Chapter 1, MH chapter 1: Me, Meds, Milieu, Chapter 2, mh ch 2 keltner, Chapter 3, mh ch 3 keltner evolve and notes, Chapter 4, Psychiatric Mental Health Nursing Chapter 4, mh ch 4 evolve and notes, Chapter 5

How should the nurse respond when a community leader comments: "These homeless people are really a problem. Many of them seem mentally ill."? 1 "You must consider funding mental health assessments and services for these people." 2 "The increase in available homeless shelters is needed to help meet their basic needs." 3 "Law enforcement authorities require effective intervention training when dealing with the mental ill homeless population." 4 "If the community could provide employment opportunities for the homeless it would help them become independent."

1 Effective management of the homeless population begins the assessment process and focuses on money and services needed in the community. While basic needs are important, evidence suggests that many homeless persons have unmet mental health needs. Law enforcement authorities intervene only on a crisis basis, as a last resort for the individual. Vocational training and job skills might be of benefit to this population but may not be the highest priority or responsive to current needs.

Whose views were most influental in shaping the practice of psychiatric nursing and are still referred to today? 1 Hildegarde Peplau 2 Harriet Bailey 3 Linda Richards 4 Dorothea Dix

1 Hildegarde Peplau (1952, 1959) developed a model for psychiatric nursing practice. Her book, Interpersonal Relations in Nursing (1952), influences practice to this day. In 1920, Harriet Bailey wrote the first psychiatric nursing textbook. Linda Richards, the first American psychiatric nurse, was a graduate of the New England Hospital for Women. Richards spent much of her professional career developing nursing care in psychiatric hospitals and also directed a school of psychiatric nursing in 1880 at the McLean Psychiatric Asylum in Waverly, Massachusetts. Dorothea Dix (1802 to 1887), one of the first major reformers in the United States, was instrumental in developing the concept of the asylum.

What elements must be present for a nurse to be found guilty of negligence and for damages to be awarded? (Select all that apply). 1 The nurse had a duty to care for the patient. Correct 2 The nurse had an obligation to provide reasonable care. Correct 3 The nurse failed to perform an expected duty. Correct 4 The nurse was aware that the standard of care was not met. 5 The nurse's actions resulted in injury to the patient.

1, 2, 3, 5 The four elements that must be present for a plaintiff to recover damages caused by negligence are the nurse's duty to care, the obligation of reasonable care (i.e., standard of care), breach of duty, and injury proximately caused by a breach of duty. It is not necessary that the nurse be aware that the standard of care was not being met. DIF: Cognitive level: Understanding REF: p. 22 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity

Which actions will best assure that the nurse is delegating to a novice, unlicensed assistive personnel (UAP) both legally and with attention to the patient's care needs? (Select all that apply). 1 Consulting the facility's policy manual to determine the UAP's scope of practice 2 Reviewing the state's nursing practice act to determine if the task is delegatable 3 Assigning the novice UAP to shadow an experienced UAP who is proficient at the task 4 Initially supervising the UAP performing the delegated task 5 Assuring the patient that the novice UAP is qualified to perform the task

1, 2, 4 When delegating, the nurse should know and follow the local hospital procedures so as to stay within his or her scope and authority, ensure that UAPs assigned have been fully trained and are qualified to carry out the tasks they are expected to perform, and know the limitations and responsibilities of nursing practice of his or her state. Such responsibility may not be delegated to another UAP. Notifying the patient is not considered a part of the delegating process. DIF: Cognitive level: Analyzing REF: p. 23 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity

The psychiatric mental health nurse who demonstrates an understanding of patient rights will (Select all that apply): 1 avoid discussions of multidisciplinary team and patient concerns except in areas of privacy. Correct 2 honor the patient's medical and psychiatric advanced directives. Correct 3 remain "logged on" to the patient's electronic medical record during the shift. 4 introduce self first before initating any patient-focused discussions. Correct 5 request permission to interact and work with the patient.

1, 2, 4, 5 Considering privacy, honoring patient requests, and demonstrating courtesy and respect are all examples of patient advocacy and appropriate professional conduct. Confidentiality requires that a patient's medical record be opened only when actual documenting is occurring. DIF: Cognitive level: Applying REF: pp. 26-30 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity

Which outcomes are associated with mental health's period of psychiatric drugs? Select all that apply. 1 Hospital stays are now shorter. 2 The cost of medications have decreased. 3 Hospital environments are now more therapeutic. 4 Medications have become a primary treatment modality. 5 Acute-care hospital stays are less expensive as a result.

1,3 Major events associated with the period of psychiatric drugs include the shortening of the length of hospital stays and the improvement of hospital environments. The introduction of mental health-oriented medications has not significantly affected costs of medications or hospital stays. While medications are a vital part of mental health treatment, they are not necessarily considered primary.

Which statement is true when comparing today's mentally ill patients with those observed in the 1960s and 1970s? 1 In the 1960s and 1970s, the primary mental health diagnosis was depression. 2 Today's patients are more aggressive and often armed when seen on initial assessment. 3 Today there are more people hospitalized with mental illness than in the 1960s and 1970s. 4 Jails and prisons house fewer mentally ill persons today than during the 1960s and 1970s.

2 Compared with the patients of the 1960s and 1970s, today's patients are more aggressive and many are armed when first seen. Depression was not necessarily the primary mental health diagnosis during the 1960s and 1970s. The hospital population peaked in 1955 and has declined steadily to this day. Today there are 300% more patients with severe mental illness in jails and prisons than there are in hospitals in the United States; these numbers have increased steadily over the last several decades.

The movement to deinstitutionalize mental patients was influentual in what legal change regarding the management of the mentally ill? 1 The length of hospital stays 2 Criteria for involuntary commitment 3 The cost of in-hosptal mental health treatment 4 The type of training required of mental health care providers

2 The deinstitutionalization movement brought about a change in commitment laws. Out of concern for the civil rights of mental patients, involuntary commitment of individuals to a state hospital became difficult. The state had to demonstrate that those accused were a clear danger to themselves or to others. Neither the length and cost of hospitalization nor the training required of health care providers was significantly affected by this movement.

When teaching colleagues the concept of community-based care,which statement will the nurse make? 1 "The greatest challenge is to work with those identifed as the worried well." 2"Homelessness is the root of all mental illness." 3"A seamless continuity of care for the mentally ill individual is a favorable goal." Correct 4 "When treating the chronically mentally ill it is best to wait for a crisis to occur before intervening with treatment."

