Chapter 5: Settings for Psychiatric Care

Which attribute would be least helpful for a community mental health nurse to have? A. Flexibility B. Reactive manner C. Nonjudgmental attitude D. Ability to cross service systems

B. Community mental health nurses need to have a calm, nonreactive, nonjudgmental manner. Reactivity often gives clues to the nurse's inner feelings, producing situations in which the nurse does not appear to be objective.

Which need is the highest priority for a seriously and persistently ill client living in the community? A. Access to medication B. Socialization and diversion C. Independent decision making D. Engaging in meaningful work

A. After basic life necessities have been met, maintenance of the medication regimen is critical to preventing relapse and recurrence of the client's illness. If the client does not have access to medication, he or she will be unable to be compliant.

Most clients who are diagnosed with chronic mental illness are not likely to have their psychiatric mental health experiences covered by A. private insurance. B. Medicare. C. Medicaid. D. Social Security.

A. Because most health insurance is employer based, few chronically ill clients have private insurance.

Which is a characteristic of a therapeutic inpatient milieu? A. It provides for the client's safety and comfort. B. Voluntarily admitted clients are generally allowed additional privileges. C. Rules and behavioral limits are flexibly enforced. D. Staff provide frequent and ongoing negative feedback to clients.

A. Because the acuity level on inpatient units is high, nurses are responsible for ensuring that the environment is safe and that elopement and self-harm opportunities are minimized. The other choices are undesirable characteristics of a therapeutic milieu.

A community mental health nurse is responsible for medication management for clients. Which general approach can be anticipated to yield the best results? A. Empowering clients to be responsible for medication compliance B. Providing frequent oversight by nurse of daily medication ingestion C. Establishing a system in which client support figures oversee medications D. Scheduling monthly blood tests to determine serum levels of prescribed medications

A. Empowerment implies supporting the client to act on his or her own behalf. A client who is empowered takes responsibility for aspects of his or her own care, such as medication compliance. Having the client function at the highest level at which he or she is capable is always a goal of care; the more autonomous the client can be, the better.

The major difference between the psychiatric nursing assessment performed for a client who is hospitalized and for a client who will be treated in the community is A. for the latter, the general assessment must be expanded. B. for the latter, the nursing focus is primarily on the mental status examination. C. for the former, the general assessment must be reimbursement based. D. for the former, the nursing focus is limited to the client's willingness to accept treatment.

A. General assessment of clients in the community is expanded to include community living challenges and resources, the client's ability to cope with the demands of living in the community, and the client's willingness to accept community support.

Which of the following structural safety precautions is most important to prevent the most common type of inpatient suicides? A. Break-away closet bars to prevent hanging B. Bedroom and dining areas with locked windows to prevent jumping C. Double-locked doors to prevent escaping from the unit D. Platform beds to prevent crush injuries

A. Hangings are the most common method of inpatient suicide. The other options are important safety measures but don't directly address the suicide method of hanging.

In addition to physicians, what other members of the mental health disciplines have been identified as having the knowledge, skills, ability, and legal authority to intervene in the full range of mental health care? A. Nurses B. Social workers C. Clinical psychologists D. Chemical dependency counselors

A. Nurses are the only caregivers listed who can provide both physical and psychological care for mental health clients.

A novice nurse is assigned to manage the milieu when there is a behavioral crisis with a client in the dining room. The nurse shows a lack of understanding of crisis management when A. requiring that all clients go in their rooms. B. moving clients from the dining room to the day room/solarium. C. encouraging the clients to express their reactions to the incident. D. reassuring clients that staff will handle the agitated client.

A. Other clients are usually taken to a safe area away from the scene of the crisis. The nurse should allow clients to express their fears, which often include fear of bodily harm from the acting-out client, fear that they, too, could lose control, and fear for the other client's safety. The nurse should provide realistic reassurance for expressed concerns.

Which activity best exemplifies the focus for a case manager? A. Arranging for rapid assessment of a newly hospitalized client B. Providing a comprehensive client social history to the treatment team C. Writing a report describing best practices in care for clients with depression D. Gathering data for a research study concerning side effects of a new medication

A. Psychiatric case management fosters success in all aspects of community living by supporting recovery from acute symptoms, reducing recidivism, and enhancing the quality of life for the client with long-term illness.

Select the example of tertiary prevention. a. Helping a person diagnosed with a serious mental illness learn to manage money b. Restraining an agitated patient who has become aggressive and assaultive c. Teaching school-age children about the dangers of drugs and alcohol d. Genetic counseling with a young couple expecting their first child

ANS: A Tertiary prevention involves services that address residual impairments, with a goal of improved independent functioning. Restraint is a secondary prevention. Genetic counseling and teaching school-age children about substance abuse and dependence are examples of primary prevention.

George W. Bush's New Freedom Commission on Mental Health's report emphasized that mental illness is not a hopeless life sentence but a condition from which people can recover. Recovery, which is still the number 1 goal, could be described as: A. the ability to work, live, and participate in the community. B. never having to visit a mental health provider again. C. a short-term journey that leaves people better able to cope with symptoms. D. a long-term journey over the individual's life span.

A. Recovery is described as the ability of the individual to work, live, and participate in the community. Never having to visit a mental health provider is unrealistic. Recovery is usually not a short-term journey but rather a long-term journey. While recovery may be a long-term journey over months or even years, it would not cover an entire life span.

The community mental health nurse recognizes that the mentally ill population will require A. frequent assessment for physical illness both acute and chronic in nature. B. continuous supervision in order to assure that their physical needs are met. C. government assistance in the form of health insurance and housing. D. legal assistance to ensure they retain their civic rights.

A. Repeated studies have shown that people with mental illnesses also have a higher risk for medical disorder than the general population.

A client admitted to the behavioral health unit with a diagnosis of schizophrenia tells the nurse that she does not wish to see her husband if he visits. The nurse tells the client's husband that A. his wife has the right to refuse visitors if she wishes. B. he is welcome to visit but may receive a cool reception. C. the client's plan of care calls for limiting visitors for 2 days. D. the client is acutely psychotic and not responsible for her present behavior.

A. The client has the right to choose or refuse visitors.

The case manager is demonstrating an understanding of the primary goals of managed care when A. arranging for the client to have a screening for prostate cancer. B. notifying the family that the client will require a wheelchair when discharged. C. providing the client with organizations that help defray the cost of prescribed drug. D. arranging for respite care when the client's family needs to attend an out-of-state affair.

