Psychiatric Mental Health Exam 2

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.

A patient in a support group says, "I'm tired of being sick. Everyone always helps me, but I will be glad when I can help someone else." This statement reflects a. altruism. b. universality. c. cohesiveness. d. corrective recapitulation.

ANS: A Altruism refers to the experience of being helpful or useful to others, a condition that the patient anticipates will happen. The other options are also therapeutic factors identified by Yalom.

A therapy group adds new members as others leave. What type of group is evident? a. Open b. Closed c. Homogeneous d. Heterogeneous

ANS: A An open group is a group that adds members throughout the life of the group as other members leave and as more persons who would benefit from the group become available. A closed group does not add new members; the membership is established at the beginning and, except for the occasional losses as some members leave, does not change thereafter. A homogeneous group includes members who are similar, and a heterogeneous group includes dissimilar members; not enough data are provided here to determine which applies in this case.

Match the group member's comment to the role it most closely represents. a. Playboy b. Energizer c. Organizer d. Follower 1. "We aren't getting much done; let's speed things up and make a decision." 2. "Last week we finished our first goal and today we are starting on our second." 3. "Everyone has had good ideas so far; so, whatever you say is fine with me." 4. "It doesn't really matter what we do. I'm just here because they make me attend."

1. ANS: B 2. ANS: C 3. ANS: D 4. ANS: A

A consumer at a rehabilitative psychosocial program says to the nurse, "People are not cleaning up behind themselves in the bathrooms. The building is dirty and cluttered." How should the nurse respond? a. Encourage the consumer to discuss it at a meeting with everyone. b. Hire a professional cleaning service to clean the restrooms. c. Address the complaint at the next staff meeting. d. Tell the consumer, "That's not my problem."

ANS: A Consumer-run programs range from informal "clubhouses," which offer socialization and recreation, to competitive businesses, such as snack bars or janitorial services, which provide needed services and consumer employment while encouraging independence and building vocational skills. Consumers engage in problem solving under the leadership of staff. See related audience response question.

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.

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.

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.

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. let 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 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.

A group has two more sessions before it ends. One member was previously vocal and has shown much progress but has now grown silent. What explanation most likely underlies this behavior? The silent member a. has participated in the group and now has nothing more to offer. b. is having trouble dealing with feelings about termination of this group. c. wants to give quieter members a chance to talk in the remaining sessions. d. is engaging in attention-seeking behavior aimed at continuation of the group.

ANS: B A chief task during the termination phase of a group is to take what has been learned in group and transition to life without the group. The end of a group can be a significant loss for members, who may experience loss and grief and respond with sadness or anger. It is unlikely he would have nothing to say; at the very least, he could be responding to the comments of others even if not focusing on his own issues. He may wish to give quieter members a chance to talk, but again, this would not require or explain his complete silence. Some members, faced with only two remaining sessions, may be becoming more dominant under this pressure of time, but here too this is unlikely to lead a previously active participant to fall completely silent. The member is not attention-seeking.

Many persons brought before a criminal court have mental illness, have committed minor offenses, and are off medications. The judge consults the nurse at the local community mental health center for guidance about how to respond when handling such cases. Which advice from the nurse would be most appropriate? a. "Sometimes a little time in jail makes a person rethink what they've been doing and puts them back on the right track." b. "Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses." c. "Arresting these people helps them in the long run. Sometimes we cannot hospitalize them, but in jail they will get their medication." d. "Research suggests that special mental health courts do not make much difference so far, but outpatient commitment does seem to help."

ANS: B Research supports the use of special mental health courts that can sentence mentally ill persons to treatment instead of jail. Jail exposes vulnerable mentally ill persons to criminals, victimization, and high levels of stimulation and stress. Incarceration can also interrupt eligibility for benefits or lead to the loss of housing and often provides lower-quality mental health treatment in other settings. Recidivism rates for both mentally ill and non-mentally ill offenders are relatively high, so it does not appear that incarceration necessarily leads people to behave more appropriately. In addition, a criminal record can leave them more desperate and with fewer options after release. Research indicates that outpatient commitment is less effective at improving the mental health of mentally ill persons than was expected.

For patients diagnosed with SMI, what is the major advantage of case management? a. The case manager can modify traditional psychotherapy. b. With one coordinator of services, resources can be more efficiently used. c. The case manager can focus on social skills training and esteem building. d. Case managers bring groups of patients together to discuss common problems.

ANS: B The case manager coordinates the care and multiple referrals that so often confuse the seriously mentally ill patient and the patient's family. Case management promotes efficient use of services. The other options are lesser advantages or are irrelevant.

The sibling of a patient who was diagnosed with a SMI asks why a case manager has been assigned. The nurse's reply should cite the major advantage of the use of case management as: a. "The case manager can modify traditional psychotherapy for homeless patients so that it is more flexible." b. "Case managers coordinate services and help with accessing them, making sure the patient's needs are met." c. "The case manager can focus on social skills training and esteem building in the real world where the patient lives." d. "Having a case manager has been shown to reduce hospitalizations, which prevents disruption and saves money."

ANS: B The case manager helps the patient gain entrance into the system of care, can coordinate multiple referrals that so often confuse the seriously mentally ill person and his family, and can help overcome obstacles to access and treatment participation. Case managers do not usually possess the credentials needed to provide psychotherapy or function as therapists. Case management promotes efficient use of services in general, but only ACT programming has been shown to reduce hospitalization (which the sibling might see as a disadvantage). Case managers operate in the community, but this is not the primary advantage of their services.