3 Providing care for those seeking services for mental illness should serve to support independence and autonomy and be delivered with the least amount of restriction. This is the goal of community mental health care. Working with the worried well is less intense and may actually preoccupy mental health care providers and keep them from working with the severely mentally ill. Though many homeless individuals may suffer from mental illness, homelessness does not cause mental illness. Mental health promotion and disease prevention is most respectful, least stressful, and more cost-effective.

Which statement accurately states the basis of the M'Naghten rule regarding its impact on the mentally ill? 1 All mental ill individuals are assured the right to treatment. 2 Nonviolent mentally ill individuals have the right to refuse treatment. 3 A legally insane individual cannot be held legally accountable for a murder he or she has committed. 4 Any threat of violence toward another made by a mentally ill individual to a health care professional must be reported.

3 The M'Naghten rule states that individuals who do not understand the nature and implications of murderous actions because of insanity cannot be held legally accountable for murder. Wyatt v. Stickney, 344 F Supp 373 (MD Ala 1972), confirmed a right to treatment. Rogers v. Okin, 478 F Supp (D Mass 1979), determined the right to refuse treatment. In this case, the ruling prohibited Boston State Hospital from forcing nonviolent patients to take medications against their will. Tarasoff v. The Regents of the University of California (1976) 17 Cal 3rd 425, ruled that mental health professionals have a duty to warn of threats of harm to others. DIF: Cognitive level: Understanding REF: p. 21 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity

Under what circumstances may a nurse take action to prevent a mentally ill patient from leaving the hospital where he or she has been receiving treatment? 1 The patient is diagnosed with a chronic mental illness. 2 The treatment goals for the patient have not yet been achieved. 3 The interdisciplinary team agrees that the patient still needs treatment. 4 The patient was committed by the court for evaluation or mental health treatment.

4 A patient committed by a court proceeding can be prevented from leaving a facility, and doing so is legal and thus cannot be considered false imprisonment. A patient cannot be forced to remain in a hospital for treatment based solely on diagnosis, achievement of goals, or the need for treatment. DIF: Cognitive level: Applying REF: p. 24 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity

In implementation of the principle of "duty to warn of threatened suicide or harm," the nurse will initially: 1 seek guidance regarding confidential client information from the agency's attorney. 2 direct all questions to the psychiatrist in charge of the patient. 3 always notify third parties whenever there is a concern of harm from the patient. 4 notify the multidisciplinary team regarding communication of client information.

4 Involve the team in discussion and decision making regarding threats; avoid working in isolation. May need to consider consulting with the agency's attorney as well in some situations. The team will need first discussion and problem solving prior to contacting the agency's attorney for guidance. The team needs discussion of the issue, along with the psychiatrist working with the patient. "Always" would be inappropriate whenever there is a concern of harm. DIF: Cognitive level: Applying REF: pp. 23-24 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity

Who introduced the terms psychoanalysis, id, ego, superego, and free association into today's psychiatric language? 1 Otto Rank 2 Helene Deutsch 3 Karen Horney 4 Sigmund Freud

4 Sigmund Freud introduced terms that have become part of our language: psychoanalysis, id, ego, superego, and free association. Although the other scientists listed made contributions to modern psychiatry, they were not responsible for these terms.

What is the most important component to be communicated when reporting to the incoming nursing staff regarding a patient who is admitted for emergency care? 1 The details of the reason the patient was brought to the facility 2 The name of the patient's significant others or advocate 3 Whether or not the patient has been adherent with medication 4 The beginning time and date of the emergency detention

4 Time is important in assessment, adhering to legal parameters and patient's rights, and preparing the patient for the upcoming options for care. The remaining information has importance but is not considered the most important among these options. DIF: Cognitive level: Analyzing REF: p. 25 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity

5. A nurse finds a mental health care directive in the medical record of a patient experiencing psychosis. The directive prohibits the prescription of specific medications. Considering the patient's impaired function, what is the nurse's primary responsibility regarding medication administration? a. Ensure that the directives are respected in treatment planning. b. Review the directive with the patient to ensure that it is current. c. Alert the prescribing psychiatrist of the directive. d. Discuss the revision of the directive with the patient's guardian or power of attorney.

ANS: A Advance directives for psychiatric care given by competent patients are considered binding and should be respected in planning treatment. The patient is not currently capable of making such decisions due to the psychosis. The decision cannot be rescinded if it was appropriately arrived at a time when the patient was cognitive. Alerting the current prescribing psychiatrist is appropriate, but it is not the primary nursing responsibility at this time.

3. An adult diagnosed with paranoid schizophrenia frequent experiences auditory hallucinations and walks about the unit, muttering. Which nursing action demonstrates the nurse's understanding of effective psychotherapeutic management of this client? a. Discussing the disease process of schizophrenia with the client and their domestic partner b. Minimizing contact between this patient and other patients to assure a stress free milieu c. Administering PRN medication when first observing the evidence that the client may be hallucinating d. Independently determining that behavior modification is appropriate to decrease the client's paranoid thoughts

ANS: A An understanding of psychopathology is the foundation on which the three components of psychotherapeutic management rest; it facilitates therapeutic communication and provides a basis for understanding psychopharmacology and milieu management. Minimizing contact between the patient and others and administering PRN medication indiscriminately are nontherapeutic interventions. Using behavior modification to decrease the frequency of hallucinations would need to be incorporated into the plan of care by the care team.

15. The spouse of a patient with panic attacks tells the nurse, "I am afraid my husband has a permanent disorder and will have many hospitalizations in the future. I wonder how I will be able to raise our children alone." The nurse's reply should be based on which form of nursing knowledge? a. Psychopathology b. Milieu management c. Psychopharmacology d. Nursing relationship therapy

ANS: A An understanding of psychopathology will enable the nurse to communicate reassurance to the spouse regarding the treatment of panic attacks in an outpatient setting. None of the other options has psychotherapeutic knowledge of psychiatric disorders as its focus.

6. A patient constantly disrupts activities on an inpatient unit. Which action would place the nurse at risk of being quality of assault? a. Threatening to rescind the patient's weekend pass b. Placing the patient in seclusion c. Refusing to medicate the patient as prescribed d. Pushing the patient out of the day room

ANS: A Assault is defined as an act that creates a reasonable apprehension of harmful or offensive contact to another without consent of the other. The nurse has threatened the patient thus risking the risk of assault. Battery is unwanted touching such as pushing. Negligence is failure to do what is reasonably prudent under the circumstances such as not providing prescribed medications. False imprisonment is associated with unwarranted seclusion.

