoxicated or delirious patient may temporarily lack capacity even though they are legally competent.

Two special cases recur on the CEN. A minor generally requires parental consent, but emancipated minors (married, in the military, or court-declared) and mature minors seeking certain care — typically reproductive health, sexually transmitted infection treatment, substance-use, or mental-health services depending on state law — may consent for themselves. And consent for an unaccompanied minor in a true emergency is implied; you never delay life-saving care to locate a parent.

Restraints and Seclusion

Restraints are a high-liability, heavily regulated intervention governed by CMS Conditions of Participation. CMS recognizes two categories. Non-violent/non-self-destructive restraints support medical healing (for example, preventing a confused patient from pulling out an endotracheal tube). Violent/self-destructive restraints manage behavior that is an immediate danger to self or others.

For violent/self-destructive restraint or seclusion, memorize:

A qualified provider (physician, LIP, and per the 2006 rule a trained RN or PA) must perform a face-to-face evaluation within 1 hour of initiating violent/self-destructive restraint or seclusion. Orders are renewed within these limits up to a 24-hour total, and restraint must be discontinued at the earliest possible time. PRN (as-needed) restraint orders are never permitted. The least restrictive effective method must always be tried first, and the patient is continuously monitored.

Monitoring obligations scale with the type of restraint. A violently restrained or secluded patient is observed continuously — by direct view or video plus audio — for vital signs, circulation, hydration, toileting, and readiness for release. Restraint is never used for staff convenience, coercion, punishment, or discipline, and a restraint applied for behavioral emergency must be removed the moment the dangerous behavior resolves, even if the order has not expired.

Mandatory Reporting and Leaving AMA

Mandatory reporting laws make emergency nurses mandated reporters. Suspected child abuse, elder/vulnerable-adult abuse, and human trafficking, plus certain injuries such as gunshot and stab wounds, must be reported to the appropriate agency. The legal standard is reasonable suspicion, not proof — the nurse reports and lets investigators determine the facts. Good-faith reporting is legally protected; failing to report can be a crime.

When a patient wants to leave against medical advice (AMA), the nurse first confirms the patient has decision-making capacity (alert, oriented, not impaired, able to repeat back the risks). The provider explains the specific risks of leaving, and the conversation — not just the signature — is documented. A patient who lacks capacity (intoxicated, suicidal, altered) cannot validly refuse, and detaining them may be justified to prevent imminent harm. The nurse never abandons the patient: offer follow-up instructions, prescriptions, and an open door to return.

HIPAA, Reporting, and the Duty to Warn

Legal duties frequently collide, and the CEN expects you to know which obligation prevails. HIPAA protects patient privacy, but it expressly yields to mandatory reporting statutes — a nurse who reports suspected child abuse to child protective services is not violating HIPAA, because the law requires the disclosure. Reporting is made in good faith on reasonable suspicion, and the reporter is granted immunity from liability for a report that later proves unfounded; conversely, a mandated reporter who knowingly fails to report can face criminal and licensure consequences.

A related concept is the duty to warn (the Tarasoff principle): when a patient makes a credible, specific threat against an identifiable person, the clinician may have an obligation to warn the intended victim or notify authorities, again overriding ordinary confidentiality. The unifying lesson for the exam is that confidentiality is the default but not absolute — it bends to clearly defined legal duties that protect vulnerable people and the public. When a scenario pits "keep it confidential" against a reporting or warning duty, the duty wins, and the defensible answer documents the action objectively.

In practice the nurse reports promptly through the correct channel, notifies the provider, and records the facts that triggered the report without speculation or labeling, so the chart reflects an objective, defensible account.