The nurse is planning a new sexuality group for patients. Which location would best enhance the effectiveness of this group? a. The hospital auditorium b. A small conference room c. A common area, such as a day room d. The corner of the music therapy room

ANS: B The conference room would provide a quiet, private area with few distractions, separate from other patient areas and effective for teaching and learning about a private topic. The auditorium is too large, and members' anxiety or lack of trust might lead them to spread out too far from each other, interfering with group process. The day room and the music therapy room are too busy and exposed, reducing privacy and increasing distractions.

A leader begins the discussion at the first meeting of a new group. Which comments should be included? (Select all that apply.) a. "We use groups to provide treatment because it's a more cost-effective use of staff in this time of budget constraints." b. "When someone shares a personal experience, it's important to keep the information confidential." c. "Talking to family members about our group discussions will help us achieve our goals." d. "Everyone is expected to share a personal experience at each group meeting." e. "It is important for everyone to arrive on time for our group."

ANS: B, E The leader must set ground rules for the group before members can effectively participate. Confidentiality of personal experiences should be maintained. Arriving on time is important to the group process. Talking to family members would jeopardize confidentiality. While groups are cost-effective, blaming the budget would not help members feel valued. Setting an expectation to share may be intimidating for a withdrawn patient.

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.

The nurse wants to enroll a patient with poor social skills in a training program for patients diagnosed with schizophrenia. Which description accurately describes social skills training? a. Patients learn to improve their attention and concentration. b. Group leaders provide support without challenging patients to change. c. Complex interpersonal skills are taught by breaking them into simpler behaviors. d. Patients learn social skills by practicing them in a supported employment setting.

ANS: C In social skills training, complex interpersonal skills are taught by breaking them down into component behaviors that are covered in a stepwise fashion. Social skills training is not based in employment settings, although such skills can be addressed as part of supported employment services. The other distracters are less relevant to social skills training.

A person diagnosed with a SMI living in the community was punched, pushed to the ground, and robbed of $7 during the day on a public street. Which statements about violence and SMI in general are accurate? (Select all that apply.) a. Persons with SMI are more likely to be violent. b. SMI persons are more likely to commit crimes than to be the victims of crime. c. Impaired judgment and social skills can provoke hostile or assaultive behavior. d. Lower incomes force SMI persons to live in high-crime areas, increasing risk. e. SMI persons experience higher rates of sexual assault and victimization than others. f. Criminals may believe SMI persons are less likely to resist or testify against them.

ANS: C, D, E, F Mentally ill persons are more likely to be victims of crime than perpetrators of criminal acts. They are often victims of criminal behavior, including sexual crimes, at a higher rate than others. When a mentally ill person commits a crime, it is usually nonviolent. Mental illnesses interfere with employment and are associated with poverty, limiting SMI persons to living in inexpensive areas that also tend to be higher-crime areas. SMI persons may inadvertently provoke others because of poor judgment or socially inappropriate behavior, or they may be victimized because they are perceived as passive, less likely to resist, and less likely to be believed as witnesses. See related audience response question.

The nurse assigned to 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 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.

A patient tells members of a therapy group, "I hear voices saying my doctor is poisoning me." Another patient replies, "I once heard voices too. They sounded real, but I found out later they were not. The voices you hear are not real either." Which therapeutic factor is exemplified in this interchange? a.Catharsis b.Universality c.Imitative behavior d.Interpersonal learning

ANS: D Here a member gains insight into his own experiences from hearing about the experiences of others through interpersonal learning. Catharsis refers to a therapeutic discharge of emotions. Universality refers to members realizing their feelings are common to most people and not abnormal. Imitative behavior involves copying or borrowing the adaptive behavior of others.

Which remark by a group participant would the nurse expect during the working stage of group therapy? a. "My problems are very personal and private. How do I know people in this group will not tell others what you hear?" b. "I have enjoyed this group. It's hard to believe that a few weeks ago I couldn't even bring myself to talk here." c. "One thing everyone seems to have in common is that sometimes it's hard to be honest with those you love most." d. "I don't think I agree with your action. It might help you, but it seems like it would upset your family."

ANS: D In the working stage, members actively interact to help each other accomplish goals, and because trust has developed, conflict and disagreement can be expressed. Focusing on trust and confidentiality typically occur in the orientation phase as part of establishing group norms. Commonality and universality are also themes typically expressed in the orientation phase, whereas reflecting on progress is a task addressed in the termination phase.

A health care provider prescribed long acting antipsychotic medication injections every 3 weeks at the clinic for a patient with a history of medication nonadherence. 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 long acting antipsychotic medication injections relieve 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.

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.

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.

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 a SMI lives independently and attends a psychosocial rehabilitation program. The patient presents at the emergency department seeking hospitalization. The patient has no acute symptoms but says, "I have no money to pay my rent or refill my prescription." Select the nurse's best action. a. Involve the patient's case manager to provide crisis intervention. b. Send the patient to a homeless shelter until housing can be arranged. c. Arrange for a short in-patient admission and begin discharge planning. d. Explain that one must have active psychiatric symptoms to be admitted.