4. To help preserve patients' rights to freedom from restraint and seclusion, the most important interventions that the nurse can use are based on which intervention? a. Therapeutic management of the patient's needs b. Reality-based communication to minimize cognitive disorientation c. Confidentiality of all documentation associated with the patient d. Effective use of ancillary personnel to monitor the patient

ANS: A Attention to the nurse-patient relationship, the therapeutic milieu, and principles of pharmacologic management can reduce the need for restrictive measures. The other options are important aspects of care but do not relate directly to the use of restraint and seclusion.

5. Which of Freud's contribution to psychiatry most affects current psychiatric nursing? a. The challenge to look at humans objectively b. Recognition of the importance of human sexuality c. Theories about the importance of sleep and dreams d. Discoveries about the effectiveness of free association

ANS: A Freud's work created a milieu for thinking about mental disorders in terms of the individual human mind. This called for therapists to look objectively at the individual, a principle that is basic to nursing. The correct answer is the most global response. Freud's theories of psychosexual development are an aspect of holistic nursing practice, but not the entire focus. Free association is not a pivotal issue in nursing practice.

11. A crisis team led by a psychiatric nurse assesses a patient with a history of paranoid schizophrenia who is standing on the lawn shouting, "Don't come near me. People are poisoning my water." Which statement made to the police officer accurately identifies the patient's immediate needs? a. "We've identified that this patient requires immediate emergency care." b. "This patient will require a hearing to implement a long-term commitment." c. "Please arrange for a probable-cause hearing for this patient." d. "This patient meets the criteria for short-term observation and treatment.

ANS: A Individuals who are deemed to be dangerous to self, dangerous to others as is possible with this patient, or those who are gravely disabled can be detained involuntarily for evaluation and emergency treatment for a specified period of time (often for 72 hours). Long-term commitment might be unnecessary. A probable-cause hearing is needed only for short-term observation and treatment.

7. Which statement most accurately describes a nurse's role regarding psychopharmacology? a. "You will need to frequently make decisions regarding the administration of PRN medications to help the client manage anger." b. "It's a nursing responsibility to adjust a medication dose to assure effective patient responses." c. "Nurses administers medications while evaluating drug effectiveness is a medical responsibility." d. "To best assure appropriate response, a patient's questions about drug therapy should be referred to the psychiatrist."

ANS: A Nursing assessment and analysis of data might suggest the need for PRN medication as patient anxiety increases or psychotic symptoms become more acute. The nurse is the health team member who makes this determination. Nurses are responsible for monitoring drug effectiveness as well as administering medication. Nurses should assume responsibility for teaching patients about the side effects of medications. Nurses cannot alter prescribed dosages of medications unless they have prescriptive privileges.

22. A nurse engaging in which behavior demonstrates a need for addition education regarding the release of patient information without expressed written consent? a. Providing the estimated date of discharge to the patient's employer b. Documenting the patient's daily behaviors during hospitalization c. Discussing the patient's history with other team members during care planning d. Documenting in the medical record the date and circumstances information was released to the court system

ANS: A Release of information to individuals or entities without patient authorization violates the patient's right to privacy. Documentation is a nursing responsibility and both the treatment care team and the court have the right to access such information.

8. A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient's insurance form. Which resource should the nurse use to discern the criteria used to establish this diagnosis? a. The Diagnostic and Statistical Manual of Mental Disorders (DSM) b. Nursing Diagnosis Manual c. A psychiatric nursing textbook d. A behavioral health reference manual

ANS: A The DSM gives the criteria used to diagnose each mental disorder. The distracters do not contain diagnostic criteria for mental illness.

11. When a nurse working in a well-child clinic asks a parent's address, the parent responds, "My children and I are homeless." What assumption should the nurse make of this response? a. It is a common occurrence, because 1 out of 50 children are homeless. b. It signals a need to investigate the possibility that the parent has severe mental illness. c. Confirms that evidence of child abuse or neglect that should be reported to social service agencies. d. Suggests that the parent may have substance abuse problem.

ANS: A The current belief is that the homeless are people (including entire families) who have been displaced by social policies over which they have no control. One out of 50 children is homeless. Although homelessness might be associated with serious mental illness, it might also be the result of having a weak support system and of social policies over which the individual or family has no control. No assumption should be made about the existence of child or substance abuse.

22. When explaining risk assessment, the nurse would indicate that the highest priority for admission to hospital-based care is associated with which goal? a. Safety of self and others b. Minimal confusion and disorientation c. Successful withdrawal from harmful substances d. Management of medical illness complicating a psychi

ANS: A The highest priority is safety. In the other situations, threats to safety might or might not exist.

21. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate to a patient diagnosed with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop. I don't want to take that medicine anymore. I hate the side effects." What action should the nurse take? a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Proceed with the injection but explain to the patient that there are medications that may help reduce the unpleasant side effects. c. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose." d. Notify other staff to report to the room for a show of force, and proceed with the injection, using restraint if necessary.

ANS: A The nurse, as an advocate and educator, should seek more information about the patient's decision and should not force the medication. Patients with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. It is not reasonable to promise a reduction in side effects without first discussing them, nor is it appropriate to pressure the patient into taking the medication. The medication cannot be given without the patient's informed consent.

24. A patient's insurance will not pay for continuing hospitalization at a private facility, so the family considers transferring the patient to a public psychiatric hospital. They express concern that the patient will "never get any treatment." Select the nurse's most helpful reply to their concern. a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern, because the right to treatment extends only to provision of food, shelter, and safety." c. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse."

ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals under federal law. The remaining statements do not accurately describe that right.

14. Which skill is most important to a nurse working as a member of a community mental health team that strives to use a seamless continuum of care? a. Case management b. Diagnostic ability c. Physical assessment skills d. Patients' rights advocacy

ANS: A To effectively use a seamless continuum of care, a nurse must have case management skills with which he or she can coordinate care using available and appropriate community resources. Psychosocial assessment and physical assessment are functions that can be fulfilled by another health care worker. Patients' rights advocacy is one aspect of case management.