A. The goal of managed care is to provide coordination of all health services with an emphasis on preventive care.

Which statement regarding clients' rights after being voluntarily admitted to a behavioral health unit is true? A. All rights remain intact. B. Only rights that do not involve decision making remain intact. C. The right to refuse treatment is no longer guaranteed. D. All rights are temporarily suspended.

A. The hospitalized client is not a convicted criminal. All civil rights remain intact. Patients' rights are clearly posted in all inpatient units.

On a hospital inpatient unit, the nurse manager primary responsible is to A. assure the safety of both clients and staff on the unit. B. assist the client to prepare a support system by the time of discharge. C. provide medication therapy for the patients on the unit. D. help the inpatient community remain supportive of each other.

A. The nurse manager is responsible for an awareness of the safety of the unit, its effectiveness in the delivery of services, and how well the components of the health care team integrate their services.

A community mental health nurse is assigned to a mobile mental health care unit in a locale where the majority of the population are newly immigrated Vietnamese. The measure that will best help the nurse initially plan and implement culturally sensitive care for clients is A. arranging for the services of an interpreter and cultural consultant. B. reading about the predominant health beliefs held by members of Asian cultures. C. attempting to place self in the position of being an unassimilated member of a culture. D. treating clients in the same manner that clients of any culture would find satisfying.

A. Use of a translator is helpful with language and with gaining explanations of culture as it might affect health care.

A nurse makes an initial visit to a homebound patient diagnosed with a serious mental illness. A family member offers the nurse a cup of coffee. Select the nurse's best response. a. "Thank you. I would enjoy having a cup of coffee with you." b. "Thank you, but I would prefer to proceed with the assessment." c. "No, but thank you. I never accept drinks from patients or families." d. "Our agency policy prohibits me from eating or drinking in patients' homes."

ANS: A Accepting refreshments or chatting informally with the patient and family represent therapeutic use of self and help to establish rapport. The distracters fail to help establish rapport.

A Category V tornado hits a community, destroying many homes and businesses. Which nursing intervention would best demonstrate compassion and caring? a. Encouraging persons to describe their memories and feelings about the event b. Arranging transportation to the local community mental health center c. Referring a local resident to a community food bank d. Coordinating psychiatric home care services

ANS: A Disaster victims benefit from telling their story. Nurses show compassion by listening and offering hope. The distracters identify other aspects of psychological first aid and services on the mental health continuum.

Inpatient hospitalization for persons with mental illness is generally reserved for patients who: a. present a clear danger to self or others. b. are noncompliant with medication at home. c. have limited support systems in the community. d. develop new symptoms during the course of an illness.

ANS: A Hospitalization is justified when the patient is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. The distracters do not necessarily describe patients who require inpatient treatment.

A community mental health nurse has worked for months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and could no longer afford prescribed medications. The patient says, "Only a traitor would make me go to the hospital." Select the nurse's best initial intervention. a. With the patient's consent, contact resources to provide medications without charge temporarily. b. Arrange a bed in a local homeless shelter with nightly on-site supervision. c. Hospitalize the patient until the symptoms have stabilized. d. Ask the patient, "Do you feel like I am a traitor?"

ANS: A Hospitalization may damage the nurse-patient relationship, even if it provides an opportunity for rapid stabilization. If medication is restarted, the patient may possibly be stabilized in the home setting, even if it takes a little longer. Programs are available to help patients who are unable to afford their medications. A homeless shelter is inappropriate and unnecessary. Hospitalization may be necessary later, but a less restrictive solution should be tried first, since the patient is not dangerous. A yes/no question is non-therapeutic communication.

A patient diagnosed with schizophrenia has been stable for 2 months. Today the patient's spouse calls the nurse to report the patient has not taken prescribed medication and is having disorganized thinking. The patient forgot to refill the prescription. The nurse arranges a refill. Select the best outcome to add to the plan of care. a. The patient's spouse will mark dates for prescription refills on the family calendar. b. The nurse will obtain prescription refills every 90 days and deliver to the patient. c. The patient will call the nurse weekly to discuss medication-related issues. d. The patient will report to the clinic for medication follow-up every week.

ANS: A The nurse should use the patient's support system to meet patient needs whenever possible. Delivery of medication by the nurse should be unnecessary for the nurse to do if patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as medication is taken as prescribed.

A nurse performed these actions while caring for patients in an inpatient psychiatric setting. Which action violated patients' rights? a. Prohibited a patient from using the telephone b. In patient's presence, opened a package mailed to patient c. Remained within arm's length of patient with homicidal ideation d. Permitted a patient with psychosis to refuse oral psychotropic medication

ANS: A The patient has a right to use the telephone. The patient should be protected against possible harm to self or others. Patients have rights to send and receive mail and be present during package inspection. Patients have rights to refuse treatment.

A nurse surveys medical records. Which finding signals a violation of patients' rights? a. A patient was not allowed to have visitors. b. A patient's belongings were searched at admission. c. A patient with suicidal ideation was placed on continuous observation. d. Physical restraint was used after a patient was assaultive toward a staff member.

ANS: A The patient has the right to have visitors. Inspecting patients' belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self.

Which principle has the highest priority when addressing a behavioral crisis in an inpatient setting? a. Resolve the crisis with the least restrictive intervention possible. b. Swift intervention is justified to maintain the integrity of a therapeutic milieu. c. Rights of an individual patient are superseded by the rights of the majority of patients. d. Patients should have opportunities to regain control without intervention if the safety of others is not compromised.

ANS: A The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the patient's legal right. Planned interventions are nearly always preferable. Intervention may be necessary when the patient threatens harm to self.

Which scenario best depicts a behavioral crisis? A patient is: a. waving fists, cursing, and shouting threats at a nurse. b. curled up in a corner of the bathroom, wrapped in a towel. c. crying hysterically after receiving a phone call from a family member. d. performing push-ups in the middle of the hall, forcing others to walk around.

ANS: A This behavior constitutes a behavioral crisis because the patient is threatening harm to another individual. Intervention is called for to defuse the situation. The other options speak of behaviors that may require intervention of a less urgent nature because the patients in question are not threatening harm to self or others.

1. Planning for patients with mental illness is facilitated by understanding that inpatient hospitalization is generally reserved for patients who: a. present a clear danger to self or others. b. are noncompliant with medications at home. c. have no support systems in the community. d. develop new symptoms during the course of an illness.

ANS: A Hospitalization is justified when the patient is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. The incorrect options do not necessarily describe patients who require inpatient treatment.