ANS: A Impaired stress tolerance and problem-solving abilities can cause persons with SMI to experience relatively minor stressors as crises. This patient has run out of money, and this has overwhelmed her ability to cope, resulting in a crisis for which crisis intervention would be an appropriate response. Inpatient care is not clinically indicated nor is the patient homeless (although she may fear she is). Telling the patient that she is not symptomatic enough to be admitted may prompt malingering.

A leader plans to start a new self-esteem building group. Which intervention would be most helpful for assuring mutual respect within the group? a.Describe the importance of mutual respect in the first session and establish it as a group norm. b.Exclude potential members whose behavior suggests they are likely to be disrespectful of others. c.Give members a brochure describing the purpose, norms, and expectations of the group. d.Explain that mutual respect is expected and confront those who are not respectful.

ANS: A It is helpful to motivate members to behave respectfully by describing how mutual respect benefits all members and is necessary for the group to be fully therapeutic. Setting a tone and expectation of mutual respect from the outset is the most helpful intervention listed. Excluding members because of how they might behave could exclude members who would have been appropriate, depriving them of the potential benefits of the group. Conveying expectations by brochure is less effective than doing so orally, because it lacks the connection to each member a skilled leader can create to motivate members and impart the expectation of respect. Confronting inappropriate behavior is therapeutic but only addresses existing behavior rather than preventing all such undesired behavior.

A nurse's neighbor says, "My sister has been diagnosed with bipolar disorder but will not take her medication. I have tried to help her for over 20 years, but it seems like everything I do fails. Do you have any suggestions?" Select the nurse's best response. a. "NAMI offers a family education series that you might find helpful." b. "Since your sister is noncompliant, perhaps it's time for her to be changed to injectable medication." c. "You have done all you can. Now it's time to put yourself first and move on with your life." d. "You cannot help her. Would it be better for you to discontinue your relationship?"

ANS: A NAMI offers a family education series that assists with the stress caregivers and other family members often experience. The nurse should not give advice about injectable medication or encourage the family member to give up on the patient.

A nurse leads a psychoeducational group for patients in the community diagnosed with schizophrenia. A realistic outcome for group members is that they will a. discuss ways to manage their illness. b. develop a high level of trust and cohesiveness. c. understand unconscious motivation for behavior. d. demonstrate insight about development of their illness.

ANS: A Patients with schizophrenia almost universally have problems associated with everyday living in the community, so discussing ways to manage the illness would be an important aspect of psychoeducation. Discussing concerns about daily life would be a goal to which each could relate. Developing trust and cohesion is desirable but is not the priority outcome of a psychoeducational group. Understanding unconscious motivation would not be addressed. Insight would be difficult for a patient with residual schizophrenia because of the tendency toward concrete thinking.

Three members of a therapy group share covert glances as other members of the group describe problems. When one makes a statement that subtly criticizes another speaker, the others nod in agreement. Which group dynamic should the leader suspect? a. Some members are acting as a subgroup instead of as members of the main group. b. Some of the members have become bored and are disregarding others. c. Three members are showing their frustration with slower members. d. The leadership of the group has been ineffective.

ANS: A Subgroups, small groups isolated within a larger group and functioning separately from it, sometimes form within therapy groups. When this occurs, subgroup members are cohesive with other subgroup members but not with the members of the larger group. Members of the subgroup may be bored or frustrated or expressing passive aggression, but the primary dynamic is the splitting off from the main group.

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.

A patient has talked constantly throughout the group therapy session, often repeating the same comments. Other members were initially attentive then became bored, inattentive, and finally sullen. Which comment by the nurse leader would be most effective? a. Say to everyone, "Most of you have become quiet. I wonder if it might be related to concerns you may have about how the group is progressing today." b. Say to everyone, "One person has done most of the talking. I think it would be helpful for everyone to say how that has affected your experience of the group." c. Say to everyone, "I noticed that as our group progressed, most members became quiet, then disinterested, and now seem almost angry. What is going on?" d. Say to the talkative patient, "You have been doing most of the talking, and others have not had a chance to speak as a result. Could you please yield to others now?"

ANS: A The most effective action the nurse leader can take will be the one that encourages the group to solve its own problem. Pointing out changes in the group and asking members to respond to them lays the foundation for a discussion of group dynamics. Asking members to respond to the talkative patient puts that patient in an awkward position, likely increasing her anxiety. As anxiety increases, monopolizing behavior tends to increase as well, so this response would be self-defeating. Asking members what is going on is a broader opening and might lead to responses unrelated to the issue that bears addressing; narrowing the focus to the group process more directly addresses what is occurring in the group. Focusing on the talkative patient would be less effective and involves the leader addressing the issue instead of members first attempting to do so themselves (giving them a chance to practice skills such as assertive communication).

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.

During group therapy, one patient says to another, "When I first started in this group, you were unable to make a decision, but now you can. You've made so much progress that I am beginning to think maybe I can conquer my fears too." Which therapeutic factor is evident by this statement? a.Hope b.Altruism c.Catharsis d.Cohesiveness

ANS: A The patient's profession that he may be able to learn to cope more effectively reflects hope. Groups can instill hope in individuals who are demoralized or pessimistic. Altruism refers to doing good for others, which can result in positive feelings about oneself. Catharsis refers to venting of strong emotions. Cohesion refers to coming together and developing a connection with other group members.

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.