1. Which interventions should the nurse apply to the care plan of a patient requiring involuntary secluded? (Select all that apply.) a. Seclusion instituted when all less restrictive interventions are ineffective in managing behavior b. Written medical order to be obtained within 2 hours of implementation of intervention c. Patient to be debriefed when seclusion is discontinued d. Patient to be offered bathroom privileges hourly e. Patient evaluation every 15 minutes

ANS: A, C, D The correct interventions include debriefing, resorting to seclusion as a last resort, and evaluations should be done every 15 minutes. A medical order must be secured within 1 hour.

3. A newcomer to a community support meeting asks a nurse, "Why aren't people with mental illnesses treated at state institutions anymore?" What would be the nurse's accurate responses? (Select all that apply.) a. "Funding for treatment of mental illness now focuses on community treatment." b. "Psychiatric institutions are no longer accepted because of negative stories in the press." c. "There are less restrictive settings available now to care for individuals with mental illness." d. "Our nation has fewer people with mental illness; therefore, fewer hospital beds are needed." e. "Better drugs now make it possible for many persons with mental illness to live in their communities."

ANS: A, C, E Deinstitutionalization and changes in funding shifted care for persons with mental illness to the community rather than large institutions. Care provided in a community setting, closer to family and significant others, is preferable. Improvements in medications to treat serious mental illness made it possible for more patients to live in their home communities. Prevalence rates for serious mental illness have not decreased. Although the national perspectives on institutional care did become negative, that was not the reason many institutions closed.

2. Which intervention demonstrates that a nurse is functioning within the scope of psychotherapeutic management? (Select all that apply.) a. Structuring meaningful unit activities b. Administering electroconvulsive therapy c. Encouraging a patient to express feelings d. Interpreting the results of psychological testing e. Assessing a patient for medication side effects

ANS: A, C, E Milieu management, patient communication, and medication administration are all within the scope of nursing practice. Electroconvulsive therapy is a medical treatment and, therefore, should be administered by a physician. Psychological testing is interpreted by a psychologist.

18. A patient who is admitted involuntarily with a diagnosis of bipolar disorder, manic phase, refuses a prescribed dose of lithium. The nurse assembles a show of force and intimidates the patient into taking the medication. What is a likely an outcome of this action for the patient? a. A lessening of mania b. Grounds for a civil suit against the nurse for assault c. Grounds to sue the hospital for false imprisonment d. Improved nurse-patient relationship

ANS: B A nurse who forces a patient to accept treatment or take medication in a nonemergency situation against the patient's wishes can be found liable for assault (threatening) and battery (nonconsenting touching) in civil court, even if the nurse had the best interest of the patient in mind. Such action would not serve to improve the nurse-patient relationship. Diminished symptoms of mania are not likely to be related to a single dose of lithium. The scenario does not describe the conditions of false imprisonment. Actions taken in the best interest of the patient that violate the patient's rights are cause for civil action.

14. A patient tells the nurse, "This medication makes me feel weird. I don't think I should take it anymore. Do you?" What is the nurse's best response? a. "I wonder why you think that." b. "Tell me how the medication makes you feel." c. "One must never stop taking medication." d. "You need to discuss this with your psychiatrist."

ANS: B As part of the psychopharmacology component of psychotherapeutic management, the responsibility of the nurse is to gather data about patients' responses to medication and to be alert for side and adverse effects of the medication. The other responses are tangential to the real issue.

18. An acutely psychotic patient is restricted to an inpatient unit. This intervention demonstrates that which milieu element has been adapted? a. Norms b. Balance c. Therapy d. Psychopathology

ANS: B Balance refers to negotiating the line between dependence and independence. The more psychotic the individual, the less independence he or she can usually handle safely. Unit restriction with careful supervision by staff helps compensate for lack of patient judgment. Norms refers to behavioral expectations for patients. Therapy is provided by advanced-practice nurses or others with advanced education and so is not an element of milieu management. Psychopathology is not considered an environmental element.

15. The broadened scope of psychiatric nursing practice is attributable primarily to what factor? a. Increased use of psychotropic drugs b. Opening of community mental health centers c. Legislation that changed nurse practice acts across the country d. Recidivism of seriously mentally ill patients in public mental hospitals

ANS: B Community mental health centers were designed and organized to provide services in addition to inpatient hospitalization, thus giving nurses opportunities to practice in a variety of treatment settings (e.g., emergency rooms, partial hospitalization settings, outpatient care) and to have new roles, such as consultant, liaison, and case manager. Increased use of psychotropic drugs is not as important a factor as are community mental health centers. Legislation changing nurse practice acts broadened the scope of practice for nurse practitioners only by allowing prescriptive privileges. Recidivism is not a relevant factor.

16. A patient diagnosed with an acute was hospitalized for a week and is now being discharged to a halfway house, where care is managed by a community mental health nurse. Which inference applies to this community? a. Additional mental health services should be made available for the severely mentally ill. b. A seamless continuum of services is in place to serve persons with severe mental illness. c. Case management services should be expanded to care for acute as well as long-term system consumers. d. Care is effective for only a few selective psychiatric diagnoses.

ANS: B Data are sufficient to suggest that a seamless continuum of service is in place, because the individual is able to move between continuum treatment sources and is given the services of a case manager to coordinate care. Data provided are insufficient to warrant any of the other assessments.

13. A nurse begins working in a clinic housed in a homeless shelter. The nurse asks the clinic director, "What topic should I review to improve my effectiveness as I begin my new job?" Which topic should the clinic director suggest? a. Care of school-age children b. Psychiatric assessment c. Communicable disease prevention strategies d. Sexually transmitted disease signs and symptoms

ANS: B It is estimated that significant numbers of the homeless population have a serious mental illness and/or suffer from substance abuse or dependence. Although the other conditions may exist, the numbers are not as significant.

25. A patient diagnosed with paranoid schizophrenia believes that evil spirits are being stirred by a local minister and verbally threatens to bomb a local church. Considering the rights of this patient, what is the initial nursing responsibility? a. Obtaining the patient's permission to release this information to the police b. Recognizing and acting upon the duty to warn and protect c. Protecting the patient's right to confidentiality d. Reviewing the criteria associated with malpractice so as to avoid committing this tort

ANS: B It is the health care professional's duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not considered a violation of confidentiality or an example of malpractice and patient consent is not required.