16. A patient tells the nurse at the clinic, "I haven't been taking my antidepressant medication as directed. I leave out the midday dose. I have lunch with friends and don't want them to ask me about the pills." Select the nurse's most appropriate intervention. a.Investigate the possibility of once-daily dosing of the antidepressant. b. Suggest to the patient to take the medication when no one is watching. c. Explain how taking each dose of medication on time relates to health maintenance. d. Add the nursing diagnosis—Ineffective therapeutic regimen management, related to lack of knowledge—to the plan of care.

ANS: A Investigating the possibility of once-daily dosing of the antidepressant has the highest potential for helping the patient achieve compliance. Many antidepressants can be administered by once-daily dosing, a plan that increases compliance. Explaining how taking each dose of medication on time relates to health maintenance is reasonable but would not achieve the goal; it does not address the issue of stigma. The self-conscious patient would not be comfortable doing this. A better etiologic statement would be related to social stigma. The question asks for an intervention, not analysis.

5. A nurse assesses an inpatient psychiatric unit, noting that exits are free from obstruction, no one is smoking, the janitor's closet is locked, and all sharp objects are being used under staff supervision. These observations relate to: a. management of milieu safety b. coordinating care of patients c. management of the interpersonal climate d. use of therapeutic intervention strategies

ANS: A Members of the nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse's concerns, are unrelated to the observations cited.

8. A nurse surveys the medical records for violations of patients' rights. Which finding signals a violation? a. No treatment plan is present in record. b. Patient belongings are searched at admission. c. Physical restraint is used to prevent harm to self. d. Patient is placed on one-to-one continuous observation.

ANS: A The patient has the right to have a treatment plan. Inspecting a patient's belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self that occur as a result of a mental disorder.

9. Which principle takes priority for the psychiatric inpatient staff when addressing behavioral crises? a. Resolve behavioral crises with the least restrictive intervention possible. b. Rights of the majority of patients supersede the rights of individual patients. c. Swift intervention is justified to maintain the integrity of the therapeutic milieu. d. Allow patients the opportunities to regain control without intervention if the safety of other patients is not compromised.

ANS: A The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the patient's legal right. Planned interventions are nearly always preferable. Intervention may be necessary when the patient threatens harm to self.

3. A multidisciplinary health care team meets 12 hours after an adolescent is hospitalized after a suicide attempt. Members of the team report their assessments. What outcome can be expected from this meeting? a. A treatment plan will be determined. b. The health care provider will order neuroimaging studies. c. The team will request a court-appointed advocate for the patient. d. Assessment of the patient's need for placement outside the home will be undertaken.

ANS: A Treatment plans are formulated early in the course of treatment to streamline the treatment process and reduce costs. It is too early to determine the need for alternative postdischarge living arrangements. Neuroimaging is not indicated for this scenario.

20. Which employer's health plan is required to include parity provisions related to mental illnesses? a. Employer with more than 50 employees b. Cancer thrift shop staffed by volunteers c. Daycare center that employs 7 teachers d. Church that employs 15 people

ANS: A Under federal parity laws, companies with more than 50 employees may not limit annual or lifetime mental health benefits unless they also limit benefits for physical illnesses.

1. A nurse can best address factors of critical importance to successful community treatment by including making assessments relative to: (Select all that apply.) a. housing adequacy. b. family and support systems. c. income adequacy and stability. d. early psychosocial development. e. substance abuse history and current use.

ANS: A, B, C, E Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a patient is homeless or fears homelessness, focusing on other treatment issues is impossible. Sufficient income for basic needs and medication is necessary. Adequate support is a requisite to community placement. Substance abuse undermines medication effectiveness and interferes with community adjustment.

1. A nurse can best address factors of critical importance to successful community treatment for persons with mental illness by including assessments related to which of the following? Select all that apply. a. housing adequacy and stability b. income adequacy and stability c. family and other support systems d. early psychosocial development e. substance abuse history and current use

ANS: A, B, C, E Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a patient is homeless or fears homelessness, focusing on other treatment issues is impossible. Sufficient income for basic needs and medication is necessary. Adequate support is a requisite to community placement. Substance abuse undermines medication effectiveness and interferes with community adjustment.

Which statements by patients diagnosed with a serious mental illness best demonstrate that the case manager has established an effective long-term relationship? "My case manager: (select all that apply) a. talks in language I can understand." b. helps me keep track of my medication." c. gives me little gifts from time to time." d. looks at me as a whole person with many needs." e. lets me do whatever I choose without interfering."

ANS: A, B, D Each correct answer is an example of appropriate nursing foci: communicating at a level understandable to the patient, providing medication supervision, and using holistic principles to guide care. The distracters violate relationship boundaries or suggest a laissez faire attitude on the part of the nurse.

A psychiatric nurse discusses rules of the therapeutic milieu and patients' rights with a newly admitted patient. Which rights should be included? (Select all that apply.) The right to: a. have visitors b. confidentiality c. a private room d. complain about inadequate care e. select the nurse assigned to their care

ANS: A, B, D Patients' rights should be discussed shortly after admission. Patients have rights related to receiving/refusing visitors, privacy, filing complaints about inadequate care, and accepting/refusing treatments (including medications). Patients do not have a right to a private room or selecting which nurse will provide care.

A person in the community asks, "People with mental illnesses went to state hospitals in earlier times. Why has that changed?" Select the nurse's accurate responses. Select all that apply. a. "Science has made significant improvements in drugs for mental illness, so now many persons may live in their communities." b. "There's now a better selection of less restrictive treatment options available in communities to care for people with mental illness." c. "National rates of mental illness have declined significantly. There actually is not a need for state institutions anymore." d. "Most psychiatric institutions were closed because of serious violations of patients' rights and unsafe conditions." e. "Federal legislation and payment for treatment of mental illness has shifted the focus to community rather than institutional settings."

ANS: A, B, E The community is a less restrictive alternative than hospitals for treatment of persons with mental illness. Funding for treatment of mental illness remains largely inadequate but now focuses on community rather than institutional care. Antipsychotic medications improve more symptoms of mental illness; hence, management of psychiatric disorders has improved. Rates of mental illness have increased, not decreased. Hospitals were closed because funding shifted to the community. Conditions in institutions have improved.

2. A community member asks a nurse, "People with mental illnesses used to go to a state hospital. Why has that changed?" Select the nurse's accurate responses. Select all that apply. a. "Science has made significant improvements in drugs for mental illness, so now many people may live in their communities." b. "A better selection of less restrictive settings is now available in communities to care for individuals with mental illness." c. "National rates of mental illness have declined significantly. The need for state institutions is actually no longer present." d. "Most psychiatric institutions were closed because of serious violations of patients' rights and unsafe conditions." e. "Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings."