An adult patient tells the case manager, "I don't have bipolar disorder anymore, so I don't need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends." Where should the nurse refer the patient? (Select all that apply.) a. Psychoeducational classes b. Vocational rehabilitation c. Social skills training d. A homeless shelter e. Crisis intervention

ANS: A, B, C The patient does not understand the illness and need for adherence to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with SMI have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking the skill down into smaller verbal and nonverbal components. Work gives meaning and purpose to life, so vocational rehabilitation can assist with this aspect of care. The nurse case manager will function in the role of crisis stabilizer, so no related referral is needed. The patient presently has a home and does not require a homeless shelter.

A psychiatric nurse discusses rules of the therapeutic milieu and patients' rights with a newly admitted patient. Which rights should be included? The right to (Select all that apply) 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.

Which statements most clearly indicate the speaker views mental illness with stigma? (Select all that apply.) a. "We are all a little bit crazy." b. "If people with mental illness would go to church, their problems would be solved." c. "Many mental illnesses are genetically transmitted. It's no one's fault that the illness occurs." d. "Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people." e. "People with mental illness are lazy. They get government disability checks instead of working."

ANS: A, B, E Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame. See related audience response question.

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.

A patient diagnosed with SMI was living successfully in a group home but wanted an apartment. The prospective landlord said, "People like you have trouble getting along and paying their rent." The patient and nurse meet for a problem-solving session. Which options should the nurse endorse? (Select all that apply.) a. Coach the patient in ways to control symptoms effectively. b. Seek out landlords less affected by the stigma associated with mental illness. c. Threaten the landlord with legal action because of the discriminatory actions. d. Encourage the patient to remain in the group home until the illness is less obvious. e. Suggest that the patient list a false current address in the rental application. f. Have the case manager meet with the landlord to provide education about mental illness.

ANS: A, B, F Managing symptoms so that they are less obvious or socially disruptive can reduce negative reactions and reduce rejection due to stigma. Seeking a more receptive landlord might be the most expeditious route to housing for this patient. Educating the landlord to reduce stigma might make him more receptive and give the case manager an opportunity to address some of his concerns (e.g., the case manager could arrange a payee to assure that the rent is paid each month). However, threatening a lawsuit would increase the landlord's defensiveness and would likely be a long and expensive undertaking. Delaying the patient's efforts to become more independent is not clinically necessary according to the data noted here; the problem is the landlord's bias and response, not the patient's illness. It would be unethical to encourage falsification and poor role modeling to do so; further, if falsification is discovered, it could permit the landlord to refuse or cancel her lease. See related audience response question.

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.

The nurse manager of a mental health center wants to improve medication adherence among the seriously mentally ill persons treated there. Which interventions are likely to help achieve this goal? (Select all that apply.) a. Maintain stable and consistent staff. b. Increase the length of medication education groups. c. Stress that without treatment, illnesses will worsen. d. Prescribe drugs in smaller but more frequent dosages. e. Make it easier to access prescribers and pay for drugs. f. Require adherence in order to participate in programming.

ANS: A, E Trust in one's providers is a key factor in treatment adherence, and mentally ill persons can sometimes take a very long time to develop such trust; therefore, interventions which stabilize staffing allow patients to have more time with staff to develop these bonds. Ready access to prescribers allows medicine-related concerns to be addressed quickly, reducing obstacles to adherence such as side effects or ineffective dosages. Medication costs can be obstacles to adherence as well. Many SMI patients have anosognosia and do not adhere to treatment because they believe they are not ill, so telling them nonadherence will worsen an illness they do not believe they have is unlikely to be helpful. Increasing medication education is helpful only when the cause of nonadherence is a knowledge deficit. Other issues that reduce adherence, particularly anosognosia and side effects, are seldom helped by longer medication education. Requiring medication adherence to participate in other programs is coercive and unethical. Smaller, more frequent doses do not reduce side effects and make the regimen more difficult for the patient to remember.

SMI is characterized as a. any mental illness of more than 2 weeks' duration. b. a major long-term mental illness marked by significant functional impairments. c. a mental illness accompanied by physical impairment and severe social problems. d. a major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities.

ANS: B "Serious mental illness" has replaced the term "chronic mental illness." Global impairments in function are evident, particularly social. Physical impairments may be present. SMI can be treated, but remissions and exacerbations are part of the course of the illness.

Which type of group is a staff nurse with 2 months' psychiatric experience best qualified to conduct? a. Psychodynamic/psychoanalytic group b. Medication education group c. Existential/Gestalt group d. Family therapy group

ANS: B All nurses receive information about patient teaching strategies and basic information about psychotropic medications, making a medication education group a logical group for a beginner to conduct. The other groups would need a leader with more education and experience.

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.

During a support group, a patient diagnosed with schizophrenia says, "Sometimes I feel sad that I will never have a good job like my brother. Then I dwell on it and maybe I should not." Select the nurse leader's best comment to facilitate discussion of this issue. a. "It is often better to focus on our successes rather than our failures." b. "How have others in the group handled painful feelings like these?" c. "Grieving for what is lost is a normal part of having a mental disorder." d. "I wonder if you might also experience feelings of anger and helplessness."

ANS: B Asking others to share their experiences will facilitate discussion of an issue. Giving information may serve to close discussion of the issue because it sounds final. Suggesting a focus on the positives implies a discussion of the issue is not appropriate. Suggesting other possible feelings is inappropriate at this point, considering the patient has identified feelings of sadness and seems to have a desire to explore this feeling. Focusing on other feelings will derail discussion of the patient's grief for his perceived lost potential.