5. A patient's haloperidol dosage was reduced 2 weeks ago to decrease side effects. What assessment question demonstrates the nurse's understanding of the resulting needs of the client? a. "Will you have any difficulty getting your prescription refilled?" b. "Have you begun experiencing any forms of hallucinations?" c. "What do you expect will occur since the dosage has been reduced?" d. "What can I do to help you manage this reduction in haloperidol therapy?"

ANS: B It will be necessary for the nurse to assess for exacerbation of the patient's symptoms of psychosis as well as for a lessening of side effects. Dosage decrease might lead to the return or worsening of positive symptoms such as hallucinations and delusions, and negative symptoms such as blunted affect, social withdrawal, and poor grooming. While the other options may be appropriate assessment questions, they are not directed at the current needs of the client; the identification of emerging psychotic behaviors.

8. When considering environmental aspects of milieu management, which intervention has the highest priority for a client admitted after a failed suicide attempt? a. Sending the client's new medication prescriptions to the pharmacy b. Assigning a staff member to one-on-one observation of the client c. Orienting the client to the milieu's public and private spaces d. Having all potentially dangerous items removed from the client's belongings

ANS: B Milieu management provides a proactive approach to care. Safety overrides all other dimensions of the milieu. Initiation of suicide precautions are the priority for this client. All the remaining options are appropriate but none protect the client from the risk of another attempt to self-harm as effectively as one-on-one observation as part of suicide precautions.

16. A patient was restrained after assaulting a staff member. Which nursing measure has priority? a. Assess the patient for comfort needs every 15 minutes. b. Maintain constant supervision of the patient. c. Administer a sedating medication after applying the restraints. d. Distract the patient at frequent intervals while restraints are in use.

ANS: B Restrained patients must be constantly observed, with documentation of physical safety and comfort interventions occurring at 15-minute intervals. Medication may be administered, but this is not the priority action. Distraction is not an effective technique to use when a patient is in restraints, because minimal stimulation is preferred.

21. A patient diagnosed with long-standing bipolar disorder comes to the mental health center. The patient says, "I lost my job and home. Now, I eat in soup kitchens and sleep at a shelter. I am so depressed that I thought about jumping from a railroad bridge into a river." Which factor has priority for the nurse who determines the appropriate level of care? a. Long-standing bipolar disorder b. Risk for suicide c. Homelessness d. Lack of income

ANS: B Risk assessment shows the patient to have suicidal thoughts, and a plan for the suicide that is highly lethal, executable, and with low potential for rescue. The other factors do not have as great an effect on the determination of the level of services needed since they are less related to acute safety.

16. Which observation during morning rounds should receive a nurse's priority attention? a. Breakfast is late being served. b. A sink is leaking, leaving water on the bathroom floor. c. The daily schedule has not been posted on the unit bulletin board. d. A small group of patients is complaining that one patient turned down the TV volume.

ANS: B Safety is the component of therapeutic milieu management that takes priority over the other components. A patient could be injured if he or she slipped and fell. The other problems do not pose a threat to patient safety.

4. Which statement made by a nurse demonstrates an understanding of the issue affecting the delivery of care to the mentally ill that motivated passage of the Community Mental Health Centers Act in 1963? a. "Involuntary hospitalized occurs only if a client demonstrated violent behavior." b. "We attempt to address the issues that occur when a client is geographically isolated from family and community." c. "Legally a voluntarily admitted client can demand to be discharged before receiving adequate treatment." d. "Mental ill clients must give informed consent before being used as subjects in pharmacologic research."

ANS: B State hospitals were often located a great distance from the patients' homes, making family visits difficult during hospitalization. The Community Mental Health Centers Act in 1963 served as the impetus for deinstitutionalization, allowing patients and families to receive care close to home. Admission only for behavior that endangers self or others is more consistent with current admission criteria. Early discharge rarely occurred before the community mental health movement. Unethical pharmacologic research was not a major issue leading to community mental health legislation.

1. Considering the M'Naghten Rule, what information is most important for the nurse to document when caring for a patient who will soon be tried on murder charges? a. The patient's participation in treatment planning b. The patient's comments about commission of the crime c. Examples of behaviors that support psychiatric diagnoses d. The patient's perceptions of the need for hospitalization and treatment

ANS: B The M'Naghten Rule states that to be held legally accountable for his or her actions, a person with mental illness must be able to understand the nature and implications of the crime. Although each of the options refers to data that should be documented, the patient's comments about the crime would be of most importance to the trial.

12. Which individual should the nurse assess as having the highest risk for homelessness? a. An older adult woman with mild dementia who lives alone in an apartment b. An adult with serious mental illness and no family c. An adolescent with an eating disorder d. A married person with alcoholism

ANS: B The adult has both a serious mental illness and a potentially weak support system. Both are risk factors for homelessness. The other individuals have psychiatric disorders but have better established support systems.

17. A community mental health nurse assessing a person with a psychiatric disorder, should refer this person to services based on which basic concept? a. Focus on interventions is on the least costly initially. b. Initial interventions are the least restrictive. c. Initial interventions offer a form of psychoeducation. d. Rapid symptom stabilization is the primary goal.

ANS: B The concept of least restrictive treatment environment preserves individual rights to freedom. Many patients are healthy enough to receive community-based treatment. Hospitalization is reserved for short periods when patients are assessed as being a danger to self or others. Cost is a consideration but is of lesser concern than safety. All facets of the continuum should offer psychoeducation as needed by patients and families. Some aspects of the care continuum are more concerned with a patient's need for symptom stabilization than others (e.g., hospitals versus psychiatric rehabilitation programs). The outcome of symptom stabilization is not a need for some patients, so it is not a correct answer.

9. The implementation of which unit policy directed at milieu balance would reflect a need for reconsideration on the part of the treatment team? a. All clients will receive verbal and written information explaining unit rules. b. Unit clients will engage in all unit activities to assure interaction with both staff and other clients. c. All clients will be uniformly expected to present themselves in a nonviolent manner to both staff and other clients. d. At times of unit stress, client will return to their rooms.

ANS: B The situation described suggests a milieu in which patients have no time for planned therapeutic encounters with staff; hence, it is a milieu lacking balance. The remaining options address unit norms, limit setting, and environmental modifications that are reasonable and will contribute to a therapeutic milieu.