ANS: A, B, E The community is a less restrictive alternative than hospitals for the treatment of people with mental illness. Funding for treatment of mental illness remains largely inadequate but now focuses on community rather than institutional care. Antipsychotic medications improve more symptoms of mental illness; hence, management of psychiatric disorders has improved. Rates of mental illness have increased, not decreased. Hospitals were closed because funding shifted to the community. Conditions in institutions have improved.

The health care team at an inpatient psychiatric facility drafts these criteria for admission. Which criteria should be included in the final version of the admission policy? Select all that apply. a. Clear risk of danger to self or others b. Adjustment needed for doses of psychotropic medication c. Detoxification from long-term heavy alcohol consumption needed d. Respite for caregivers of persons with serious and persistent mental illness e. Failure of community-based treatment, demonstrating need for intensive treatment

ANS: A, C, E Medication doses can be adjusted on an outpatient basis. The goal of caregiver respite can be accomplished without hospitalizing the patient. The other options are acceptable, evidence-based criteria for admission of a patient to an inpatient service.

A patient diagnosed with schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns that the patient: · wants to attend an activity group at the mental health outreach center. · is worried about being able to pay for the therapy. · does not know how to get from home to the outreach center. · has an appointment to have blood work at the same time an activity group meets. · wants to attend services at a church that is a half-mile from the patient's home. Which tasks are part of the role of a community mental health nurse? Select all that apply. a. Rearranging conflicting care appointments b. Negotiating the cost of therapy for the patient c. Arranging transportation to the outreach center d. Accompanying the patient to church services weekly e. Monitoring to ensure the patient's basic needs are met

ANS: A, C, E The correct answers reflect the coordinating role of the community psychiatric nurse case manager. Negotiating the cost of therapy and accompanying the patient to church services are interventions the nurse would not be expected to undertake. The patient can walk to the church services; the nurse can provide encouragement.

Which characteristic would be more applicable to a community mental health nurse than to a nurse working in an operating room? a. Kindness b. Autonomy c. Compassion d. Professionalism

ANS: B A community mental health nurse often works autonomously. Kindness, compassion, and professionalism apply to both nurses.

Which level of prevention activities would a nurse in an emergency department employ most often? a. Primary b. Secondary c. Tertiary

ANS: B An emergency department nurse would generally see patients in crisis or with acute illness, so secondary prevention is used. Primary prevention involves preventing a health problem from developing, and tertiary prevention applies to rehabilitative activities.

A nurse receives these three phone calls regarding a newly admitted patient. · The psychiatrist wants to complete an initial assessment. · An internist wants to perform a physical examination. · The patient's attorney wants an appointment with the patient. The nurse schedules the activities for the patient. Which role has the nurse fulfilled? a. Advocate b. Case manager c. Milieu manager d. Provider of care

ANS: B Nurses on psychiatric units routinely coordinate patient services, serving as case managers as described in this scenario. The role of advocate would require the nurse to speak out on the patient's behalf. The role of milieu manager refers to maintaining a therapeutic environment. Provider of care refers to giving direct care to the patient.

A nurse inspects an inpatient psychiatric unit and finds that exits are free of obstructions, no one is smoking, and the janitor's closet is locked. These observations relate to: a. coordinating care of patients. b. management of milieu safety. c. management of the interpersonal climate. d. use of therapeutic intervention strategies.

ANS: B Nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse's concerns, are unrelated to the observations cited.

Which assessment finding for a patient in the community deserves priority intervention by the psychiatric nurse? The patient: a. receives Social Security disability income plus a small check from a trust fund every month. b. was absent from two of six planned Alcoholics Anonymous meetings in the past 2 weeks. c. lives in an apartment with two patients who attend partial hospitalization programs. d. has a sibling who was recently diagnosed with a mental illness.

ANS: B Patients who use alcohol or illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of substances on cellular brain function, promotes relapse. The distracters do not suggest problems.

Which activity is appropriate for a nurse engaged exclusively in community-based primary prevention? a. Medication follow-up b. Teaching parenting skills c. Substance abuse counseling d. Making a referral for family therapy

ANS: B Primary prevention activities are directed to healthy populations to provide information for developing skills that promote mental health. The distracters represent secondary or tertiary prevention activities.

Select the example of primary prevention. a. Assisting a person diagnosed with a serious mental illness to fill a pill-minder b. Helping school-age children identify and describe normal emotions c. Leading a psychoeducational group in a community care home d. Medicating an acutely ill patient who assaulted a staff person

ANS: B Primary preventions are directed at healthy populations with a goal of preventing health problems from occurring. Helping school-age children describe normal emotions people experience promotes coping, a skill that is needed throughout life. Assisting a person with serious and persistent mental illness to fill a pill-minder is an example of tertiary prevention. Medicating an acutely ill patient who assaulted a staff person is a secondary prevention. Leading a psychoeducational group in a community care home is an example of tertiary prevention.

13. A community mental health nurse has worked for 6 months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and stopped taking medications because of inadequate money. The patient says, "Only a traitor would make me go to the hospital." Which solution is best? a. Arrange a bed in a local homeless shelter with nightly onsite supervision. b. Negotiate a way to provide medication so the patient can remain at home. c. Hospitalize the patient until the symptoms have stabilized. d. Seek inpatient hospitalization for up to 1 week.

ANS: B Hospitalization may damage the nurse-patient relationship even if it provides an opportunity for rapid stabilization. If medication can be obtained and restarted, the patient can possibly be stabilized in the home setting, even if it takes a little longer. A homeless shelter is inappropriate and unnecessary. Hospitalization may be necessary later, but a less restrictive solution should be tried first because the patient is not dangerous.

17. A community psychiatric nurse assesses that a patient with a mood disorder is more depressed than on the previous visit a month ago; however, the patient says, "I feel the same." Which intervention supports the nurse's assessment while preserving the patient's autonomy? a. Arrange for a short hospitalization. b. Schedule weekly clinic appointments. c. Refer the patient to the crisis intervention clinic. d. Call the family and ask them to observe the patient closely.

ANS: B Scheduling clinic appointments at shorter intervals will give the opportunity for more frequent assessment of symptoms and allow the nurse to use early intervention. If the patient does not admit to having a crisis or problem, this referral would be useless. The remaining options may produce unreliable information, violate the patient's privacy, and waste scarce resources.