A person diagnosed with a SMI enters a shelter for the homeless. Which intervention should be the nurse's initial priority? a. Find supported employment. b. Develop a trusting relationship. c. Administer prescribed medication. d. Teach appropriate health care practices.

ANS: B Basic psychosocial needs do not change because a person is homeless. The first step in caring for health care needs is establishing rapport. Once a trusting relationship is established, the nurse pursues other interventions.

A homeless patient diagnosed with a SMI became suspicious and delusional. Depot antipsychotic medication began and housing was obtained in a local shelter. One month later, which statement by the patient indicates significant improvement? a. "They will not let me drink. They have many rules in the shelter." b. "I feel comfortable here. Nobody bothers me." c. "Those shots make my arm very sore." d. "Those people watch me a lot."

ANS: B Evaluation of a patient's progress is made based on patient satisfaction with the new health status and the health care team's estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being "bothered" by others denotes improvement in the patient's condition. The other options suggest that the patient is in danger of relapse.

After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This patient now requires continual direction to accomplish activities of daily living and expects others to provide meals and do laundry. The nurse assesses this behavior as the probable result of a. side effects of antipsychotic medications. b. dependency caused by institutionalization. c. cognitive deterioration from schizophrenia. d. stress associated with acclimation to the community.

ANS: B Institutions tend to impede independent functioning; for example, daily activities are planned and directed by staff; others provide meals and only at set times. Over time, patients become dependent on the institution to meet their needs and adapt to being cared for rather than caring for themselves. When these patients return to the community, many continue to demonstrate passive behaviors despite efforts to promote. Cognitive dysfunction and antipsychotic side effects can make planning and carrying out activities more difficult, but the question is more suggestive of adjustment to institutional care and difficulty readjusting to independence instead.

A nurse receives these three phone calls regarding a newly admitted patient. 1. The psychiatrist wants to complete an initial assessment. 2. An internist wants to perform a physical examination. 3. 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 diagnosed with serious and persistent mental illness and living in the community merits 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 non-adherent. Medication non-adherence, along with the disorganizing influence of substances on cellular brain function, promotes relapse. The distracters do not suggest problems.

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.

A patient diagnosed with a SMI died suddenly at age 52. The patient lived in the community for 5 years without relapse and held supported employment the past 6 months. The distressed family asks, "How could this happen?" Which response by the nurse accurately reflects research and addresses the family's question? a. "A certain number of people die young from undetected diseases, and it's just one of those sad things that sometimes happen." b. "Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, smoke more, or are overweight." c. "We will have to wait for the autopsy to know what happened. There were some medical problems, but we were not expecting death." d. "We are all surprised. The patient had been doing so well and saw the nurse every other week."

ANS: B The family is in distress. Because they do not understand his death, they are less able to accept it and seek specific information to help them understand what happened. Persons with SMI die an average of 25 years prematurely. Contributing factors include failing to provide for their own health needs (e.g., forgetting to take medicine), inability to access or pay for care, higher rates of smoking, poor diet, criminal victimization, and stigma. The most accurate answer indicates that seriously mentally ill people are at much higher risk of premature death for a variety of reasons. Staff would not have been surprised that the patient died prematurely, and they would not attribute his death to random, undetected medical problems. Although the cause of death will not be reliably established until the autopsy, this response fails to address the family's need for information.

A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, "You cause too much trouble." What problem is the patient experiencing? a. Grief b. Stigma c. Homelessness d. Nonadherence

ANS: B The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a patient problem. Data do not suggest that the patient is actually homeless. See relationship to audience response question.

During a therapy group that uses existential/Gestalt theory, patients shared feelings that occurred at the time of their admission. After a brief silence, one member says, "Several people have described feeling angry. I would like to hear from members who had other feelings." Which group role is evident by this comment? a. Energizer b. Encourager c. Compromiser d. Self-confessor

ANS: B The member is filling the role of encourager by acknowledging those who have contributed and encouraging input from others. An energizer encourages the group to make decisions or take an action. The compromiser focuses on reducing or resolving conflict to preserve harmony. A self-confessor verbalizes feelings or observations unrelated to the group.

A patient in a detoxification unit asks, "What good it will do to go to Alcoholics Anonymous and talk to other people with the same problem?" The nurse's best response would be to explain that self-help groups such as AA provide opportunities for a. newly discharged alcoholics to learn about the disease of alcoholism. b. people with common problems to share their experiences with alcoholism and recovery. c. patients with alcoholism to receive insight-oriented treatment about the etiology of their disease. d. professional counselors to provide guidance to individuals recovering from alcoholism.

ANS: B The patient needs basic information about the purpose of a self-help group. The basis of self-help groups is sharing by individuals with similar problems. Self-help is based on the belief that an individual with a problem can be truly understood and helped only by others who have the same problem. The other options fail to address this or provide incorrect information.

After a Category 5 tornado hits a community and destroys many homes and businesses, a community mental health nurse encourages victims to describe their memories and feelings about the event. This action by the nurse best demonstrates a. triage. b. primary prevention. c. psychosocial rehabilitation. d. psychiatric case management.