23. What explanation regarding the unit milieu would be most important for the nurse to give to a newly admitted patient? a. "Your behavior will be carefully monitored during your hospital stay." b. "Unit activities will help you cope with immediate needs and stressors." c. "You will be given enough medication to bring your symptoms under control." d. "I will be gathering information about you to plan your care and your discharge."

ANS: B This choice best reflects the purpose of milieu management in psychotherapeutic management as demonstrated through unit activities. Stating that behavior will be monitored creates suspicion. Discussing medication administration is a psychopharmacology issue and is not pertinent to unit milieu. Stating that assessment will take place is not directly related to milieu.

6. Which statement forms the foundation upon which a nurse should base the implementation of psychotherapeutic management to the care of a patient with mental illness? a. The nurse's role in client care is supported by the multidisciplinary team. b. Omitting any one component will compromise the effectiveness of the treatment. c. The most important element of psychotherapeutic management is drug therapy. d. A therapeutic nurse-patient relationship is the most important aspect of treatment.

ANS: B When one element is missing, treatment is usually compromised. No single element is more important than the others; however, patients' needs govern the application of the components and permit judicious use. The remaining options identify components of the psychotherapeutic management process.

2. When discussing the precedent established in Wyatt v. Stickney with nursing students, the nurse demonstrates an accurate understanding or the decision by focusing on what factor? a. Intellectualization of the client's condition b. About the client's rights to adequate treatment c. Minimizing the client's risk of being coerced into treatment d. Risks created by a request for immediate discharge from the facility

ANS: B Wyatt v. Stickney was a case in which the court ruled that patients had the right to adequate treatment while hospitalized. Intellectualizing is a defense mechanism. Right to refuse treatment and commitment issues were not the focus of Wyatt v. Stickney.

1. Which changes in psychiatric nursing practice are directly attributable to events occurring during the Decade of the Brain? (Select all that apply.) a. Homeless shelters became practice sites. b. Nurses upgraded knowledge of psychopharmacology. c. Nurses provided psychoeducation to patients and families. d. Nurses viewed psychiatric symptoms as resulting from brain irregularities. e. Nurses were more likely to advocate for patients' rights related to involuntary commitment.

ANS: B, C, D Psychobiologic research relating to brain structure and function made it possible for psychiatric nurses to view symptoms as brain irregularities and made it necessary for them to become knowledgeable about psychotropic medications to make appropriate assessments regarding desired outcomes and side and toxic effects of therapy. With hospital stays shortened, it became necessary for nurses to provide psychoeducation to patients and families who would need to monitor outcomes, symptoms of relapse, and side and toxic effects of medication. Homeless shelters became practice sites with the onset of deinstitutionalization. Advocacy for patients' rights relating to hospitalization and commitment became an ethical issue before the Decade of the Brain.

1. What data should a nurse analyze when deciding to refer a patient with a psychiatric disorder to community-based care? (Select all that apply.) a. Need for PRN medication b. Severity of the patient's illness c. Need for structured formal therapy d. Presence of suicidal or homicidal ideation e. Amount of supervision required by the patient

ANS: B, D, E The decision tree for the continuum of care calls for the assessment of severity of the illness, the presence or absence of suicidal or homicidal ideation, whether or not the disability is so great that the patient is unable to provide for his or her own basic needs, and the amount of supervision required for patient safety. The frequency of need for PRN medication and the need for structured formal therapy are not considerations mentioned in the decision tree.

10. Which intervention should the nurse implement when focusing on communicating therapeutically with a client? a. Explaining to the client why they will need to ask for a razor b. Providing the client with options to help achieve smoking cessation c. Encouraging the client to identify personal stressors d. Assuring the client that they can receive telephone call on the unit telephone

ANS: C A nurse uses therapeutic communication techniques as part of the therapeutic nurse-patient relationship. An example of such communication is providing the client with an opportunity to safely identify personal stressors. The remaining options address safety, balance, and norms associated with their care.

10. An adult with serious mental illness is being admitted to a community behavioral health inpatient unit. Recognizing current trends in hospitalization, the nurse can reasonable assume the need to prioritize which intervention? a. Providing education regarding the need for medication adherence b. Evaluating whether the client has a clear understanding of the illness c. Implementing safety precautions to address aggressive behavior d. Counseling the client concerning risks involved in demanding discharge against medical advice

ANS: C Compared with patients of the 1960s and 1970s, today's patients are likely to display more aggressive behavior. This understanding is critical to making astute assessments that lead to planning for the provision of safety for patients and staff. Treatment compliance, understanding of the illness process, and discharge against medical advice are possible issues with which the nurse might deal, but these are less relevant when admission assessment is performed.

13. A patient tells the nurse, "This medicine makes me feel weird. I don't think I should take it anymore. Do you?" The most effective reply that the nurse could make is based on which psychotherapeutic management model? a. Psychopathology b. Milieu management c. Psychopharmacology d. Therapeutic nurse-patient relationship

ANS: C Concerns about medication voiced by patients require the nurse to have knowledge about psychotherapeutic drugs to make helpful responses. The nurse-patient relationship component is based on use of self. Milieu management is concerned with the environment of care. Psychopathology provides foundational knowledge of mental disorders but would be less relevant in framing a response to the patient than knowledge of psychopharmacology.

1. A person says, "What mental health issues are a major concern for the general population." The nurse's reply should be based on what confirmed fact concerning mental health issues? a. Bipolar disorder is a rare diagnosis among the general population. b. A diagnosis of schizophrenia is rarely confirmed during the teenage years. c. Major depression is very prevalent among the adult population. d. Alcohol-related issues are minimal considering the entire adult population.

ANS: C Four of the top medical disorders causing disability are psychiatric disorders (i.e., major depression, schizophrenia, bipolar disorder, and alcohol abuse). About half of all mental disorders start by the midteens.

17. Which patient behavior should be considered when evaluating the need for an involuntary commitment for psychiatric treatment? a. Noncompliant with the treatment regimen b. Engaging in the selling and distribution of illegal drugs c. Verbalizing the threat to "eliminate anyone who comes near me" d. Living on the streets

ANS: C Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization since there is not direct threat of harm to self or to others.

9. A patient tells the nurse, "I still have suicidal thoughts, but don't tell anyone because I am supposed to be discharged today." Select the nurse's best course of action. a. Have the patient sign a "no suicide" contract. b. Respect the patient's request related to confidentiality. c. Inform the health care provider and other team members. d. Search the patient's belongings for potentially hazardous items.