12. A patient with schizophrenia has been stable in the community. Today, the spouse reports the patient is delusional and explosive. The patient says, "I'm willing to take my medicine, but I forgot to get my prescription refilled." Which outcome should the nurse add to the plan of care? a. Nurse will obtain prescription refills every 90 days and deliver them to the patient. b. Patient's spouse will mark dates for prescription refills on the family calendar. c. Patient will report to the hospital for medication follow-up every week. d. Patient will call the nurse weekly to discuss medication-related issues.

ANS: B The nurse should use the patient's support system to meet patient needs whenever possible. Delivery of medication by the nurse should be unnecessary for the nurse to do if the patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as he or she continues to take the medications as prescribed. No patient issues except failure to obtain medication refills were identified.

A suspicious, socially isolated patient lives alone, eats one meal a day at a local shelter, and spends the remaining daily food allowance on cigarettes. Select a community psychiatric nurse's best initial action. a. Explore ways to help the patient stop smoking. b. Report the situation to the manager of the shelter. c. Assess the patient's weight; determine foods and amounts eaten. d. Arrange hospitalization for the patient in order to formulate a new treatment plan.

ANS: C Assessment of biopsychosocial needs and general ability to live in the community is called for before any other action is taken. Both nutritional status and income adequacy are critical assessment parameters. A patient may be able to maintain adequate nutrition while eating only one meal a day. The rule is to assess before taking action. Hospitalization may not be necessary. Smoking cessation strategies can be pursued later.

A patient diagnosed with schizophrenia had an exacerbation related to medication noncompliance and was hospitalized for 5 days. The patient's thoughts are now more organized, and discharge is planned. The patient's family says, "It's too soon for discharge. We will just go through all this again." The nurse should: a. ask the case manager to arrange a transfer to a long-term care facility. b. notify hospital security to handle the disturbance and escort the family off the unit. c. explain that the patient will continue to improve if the medication is taken regularly. d. contact the health care provider to meet with the family and explain the discharge rationale.

ANS: C Patients do not stay in a hospital until every symptom disappears. The nurse must assume responsibility to advocate for the patient's right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. The health care provider will use the same rationale. Shifting blame will not change the discharge. Security is unnecessary. The nurse can handle this matter.

An example of deinstitutionalization would include A. providing a recovering alcoholic with transportation to nightly AA meetings. B. discharging a stabilized psychotic client to a transitional halfway house. C. psychiatric in-home visits for a new mother experiencing post-partum depression. D. conducting regular depression screening at a local homeless shelter.

B. Deinstitutionalization involves interventions that move a hospitalized mental health client into community-based outpatient services.

A patient usually watches television all day, seldom going out in the community or socializing with others. The patient says, "I don't know what to do with my free time." Which member of the treatment team would be most helpful to this patient? a. Psychologist b. Social worker c. Recreational therapist d. Occupational therapist

ANS: C Recreational therapists help patients use leisure time to benefit their mental health. Occupational therapists assist with a broad range of skills, including those for employment. Psychologists conduct testing and provide other patient services. Social workers focus on the patient's support system.

The case manager plans to discuss the treatment plan with a patient's family. Select the case manager's first action. a. Determine an appropriate location for the conference. b. Support the discussion with examples of the patient's behavior. c. Obtain the patient's permission for the exchange of information. d. Determine which family members should participate in the conference.

ANS: C The case manager must respect the patient's right to privacy, which extends to discussions with family. Talking to family members is part of the case manager's role. Actions identified in the distracters occur after the patient has given permission.

A patient was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the case manager learned that the patient received a notice of eviction immediately prior to admission. Select the case manager's most appropriate action. A. Postpone the patient's discharge from the hospital. b. Contact the landlord who evicted the patient to further discuss the situation. c. Arrange a temporary place for the patient to stay until new housing can be arranged. d. Determine whether the adverse medication reaction was genuine because the patient had nowhere to live.

ANS: C The case manager should intervene by arranging temporary shelter for the patient until an apartment can be found. This activity is part of the coordination and delivery of services that falls under the case manager role. None of the other options is a viable alternative.

The unit secretary receives a phone call from the health insurer for a hospitalized patient. The caller seeks information about the patient's projected length of stay. How should the nurse instruct the unit secretary to handle the request? a. Obtain the information from the patient's medical record and relay it to the caller. b. Inform the caller that all information about patients is confidential. c. Refer the request for information to the patient's case manager. d. Refer the request to the health care provider.

ANS: C The case manager usually confers with insurers and provides the treatment team with information about available resources. The unit secretary should be mindful of patient confidentiality and should neither confirm that the patient is an inpatient nor disclose other information.

10. To provide comprehensive care to patients, which competency is more important for a nurse who works in a community mental health center than a psychiatric nurse who works in an inpatient unit? a. Problem-solving skills b. Calm external manner c. Ability to cross service systems d. Knowledge of psychopharmacology

ANS: C A community mental health nurse must be able to work with schools, corrections facilities, shelters, health care providers, and employers. The mental health nurse working in an inpatient unit needs only to be able to work within the single setting. Problem-solving skills are needed by all nurses. Nurses in both settings must have knowledge of psychopharmacology.

11. A suspicious and socially isolated patient lives alone, eats one meal a day at a nearby shelter, and spends the remaining daily food allowance on cigarettes. Select the community psychiatric nurse's best initial action. a. Report the situation to the manager of the shelter. b. Tell the patient, "You must stop smoking to save money." c. Assess the patient's weight; determine the foods and amounts eaten. d. Seek hospitalization for the patient while a new plan is being formulated.

ANS: C Assessment of biopsychosocial needs and general ability to live in the community is called for before any action is taken. Both nutritional status and income adequacy are critical assessment parameters. A patient may be able to maintain adequate nutrition while eating only one meal a day. Nurses assess before taking action. Hospitalization may not be necessary.

18. A patient hurriedly tells the community mental health nurse, "Everything's a disaster! I can't concentrate. My disability check didn't come. My roommate moved out, and I can't afford the rent. My therapist is moving away. I feel like I'm coming apart." Which nursing diagnosis applies? a. Decisional conflict, related to challenges to personal values b. Spiritual distress, related to ethical implications of treatment regimen c. Anxiety, related to changes perceived as threatening to psychological equilibrium d. Impaired environmental interpretation syndrome, related to solving multiple problems affecting security needs

ANS: C Subjective and objective data obtained by the nurse suggest the patient is experiencing anxiety caused by multiple threats to security needs. Data are not present to suggest Decisional conflict, ethical conflicts around treatment causing Spiritual distress, or Impaired environmental interpretation syndrome.