ANS: B Tornado victims are at risk for psychiatric problems as a consequence of stress and trauma. Primary prevention occurs before any problem is manifested and seeks to reduce the incidence, or rate of new cases. Primary prevention may prevent or delay the onset of symptoms in predisposed individuals. Coping strategies and psychosocial support for vulnerable people are effective interventions in prevention. Disaster victims benefit from telling their story. Triage refers to the process of sorting out victims based on the immediacy of their needs for treatment. Psychosocial rehabilitation programs are designed to assist persons diagnosed with serious mental illness to develop living skills. Psychiatric case management refers to services to assist patients in finding housing or obtaining entitlements.

A person diagnosed with SMI has frequent relapses, usually precipitated by situational stressors such as running out of money or the absence of key staff at the mental health center. Which interventions would the nurse suggest to reduce the risk of stressors to cause relapse? (Select all that apply.) a. Discourage potentially stressful activities such as groups or volunteer work. b. Develop written plans that will help the patient remember what to do in a crisis. c. Help the patient identify and anticipate events that are likely to be overwhelming. d. Encourage health-promoting activities such as exercise and getting adequate rest. e. Accompany the patient to a NAMI support group.

ANS: B, C, D, E Basic interventions for coping with crises involve anticipating crises where possible and then developing a plan with specific actions to take when faced with an overwhelming stressor. Written plans are helpful; it can be difficult for anyone, especially a person with cognitive or memory impairments, to develop or remember steps to take when under overwhelming stress. Health-promoting activities enhance a person's ability to cope with stress. As the name suggests, support groups help a person develop a support system, and they provide practical guidance from peers who learned from experience how to deal with issues the patient may be facing. Groups and volunteer work may involve a measure of stress but also provide benefits that help persons cope and should not be discouraged unless they are being done to excess.

The next-to-last meeting of an interpersonal therapy group is taking place. The leader should take which actions? (Select all that apply.) a. Support appropriate expressions of disagreement by the group's members. b. Facilitate discussion and resolution of feelings about the end of the group. c. Encourage members to reflect on their progress and that of the group itself. d. Remind members of the group's norms and rules, emphasizing confidentiality. e. Help members identify goals they would like to accomplish after the group ends. f. Promote the identification and development of new options for solving problems.

ANS: B, C, E The goals for the termination phase of groups are to prepare the group for separation, resolve related feelings, and prepare each member for the future. Contributions and accomplishments of members are elicited, post-group goals are identified, and feelings about the group's ending are discussed. Group norms are the focus of the orientation phase, and conflict and problem solving are emphasized in the working phase

Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with SMI? a. Clubhouse model b. Cognitive-behavioral therapy (CBT) c. Assertive community treatment (ACT) d. Cognitive enhancement therapy (CET)

ANS: C ACT involves consumers working with a multidisciplinary team that provides a comprehensive array of services. At least one member of the team is available 24 hours a day for crisis needs, and the emphasis is on treating the patient within his own environment.

Which nursing diagnosis is likely to apply to an individual diagnosed with a SMI who is homeless? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome

ANS: C Many individuals with SMI do not live with their families and become homeless. Life on the street or in a shelter has a negative influence on the individual's self-esteem, making this nursing diagnosis one that should be considered. Substance abuse is not an approved North American Nursing Diagnosis Association (NANDA)-International diagnosis. Insomnia may be noted in some patients but is not a universal problem. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not seen in a majority of the homeless.

A group is in the working phase. One member states, "That is the stupidest thing I've ever heard. Everyone whines and tells everyone else what to do. This group is a waste of my time." Which initial action by the group leader would be most therapeutic? a. Advise the member that hostility is inappropriate. Remove the member if it continues. b. Keep the group's focus on this member so the person can express the anger. c. Meet privately with the member outside of group to discuss the anger. d. Change to a more positive topic of discussion in this group session.

ANS: C Meeting privately with the member can convey interest and help defuse the anger so that it is less disruptive to the group. Removing the member would be a last resort and used only when the behavior is intolerably disruptive to the group process and all other interventions have failed. Decreasing the focus on the hostile member and focusing more on positive members can help soften the anger. Angry members often hide considerable vulnerability by using anger to keep others at a distance and intimidated. Changing the subject fails to respond to the behavior.

A patient diagnosed with schizophrenia had an exacerbation related to medication non-adherence 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.

A patient in a group therapy session listens to others and then remarks, "I used to think I was the only one who felt afraid. I guess I'm not as alone as I thought." This comment is an example of a. altruism. b. ventilation. c. universality. d. group cohesiveness.

ANS: C Realizing that one is not alone and that others share the same problems and feelings is called universality.Ventilation refers to expressing emotions. Altruism refers to benefitting by being of help to others. Group cohesiveness refers to the degree of bonding among members of the group.

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.

A group is in the working phase. One member says, "That is the stupidest thing I've ever heard. Everyone whines and tells everyone else what to do. This group is a total waste of my time." Which comment by the group leader would be most therapeutic? a. "You seem to think you know a lot already. Since you know so much, perhaps you can tell everyone why you are back in the hospital?" b. "I think you have made your views clear, but I wonder if others feel the same way. How does everyone else feel about our group?" c. "It must be hard to be so angry." Direct this comment to another group member, "You were also angry at first but not now. What has helped you?" d. "I would like to remind you that one of our group rules is that everyone is to offer only positive responses to the comments of others."