ANS: C Patient right to confidentiality never includes keeping important clinical information secret, especially information related to patient safety. Patients should be informed that all relevant information will be shared with the health care team. None of the other options sufficiently address the safety issue presented by a patient who expresses suicidal thoughts.

2. Which component of the nursing process will the nurse focus upon to address the responsibility to match individual patient needs with appropriate services? a. Planning b. Evaluation c. Assessment d. Implementation

ANS: C Proper assessment is critical for being able to determine the appropriate level of services that will provide optimal care while considering patient input and at the lowest cost. Planning and implementation utilizes the assessment data to identify and execute actions (treatment plan) that will provide appropriate care. Evaluation validates the effectiveness of the treatment plan.

12. Risk assessment for a patient shows these findings: schizophrenia but not currently; not a danger to self or others; lives in parents' home. Which decision regarding placement on the continuum of care is appropriate? a. Hospitalize the patient. b. Discharge the patient from the system. c. Refer the patient to outpatient services. d. Refer the patient to self-help resources in the community.

ANS: C Referral should be made to the least restrictive, most effective, and most cost-conscious source of services. Because the patient is not a danger to self or others, hospitalization is not needed. However, follow-up as an outpatient would be more appropriate than referral to a self-help group, in which structure might be lacking, or discharge from the system.

11. During the risk assessment phase of care for a psychiatric patient, what is the nurse's primary goal? a. Making an initial assessment b. Confirming the patient's problem c. Assessing potential dangerousness to self or others d. Determining the level of supervision needed for the patient

ANS: C Risk assessment involves looking at dangerousness to self or others, the degree of disability, and whether or not the individual is acutely psychotic to determine the feasibility of community-based care versus hospital-based care. Risk assessment usually follows the initial assessment. Confirmation of the patient's problem is not part of the risk assessment protocol. Arranging entry into the mental health system will follow risk assessment if the patient is assessed as needing service.

3. A patient shouts, "I'm holding you responsible for mistreatment based on Rogers v. Orkin." The nurse should review past care related to what focus? a. Loss of privileges b. Inability to make phone calls c. Medication administration d. Involuntary hospitalization

ANS: C Rogers v. Orkin was a case in which the court ruled that nonviolent patients could not be forced to take medication. It did not have implications related to hospitalization or application of patient privileges.

6. The greatest impact in the care of the mentally ill over the past 50 years is represented in which nursing statement to a newly admitted patient? a. "You will benefit from attending the assigned self-help groups" b. "Outpatient therapy will be prescribed as a part of your post discharge therapy." c. "Let's talk about the psychotropic drugs you've been prescribed." d. "This is a written copy of your patients' rights."

ANS: C The advent of psychotropic drugs allowed patients to normalize thinking and feeling. As psychosis diminished, the individual became accessible for psychotherapeutic interventions. Hospital stays were shortened. Hospital milieus improved. Though important, none of the other choices has had such a significant impact.

17. Which of these services is most appropriate for an older client requiring minimal mental health interventions? a. Day treatment b. Hospitalization c. Scheduled visits at a community mental health center d. Regular attendance at a senior center facility

ANS: C The continuum of care represents treatment services along a range of intensity. Hospitalization is the most intensive, progressing to day treatment, and finally to routine visits at a community mental health center. A senior center is not prepared to provide mental health interventions.

13. An involuntarily admitted inpatient diagnosed with paranoid schizophrenia repeatedly calls the local mayor. The patient verbally abuses the person who answers the phone as well as the mayor. Select the most appropriate initial nursing intervention to help manage this behavior. a. Document the behavior and inform the patient that their phone privileges could be revoked. b. Include the patient in a social skills building group. c. Suspend the patient's phone privileges temporarily, and document the reason. d. Ask the patient advocate to review the limits of the patient's rights with the patient.

ANS: C The patient requires a consequence for unacceptable behavior. The nurse should document that the patient's calls violated the rights of others, thus providing a basis for temporary suspension of the right to make phone calls to the mayor's office. Allowing continued calls violates the rights of others. It might require several days for the advocate to meet with the patient. Social skill building is valuable but doesn't address the immediate behavior.

3. A nurse is preparing to present a discussion to a group of nursing students on meeting the needs of the mentally ill. What concerns should be identified as the focus of society's concerns during both the Period of Enlightenment and the Period of Community Mental Health? a. Moving patients out of asylums b. Studying brain structure and function c. Meeting basic human needs humanely d. Providing medication to control symptoms

ANS: C The use of asylums signaled concern for meeting basic needs of the mentally ill, who in earlier times often wandered the countryside. With deinstitutionalization, many patients who were poorly equipped to provide for their own needs were returned to the community. The current system must now concern itself with ensuring that patients have such basic needs as food, shelter, and clothing. Studying brain structure and function is more a concern of modern times, as is t

19. To reduce the risk of a lawsuit based on false imprisonment, mental health nurses must give the highest priority to which intervention? a. Educating patients about unit protocols b. Providing adequate treatment during hospitalization c. Selecting the least restrictive treatment environment that will be effective d. Ensuring that patients have probable-cause hearings within 24 hours of admission

ANS: C Treating a patient in the least restrictive environment that will be effective lessens the threat of the patient bringing civil suit for false imprisonment. In the least restrictive environment, the disruption to patient rights is minimized. Providing information about unit rules and providing adequate treatments are of less immediate importance than ensuring the least restrictive alternative. Probable-cause hearings are necessary only in certain cases.

2. A patient diagnosed with bipolar disorder is admitted involuntarily during a manic phase. Lithium 300 mg PO t.i.d. is prescribed. The patient refuses the morning dose. What are the nurse's best actions? (Select all that apply.) a. Get the prescription changed to an elixir, and administer it in juice. b. Assemble adequate help to force the patient to take the medication. c. Educate the patient about the importance of lithium in stabilizing the mood. d. Allow the patient to refuse the medication, and document the patient's comments. e. Inform the patient that unit privileges are contingent on taking prescribed medications.