2. A patient is hospitalized for a reaction to a psychotropic medication and then is closely monitored for 24 hours. During a predischarge visit, the case manager learns the patient received a notice of eviction on the day of admission. The most appropriate intervention for the case manager is to: a. cancel the patient's discharge from the hospital. b. contact the landlord who evicted the patient to further discuss the situation. c. arrange a temporary place for the patient to stay until new housing can be arranged. d. document that the adverse medication reaction was feigned because the patient had nowhere to live.

ANS: C The case manager should intervene by arranging temporary shelter for the patient until suitable housing can be found. This is part of the coordination and delivery of services that falls under the case manager role. The other options are not viable alternatives.

7. A student nurse prepares to administer oral medications to a patient with major depression, but the patient refuses the medication. The student nurse should: a. tell the patient, "I'll get an unsatisfactory grade if I don't give you the medication." b. tell the patient, "Refusing your medication is not permitted. You are required to take it." c. explore the patient's concerns about the medication, and report to the staff nurse. d. document the patient's refusal of the medication without further comment.

ANS: C The patient has the right to refuse medication in most cases. The patient's reason for refusing should be ascertained, and the refusal should be reported to a unit nurse. Sometimes refusals are based on unpleasant side effects that can be ameliorated. Threats and manipulation are inappropriate. Medication refusal should be reported to permit appropriate intervention.

Which statements most clearly reflect the stigma of mental illness? Select all that apply. a. "Many mental illnesses are hereditary." b. "Mental illness can be evidence of a brain disorder." c. "People claim mental illness so they can get disability checks." d. "Mental illness results from the breakdown of American families." e. "If people with mental illness went to church, their symptoms would vanish."

ANS: C, D, E Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. Many mental illnesses are genetically transmitted. Neuroimaging can show changes associated with some mental illnesses.

The patients below were evaluated in the emergency department. The psychiatric unit has one bed available. Which patient should be admitted? The patient: a. feeling anxiety and a sad mood after separation from a spouse of 10 years. b. who self-inflicted a superficial cut on the forearm after a family argument. c. experiencing dry mouth and tremor related to taking haloperidol (Haldol). d. who is a new parent and hears voices saying, "Smother your baby."

ANS: D Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.

The nurse assigned to assertive community treatment (ACT) should explain the program's treatment goal as: a. assisting patients to maintain abstinence from alcohol and other substances of abuse. b. providing structure and a therapeutic milieu for mentally ill patients whose symptoms require stabilization. c. maintaining medications and stable psychiatric status for incarcerated inmates who have a history of mental illness. d. providing services for mentally ill individuals who require intensive treatment to continue to live in the community.

ANS: D An assertive community treatment (ACT) program provides intensive community services to persons with serious, persistent mental illness who live in the community but require aggressive services to prevent repeated hospitalizations.

Which patient would be most appropriate to refer for assertive community treatment (ACT)? A patient diagnosed with: a. a phobic fear of crowded places. b. a single episode of major depression. c. a catastrophic reaction to a tornado in the community. d. schizophrenia and four hospitalizations in the past year.

ANS: D Assertive community treatment (ACT) provides intensive case management for persons with serious persistent mental illness who live in the community. Repeated hospitalization is a frequent reason for this intervention. The distracters identify mental health problems of a more episodic nature.

Which aspect of direct care is an experienced, inpatient psychiatric nurse most likely to provide for a patient? a. Hygiene assistance b. Diversional activities c. Assistance with job hunting d. Building assertiveness skills

ANS: D Assertiveness training relies on the counseling and psychoeducational skills of the nurse. Assistance with personal hygiene would usually be accomplished by a psychiatric technician or nursing assistant. Diversional activities are usually the province of recreational therapists. The patient would probably be assisted in job hunting by a social worker or vocational therapist.

Clinical pathways are used in managed care settings to: a. stabilize aggressive patients. b. identify obstacles to effective care. c. relieve nurses of planning responsibilities. d. streamline the care process and reduce costs.

ANS: D Clinical pathways provide guidelines for assessments, interventions, treatments, and outcomes as well as a designated timeline for accomplishment. Deviations from the timeline must be reported and investigated. Clinical pathways streamline the care process and save money. Care pathways do not identify obstacles or stabilize aggressive patients. Staff are responsible for the necessary interventions. Care pathways do not relieve nurses of the responsibility of planning; pathways may, however, make the task easier.

A health care provider prescribed depot injections every 3 weeks at the clinic for a patient with a history of medication noncompliance. For this plan to be successful, which factor will be of critical importance? a. The attitude of significant others toward the patient b. Nutrition services in the patient's neighborhood c. The level of trust between the patient and nurse d. The availability of transportation to the clinic

ANS: D The ability of the patient to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the patient of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, non-adherence will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem.

The nurse should refer which of the following patients to a partial hospitalization program? A patient who: a. has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up. b. needs psychoeducation for relaxation therapy related to agoraphobia and panic episodes. c. spent yesterday in a supervised crisis care center and continues to have active suicidal ideation. d. states, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning."

ANS: D This patient could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends, the spouse could assume responsibility for supervision. A suicidal patient needs inpatient hospitalization. The other patients can be served in the community or with individual visits.

6. The following patients are seen in the emergency department. The psychiatric unit has one bed available. Which patient should the admitting officer recommend for admission to the hospital? The patient who: a. experiencing dry mouth and tremor related to side effects of haloperidol (Haldol). b. experiencing anxiety and a sad mood after a separation from a spouse of 10 years. c. who self-inflicted a superficial cut on the forearm after a family argument. d. who is a single parent and hears voices saying, "Smother your infant."

ANS: D Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.

4. The relapse of a patient with schizophrenia is related to medication noncompliance. The patient is hospitalized for 5 days, medication is restarted, and the patient's thoughts are now more organized. The patient's family members are upset and say, "It's too soon about the patient being scheduled for discharge. Hospitalization is needed for at least a month." The nurse should: a. call the psychiatrist to come explain the discharge rationale. b. explain that health insurance will not pay for a longer stay for the patient. c. call security to handle the disturbance and escort the family off the unit. d. explain that the patient will continue to improve if medication is taken regularly.

ANS: D Patients no longer stay in the hospital until every vestige of a symptom disappears. The nurse must assume responsibility to advocate for the patient's right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. The health care provider will use the same rationale. Shifting blame will not change the discharge. Calling security is unnecessary. The nurse can handle this matter.