ANS: C The member's comments demean the group and its members and suggest that the member is very angry. Labeling the emotion and conveying empathy would be therapeutic. Focusing on members who are likely to be more positive can balance the influence of demoralizing members. "You seem to know a lot ..." conveys hostility from the leader, who confronts and challenges the member to explain how he came to be readmitted if he was so knowledgeable, implying that he is less knowledgeable than he claims. This comment suggests countertransference and is non-therapeutic. Shifting away from the complaining member to see if others agree seeks to have others express disagreement with this member, but that might not happen. In the face of his anger, they might be quiet or afraid to oppose him, or they could respond in kind by expressing hostility themselves. A rule that only positive exchanges are permitted would suppress conflict, reducing the effectiveness of the therapy group.

A nurse at the well child clinic realizes that many parents have misconceptions about effective ways of disciplining their children. The nurse decides to form a group to address this problem. What should be the focus of the group? a. Support b. Socialization c. Health education d. Symptom management

ANS: C The nurse has diagnosed a knowledge deficit. The focus of the group should be education. Support and socialization are beneficial but should not be the primary focus of the group, and symptoms are not identified for intervention here.

An adult diagnosed with a serious mental illness (SMI) says, "I do not need help with money management. I have excellent ideas about investments." This patient usually does not have money to buy groceries by the middle of the month. The nurse assesses the patient as demonstrating: a. rationalization. b. identification. c. anosognosia. d. projection.

ANS: C The patient scenario describes anosognosia, the inability to recognize one's deficits due to one's illness. The patient is not projecting an undesirable thought or emotion from himself onto others. He is not justifying his behavior via rationalization and is not identifying with another.

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 disappear."

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.

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.

During a group therapy session, a newly admitted patient suddenly says to the nurse, "How old are you? You seem too young to be leading a group." Select the nurse's most appropriate response. a."I am wondering what leads you to ask. Please tell me more." b."I am old enough to be a nurse, which qualifies me to lead this group." c."My age is not pertinent to why we are here and should not concern you." d."You are wondering whether I have enough experience to lead this group?"

ANS: D A question such as this is common in the initial phase of group development when members are getting to know one another, dealing with trust issues, and testing the leader. Making explicit the implied serves to role model more effective communication and prompts further discussion of the patient's concern. Asking the patient to tell the leader more about the question focuses on the reason for the member's concern rather than on the issue raised (the experience and ability of the leader) and is a less helpful response. "I am old enough to be a nurse" and "age is not pertinent" are defensive responses and fail to address the patient's valid concern.

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 depressive disorder. c. a catastrophic reaction to a tornado in the community. d. schizophrenia and four hospitalizations in the past year.

ANS: D 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.

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 antipsychotic medication. 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.

Which outcome would be most appropriate for a symptom-management group for persons diagnosed with schizophrenia? Group members will a. state the names of their medications. b. resolve conflicts within their families. c. rate anxiety at least two points lower. d. describe ways to cope with their illness.

ANS: D An appropriate psychoeducational focus for patients with schizophrenia is managing their symptoms; coping with symptoms such as impaired memory or impaired reality testing can improve functioning and enhance their quality of life. Names of medications might be appropriate for a medication education group but would be a low priority for symptom management. Addressing intra-family issues would be more appropriate within a family therapy group or possibly a support group. Rating anxiety lower would be an expected outcome for a stress-management group.

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 nurse assesses a patient for inclusion in group therapy. This patient has a childhood history of neglect and ridicule by parents. The patient says to the nurse, "My boss always expects more of me than the others, but talking to him would only make it worse." Which type of group would best address the patient's needs? a. Support b. Self-Help c. Psychoeducational d. Cognitive-behavioral

ANS: D Cognitive-behavioral group therapy focuses on specific maladaptive behaviors and thought patterns. Patients often repeat patterns of behavior in a group that they learned in their families. This type of group will afford the patient an opportunity for a corrective recapitulation of the primary family group. The incorrect answers identify groups appropriate for other types of problems.

A homeless individual diagnosed with SMI and a history of persistent treatment nonadherence plans to begin attending the day program at a community mental health center. Which intervention should be the team's initial focus? a. Teach appropriate health maintenance and prevention practices. b. Educate the patient about the importance of treatment adherence. c. Help the patient obtain employment in a local sheltered workshop. d. Interact regularly and supportively without trying to change the patient.

ANS: D Given the history of treatment nonadherence and the difficulty achieving other goals until psychiatrically stable and adherent, getting the patient to accept and adhere to treatment is the fundamental goal to address. The intervention most likely to help meet that goal at this stage is developing a trusting relationship with the patient. Interacting regularly, supportively, and without demands is likely to build the necessary trust and relationships that will be the foundation for all other interventions later on. No data here suggest the patient is in crisis, so it is possible to proceed slowly and build this foundation of trust.

A hospitalized patient diagnosed with schizophrenia has a history of multiple relapses. The patient usually responds quickly to antipsychotic medication but soon discontinues the medication. Discharge plans include follow-up at the mental health center, group home placement, and a psychosocial day program. Which strategy should apply first as the patient transitions from hospital to community? a. Administer a second-generation antipsychotic to help negative symptoms. b. Use a quick-dissolving medication formulation to reduce "cheeking." c. Prescribe a long-acting intramuscular antipsychotic medication. d. Involve the patient in decisions about which medication is best.