15. Which assessment finding for a patient in the community requires priority intervention by the nurse? The patient: a. receives Social Security disability income plus a small check from a trust fund. b. lives in an apartment with two patients who attend day hospital programs. c. has a sibling who is interested and active in care planning. d. purchases and uses marijuana on a frequent basis.

ANS: D Patients who regularly buy illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of illegal drugs on cellular brain function, promotes relapse. The remaining options do not suggest problems.

14. A community psychiatric nurse facilitates medication compliance for a patient by having the health care provider prescribe depot medications by injection every 3 weeks at the clinic. For this plan to be successful, which factor will be of critical importance? a. Attitude of significant others toward the patient b. Nutritional services in the patient's neighborhood c. Level of trust between the patient and the nurse d. Availability of transportation to the clinic

ANS: D The ability of the patient to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the patient of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, noncompliance will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem.

19. Which patient would a nurse refer to partial hospitalization? An individual who: a. spent yesterday in the 24-hour supervised crisis care center and continues to be actively suicidal. b. because of agoraphobia and panic episodes needs psychoeducation for relaxation therapy c. has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up. d. states, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning."

ANS: D This patient could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends, the spouse could assume supervision responsibilities. The patient who is actively suicidal needs inpatient hospitalization. The patient in need of psychoeducation can be referred to home care. The patient who reports regularly for blood tests and clinical follow-up can continue on the same plan.

The nurse who provides therapeutic milieu management supports the clients best by A. allowing them to act out their fears and frustrations. B. providing a safe place for them to practice coping skills. C. meeting their physical as well as emotional needs. D. encouraging them to talk about their problems with others.

B. A therapeutic milieu can serve as a real-life training ground for learning about the self and practicing communication and coping skills in preparation for a return to the community.

The primary advantage of using a case manager is to A. increase collaborative practice. B. enhance resource management. C. increase client satisfaction with care. D. promote evidence-based psychiatric nursing.

B. Case management coordinates and monitors the effectiveness of services appropriate for the client. In the community setting, for example, close monitoring permits rapid assessment of the need for crisis intervention to avoid costly readmission.

A client was admitted to the behavioral health unit for evaluation and diagnosis after being found wandering the streets. His personal hygiene is poor, and his responses to questions are bizarre and inappropriate. The client's constitutional rights are violated when the nurse states: A. "We will help you make decisions that will keep you safe." B. "I am going to help you shower, so you will not smell so bad." C. "Your pocket knife and nail clippers will be kept in the nurses' station." D. "You will be having a number of tests to help us learn about your condition."

B. Every client has the right to be treated with dignity. This statement is demeaning.

A nurse says, "I work with a mobile mental health unit." The listener can assume that the nurse A. works with patients who are incarcerated. B. sees clients in unconventional settings. C. is a preferred provider for a large HMO. D. is a clinical specialist with the visiting nurse service.

B. Mobile mental health units travel throughout the community, seeing clients on their own "turf," such as in shelters, on street corners, in homes, and at factories.

For the psychiatric client, the greatest negative aspect of the multidisciplinary treatment team approach to care is that it A. is an expensive treatment model. B. can increase anxiety in the newly admitted client. C. requires the client to answer the same questions repeatedly. D. puts demands on the client's time and energy.

B. Newly admitted clients can find the interaction with numerous team members stressful or even threatening.

An ongoing, crucial responsibility of nurses working on an inpatient psychiatric unit is A. fostering research. B. maintaining a therapeutic milieu. C. sympathetic listening. D. providing constructive negative feedback.

B. Nursing is the discipline primarily responsible for maintenance of a therapeutic milieu, an environment that serves as a real-life training ground for learning about self and practicing communication and coping skills in preparation for a return to the community outside the hospital.

Which of the following patients would be appropriate to refer to a partial hospitalization program (PHP)? A. Ramon, who is suicidal with a plan B. Marty, a substance abuser who is being discharged from an inpatient alcohol rehabilitation unit C. Ellen, who stopped taking her antipsychotic medication and is decompensated and not caring for herself D. Jeff, who has mild depression symptoms and is starting outpatient therapy

B. PHP is for patients who may need a "step-down" environment from inpatient status or for those who are being diverted from hospitalization with intensive, short-term care from which they return home each day. This patient would be a good candidate after completing alcohol rehab; PHP could possibly help prevent relapse in the early stages after rehab. This patient can be managed with regular outpatient therapy and does not need intensive short-term therapy such as PHP. Someone who is suicidal would require inpatient hospitalization for safety as would someone who is decompensated and not caring for herself. A patient exhibiting mild depression would be managed with outpatient therapy and would not need intensive short-term therapy such as PHP.

When preparing an education program focused on the history of the community mental health movement in the United States, the nurse includes the fact that A. use of community settings began after World War II with the discharge of large numbers of veterans with mental illness. B. the shift from care in psychiatric hospitals to community mental health centers began in the 1960s. C. movement of services out of hospitals and into the community is a baby-boomer phenomenon that began in the 1980s. D. the community mental health movement is an outgrowth of managed care's response to rising health care costs beginning in the 1990s.

B. The community mental health movement began as a result of legislation passed during the Kennedy administration.

When asked to explain what a psychosocial rehabilitation program is, the nurse responds best when sharing A. "The concept started in the 1960s and provides psychiatric care for those without private insurance." B. "The individual program can provide medication, therapies, and social services for the mentally ill." C. "Referrals from inpatient and intensive outpatient facilities are provided with long-term care that focuses on desired goals." D. "It is a multidisciplinary team approach that is composed of nurses, psychiatrics, social workers, and psychologists."

C. Clients are referred to the clinic program for long-term follow-up from inpatient units or other providers or outpatient care. The treatment can last for years, and discharge is achieved when improvement is shown or desired outcomes are reached.

In 1963 the Community Mental Health Centers Act was signed with the primary purpose of A. having mental health care services funded by the federal government while provided by state government. B. providing mental health care to the uninsured in an economical reasonable manner. C. providing mental health care on an outpatient basis in order to maintain the client as a member of an established community. D. assuring all Americans of the mental health care services they need and/or desire.

C. Community mental health centers were created as a result of the 1963 Community Mental Health Centers Act for the purpose of providing mental health services while maintaining the client in his own community.

Which assessment information is uniquely important to the mental health client receiving outpatient care? A. Mental status examination results B. The client's strengths and deficits C. Housing adequacy and stability D. The presenting problem and referring party

C. For hospitalized clients, the treatment team does not have to worry about whether the client has a clean, safe place to stay and adequate food to eat. For the client receiving care in the community, these are legitimate planning concerns.