ANS: D Persons with schizophrenia are at high risk for treatment nonadherence, so the strategy needs primarily to address that risk. Of the options here, involving the patient in the decision is best because it will build trust and help establish a therapeutic alliance with care providers, an essential foundation to adherence. Intramuscular depot medications can be helpful for promoting adherence if other alternatives have been unsuccessful, but IM medications are painful and may jeopardize the patient's acceptance. All of the other strategies also apply but are secondary to trust and bonding with providers.

The parent of a seriously mentally ill adult asks the nurse, "Why are you making a referral to a vocational rehabilitation program? My child won't ever be able to hold a job." Which is the nurse's best reply? a. "We make this referral to continue eligibility for federal funding." b. "Are you concerned that we're trying to make your child too independent?" c. "If you think the program would be detrimental, we can postpone it for a time." d. "Most patients are capable of employment at some level, competitive or supported."

ANS: D Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression.

Guidelines followed by the leader of a therapeutic group include focusing on recognizing dysfunctional behavior and thinking patterns, followed by identifying and practicing more adaptive alternate behaviors and thinking. Which theory is evident by this approach? a. Behavioral b. Interpersonal c. Psychodynamic d. Cognitive-behavioral

ANS: D The characteristics described are those of cognitive-behavioral therapy, in which patients learn to reframe dysfunctional thoughts and extinguish maladaptive behaviors. Behavioral therapy focuses solely on changing behavior rather than thoughts, feelings, and behaviors together. Interpersonal theory focuses on interactions and relationships. Psychodynamic groups focus on developing insight to resolve unconscious conflicts.

A family discusses the impact of a seriously mental ill member. Insurance partially covers treatment expenses, but the family spends much of their savings for care. The patient's sibling says, "My parents have no time for me." The parents are concerned that when they are older, there will be no one to care for the patient. Which response by the nurse would be most helpful? a. Acknowledge their concerns and consult with the treatment team about ways to bring the patient's symptoms under better control. b. Give them names of financial advisors that could help them save or borrow sufficient funds to leave a trust fund to care for their loved one. c. Refer them to crisis intervention services to learn ways to manage caregiver stress and provide titles of some helpful books for families. d. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the patient become more independent.

ANS: D The family has raised a number of concerns, but the major issues appear to be the effects caregiving has had on the family and their concerns about the patient's future. NAMI offers support, education, resources, and access to other families who have experience with the issues now facing this family. NAMI can help address caregiver burden and planning for the future needs of SMI persons. Improving the patient's symptom control and general functioning can help reduce caregiver burden but would likely be a slow process, whereas NAMI involvement could benefit them on a number of fronts, possibly in a shorter time period. The family will need more than financial planning; their issues go beyond financial. The family is distressed but not in crisis. Crisis intervention is not an appropriate resource for the longer-term issues and needs affecting this family.

An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, "I threw away the pills because they keep me from hearing God." Which response by the nurse would most likely to benefit this patient? a. "You need your medicine. Your schizophrenia will get worse without it." b. "Do you want to be hospitalized again? You must take your medication." c. "I would like you to come to the medication education group every Thursday." d. "I noticed that when you take the medicine, you are able to keep the job you wanted."

ANS: D The patient appears not to understand that he has an illness. He has stopped his medication because it interferes with a symptom that he finds desirable (auditory hallucinations—the voice of God). Connecting medication adherence to one of the patient's goals (the job) can serve to motivate the patient to take the medication and override concerns about losing the hallucinations. Exhorting a patient to take medication because it is needed to control his illness is unlikely to be successful; he does not believe he has an illness. Medication psychoeducation would be appropriate if the cause of nonadherence was a knowledge deficit.

A patient diagnosed with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." The nurse identifies the etiology of the patient's ineffective management of the medication regime as a. inadequate discharge planning. b. poor therapeutic alliance with clinicians. c. dislike of antipsychotic medication side effects. d. impaired reasoning secondary to the schizophrenia.

ANS: D The patient's ineffective management of the medication regime is most closely related to impaired reasoning associated with the thought disturbances of schizophrenia. The patient believes in being an exalted personage who hears God's voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest any of the other factors often related to medication nonadherence.

An outpatient diagnosed with schizophrenia tells the nurse, "I am here to save the world. I threw away the pills because they make God go away." The nurse identifies the patient's reason for medication nonadherence as a. poor alliance with clinicians. b. inadequate discharge planning. c. dislike of medication side effects. d. thought disturbances associated with the illness.

ANS: D The patient's nonadherence is most closely related to thought disturbances associated with the illness. The patient believes he is an exalted personage who hears God's voice rather than an individual with a serious mental disorder who needs medication to control his symptoms. While the distracters may play a part in the patient's nonadherence, the correct response is most likely.

A young female member in a therapy group says to an older female member, "You are just like my mother, always trying to control me with your observations and suggestions." Which therapeutic factor of a group is evident by this behavior? a.Instillation of hope b.Existential resolution c.Development of socializing techniques d.Corrective recapitulation of the primary family group

ANS: D The younger patient is demonstrating an emotional attachment to the older patient that mirrors patterns within her own family of origin, a phenomenon called corrective recapitulation of the primary family group. Feedback from the group then helps the member gain insight about this behavior and leads to more effective ways of relating to her family members. Instillation of hope involves conveying optimism and sharing progress. Existential resolution refers to the realization that certain existential experiences such as death are part of life, aiding the adjustment to such realities. Development of socializing techniques involves gaining social skills through the group's feedback and practice within the group.

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.