In an attempt to provide both safety and client comfort, psychiatric units generally have A. a varied client menu served on nonbreakable plastic dinnerware. B. comfortable seating that is well padded but secured to the floor. C. bedrooms that resemble hotel rooms but with specific safety features. D. a dayroom that has audiovisual equipment and is visible from the nurses' station.

C. One of the most important safety features of a psychiatric unit is the noninstitutional bedroom, which is equipped with many safety-specific features.

The psychiatric community health nurse engages in primary prevention when A. visiting a homeless shelter to provide crisis intervention for its clients. B. discussing the need for proper nutrition with a depressed new mother. C. providing stress reduction seminars at the local senior center. D. visiting the home of a client currently displaying manic behavior.

C. Primary prevention is directed at healthy individuals with the purpose of preventing mental illness.

Which criterion must be met to refer a client to a partial hospitalization program? A. The client is hospitalized at night in an inpatient setting. B. The client must be able to provide his or her own transportation daily. C. The client is able to return home each day. D. The client is able to care for his or her own physical and psychological needs.

C. Returning home each day is a criterion because doing so allows the person to test out new skills and gradually re-enter the family and society

A chronically ill client was readmitted when symptoms of the illness exacerbated. The client lives alone and has few outside activities. To best prepare the client for discharge, the nurse will focus on A. improving client-family relationships. B. placing the client in a sheltered workshop. C. psychoeducation to promote medication compliance. D. involving the client in daily visits to a psychosocial club.

C. To prepare clients for discharge, nurses should focus on precipitants of the crisis that led to hospital admission.

There is one bed on a locked psychiatric unit. Which of the following patients is appropriate for involuntary admission? A. Jill, aged 23 years, a college student who has developed symptoms of anxiety and is missing classes and work B. Michael, aged 30 years, an accountant who has developed symptoms of depression C. Mia, aged 26 years, a kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road D. Rose, aged 76 years, a retired librarian who is experiencing memory loss and some confusion at times

C. Inpatient involuntary admission is reserved for patients who are at risk for self-harm or who cannot adequately protect themselves from harm because of their illness (e.g., a psychotic patient). The other options can all be managed at this point in the community setting and don't meet criteria (risk of harm to self and/or others) for admission.

A function shared by advanced practice and general practice psychiatric nurses is A. prescriptive authority. B. hospital privileges. C. provision of consultation services. D. collaboration with a multidisciplinary team.

D. Nurses at both levels are expected to collaborate with multidisciplinary teams; only the advanced practice nurse has prescriptive authority and admitting privileges and can provide consultation.

It is not always guaranteed that all clients who are voluntarily admitted to a behavioral health unit will have the right to A. refuse treatment. B. send and receive mail. C. seek legal counsel. D. access all personal possessions.

D. A client has the right to keep personal belongings unless they are dangerous. Items such as sharp objects, glass containers, and medication are usually removed from the client's possession and kept in a locked area to be used by the client under supervision or returned at discharge.

One primary goal and benefit of Assertive Community Treatment (ACT) is: A. forming closer relationships with the patient's family. B. more flexible work schedule for staff. C. more reimbursement to staff for services provided. D. preventing rehospitalization.

D. A primary goal of ACT is working intensely with the patient in the community to prevent rehospitalization. The other options are not goals of ACT.

The community mental health movement was least influenced by A. the advent of antipsychotic medications. B. increasing public awareness of the poor care given in some large psychiatric hospitals. C. the proliferation of federal entitlement programs, making it possible to move the mentally ill out of hospitals. D. the increasingly larger numbers of advanced practice nurses prepared to care for the mentally ill in the community.

D. At the time the community mental health movement began, relatively few advanced practice psychiatric nurses were practicing, and fewer still were prepared to care for the mentally ill in the community.

In order to be most effective, the community mental health nurse involved in assertive community treatment (ACT) needs to possess A. knowledge of both national and local political activism. B. the ability to cross service systems. C. an awareness of own cultural and personal values. D. creative problem-solving and intervention skills.

D. Creative problem-solving and intervention skills are the hallmark of care provided by the ACT team.

Which would NOT be considered a crisis on a psychiatric unit? A. Mr. R reports chest pain after eating a spicy lunch. B. Ms. T cannot speak and is holding her hands up to her neck. C. Mr. S demonstrates anger that escalates to physical assault. D. Mr. U reports hearing voices telling him to hit others.

D. Crises on a psychiatric unit can be either medical in nature or behavioral. Medical crises include shock, cardiopulmonary arrest, hemorrhage, and status epilepticus, whereas behavioral crises include actual or potential violence against self, others, or the environment. Option D is not considered a crisis, but rather a potential crisis that was averted.

When mental health care is provided for in a community setting, goal setting is A. client-directed and focused on the individual's expressed wishes. B. society-driven and focused on returning the client into the social community. C. determined by the care provider and focused on cost-effective measures. D. negotiated by both client and staff and focused on long-term functioning.

D. In the community setting treatment goals and interventions directed at long-term function within the community are negotiated rather than imposed on the client.

Which situation demonstrates the nurse functioning in the role of advocate? A. Providing one-to-one supervision for a client on suicide precautions B. Co-leading a medication education group for clients and families C. Attending an inservice education program to obtain recertification in cardiopulmonary resuscitation D. Negotiating with the client's HMO for extension of a 3-day hospitalization to 5 days

D. In the inpatient setting, case managers on the hospital team communicate daily or weekly with the client's insurer and provide the treatment team guidance regarding the availability of resources. In the community, multiple levels of intervention are available within case management service, ranging from daily assistance with medications to ongoing resolution of housing and financial issues.

Although mental illness still carries a stigma, acceptance has improved over the past 40 years, partly due to A. better control of symptoms through drug therapy. B. public screenings that are well advertized in the community. C. community psychiatric nursing programs that provide in-home care. D. acknowledgment of personal mental health issues by well-known people.

D. Public discussion of mental illness by famous political, entertainment, and sports figures has proven helpful in minimizing the stigma attached to problems such as depression, anxiety, and eating disorders.

Which symptomatology has priority for admission to an inpatient behavioral health unit? A. Severe anxiety and feeling as though one is suffocating B. Profound grieving over the recent death of one's identical twin C. Hearing voices that proclaim one to be "the exalted ruler of the universe" D. History of seizures and an elevated lithium level

D. This modification requires careful titration and observation that would be difficult to provide on an outpatient basis. (Lithium toxicity can proceed to death.)