ANS: C, D Patients have the right to refuse consent to treatment, including medication administration. The courts have ruled that neither voluntary nor involuntary patients can be forced to take psychotropic medication. Hiding the medication in food or fluids is not ethical. Assembling a show of force implies that forcible administration will occur. Making privileges contingent on medication ingestion is

4. An adult diagnosed with chronic depression is hospitalized after a suicide attempt. Which intervention is critical in assuring long-term, effective client care as described by psychotherapeutic management? a. Involvement in group therapies b. Focus of close supervision by the unit staff c. Maintaining effective communication with support system d. Frequently scheduled one-on-one time with nursing staff

ANS: D A critical element of psychotherapeutic management is the presence of a therapeutic nurse-patient relationship. One-on-one time with nursing staff will help in establishing this connection. While the other options are appropriate and client centered, the nurse-client relation is critical in the long-term delivery of quality effective care to this client.

10. Which nurse is at risk of being guilty of committing a legal tort? a. The primary nurse who does not complete the plan of care for a patient within 24 hours of the patient's admission. b. An advanced-practice nurse who recommends that a patient who is dangerous to self and others be involuntarily hospitalized. c. A nurse who suggests that a patient's admission status be changed from involuntary to voluntary after the patient's hallucinations subside. d. A nurse who gives a PRN dose of an antipsychotic drug to a patient to prevent violent acting out because the unit is short staffed.

ANS: D A tort is a civil wrong demonstrated by a person who violates the legal rights of another. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify a tort since considering the situations described, no patient right has been violated.

19. An individual diagnosed with schizophrenia has a history of medication nonadherence. When inpatient psychiatric care is not indicated, which service is the preferred referral? a. Primary care b. Outpatient counseling c. Apartment residential living d. A group home with 24-hour supervision

ANS: D Although inpatient hospitalization is unnecessary, the individual requires an environment in which medication compliance can be fostered. In this case, the group home would provide the best alternative. The other options do not provide adequate supervision.

20. A patient diagnosed with bipolar disorder has stabilized and is being discharged from the hospital. The patient will live independently at home but lacks social skills and transportation. Which referral would be most appropriate? a. A group home b. A self-help group c. A day treatment program d. Assertive community treatment (ACT)

ANS: D Assertive community treatment (ACT) provides intensive supervision, which includes assistance with medications and transportation that would support the goal of minimizing future hospitalizations. A group home is unnecessary, because the patient will reside at home. A day treatment program would provide a therapeutic program directed toward symptoms, but the patient's symptoms have stabilized so this service is not indicated. A self-help group would not provide the intensity of service this patient needs.

23. An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my parents, but you can't tell them." Select the nurse's initial response. a. "You're right. Federal law requires me to keep information private." b. "Those kinds of threats will make your hospitalization last much longer." c. "You really should share this thought with your psychiatrist." d. "I am required to talk to the treatment team about your threats."

ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances, because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the patient's parents of the risk for harm. Considering this information, none of the other options is accurate.

20. How many violations of Medicare and Medicaid guidelines are evident in this documentation? Patient assaulted nurse in hall at 1730. Staff provided verbal intervention, but patient continued to strike out. Patient placed in seclusion at 1745. Observation instituted at hourly intervals. Order received from physician at 1930. Patient sleeping soundly at 2100. Patient released from seclusion at 2230 and returned to own room. a. Two b. Three c. Four d. Five

ANS: D Constant observation of a secluded individual is necessary, with attention given at frequent intervals for safety and comfort interventions. No mention is made of providing fluids or bathroom privileges. Seclusion requires a written order posted within 1 hour. Seclusion must be terminated when patient behavior permits. If the patient is calm enough to sleep, the need for seclusion should be re-evaluated.

24. Referral to a psychiatric extended-care facility would be most appropriate for which of the following patients? a. An adult with generalized anxiety disorder b. A severely depressed 70-year-old retiree c. A patient with personality disorder who frequently self-mutilates d. A severely ill person with schizophrenia who is regressed and withdrawn

ANS: D Extended care often serves those with severe and persistent mental illness and those with a combination of psychiatric and medical illnesses. The patient demonstrating the signs and symptoms described in the correct option is at risk for developing psychotic behaviors that increases the risk for self and other directed harm. Patients with anxiety disorders can be referred to outpatient services. Severely depressed patients would need more intensive care, as would a self-mutilating individual.

8. A cognitively impaired psychiatric patient has been a court appointed guardian. What the nurse is appropriate in seeking the opinion of the guardian regarding what matter? a. The patient's need for a winter coat b. Accompanying the patient on an outing off of facility grounds c. Addressing the patient's financial issues d. TA change in needed treatment

ANS: D Guardians make decisions on behalf of the patient related to their well-being. Being consulted about treatment planning is an appropriate area for a guardian's input. None of the other options are directly associated with the role of a guardian. D

12. Which individual would be the most likely candidate to require at court appointed guardian? a. A patient diagnosed with panic attacks b. A patient who frequently refuses medication c. A patient with frequent admissions for drug abuse d. A patient diagnosed with chronic, paranoid schizophrenia

ANS: D Guardians or conservators are appointed by the courts to manage the affairs of mentally ill individuals found to be incompetent and unable to manage their own affairs appropriately. A patient diagnosed with chronic, paranoid schizophrenia would be in need of a conservator or guardian, whereas the other individuals would more likely be judged competent since their diagnoses are not necessarily chronic in nature or as likely to impair rational thinking.

2. A nurse, preparing a community presentation, should include what information concerning the most accurate characterization of treatment of the mentally ill prior to the Period of Enlightenment? a. Large public asylums provided custodial care. b. Care for the mentally ill was more compassionate. c. Care focused on reducing stress and meeting basic human needs. d. Patients were often displayed for public amusement.

ANS: D In the 1700s it was common practice for caretakers to display mentally ill patients for the amusement of the paying public. The creation of large asylums took place during the Period of Enlightenment. Mental illness was first studied during the Period of Scientific Study. Dealing with stress and meeting basic needs are concerns of the modern era.

14. A nurse in a community mental health center receives a call asking for information about a patient. Under which condition can the nurse release information to the caller? a. The caller is related to the patient. b. The psychiatrist approves the request. c. The caller is a mental health professional. d. The patient has given written consent for release of information.

ANS: D Patient information is privileged. Information cannot be released without consent signed by the patient. None of the other conditions meet that criteria.

7. An adult diagnosed with schizophrenia is being discharged from a state mental hospital after 20 years of institutionalization. What intervention should the nurse include in discharge planning to best manage the relapse of symptoms? a. Discuss methods to assist in the transition from hospitalization to community. b. Encourage the client to use community support services. c. Evaluate the client's ability to effectively self-administer antipsychotic medications as prescribed. d. Educate the client and family to the likely need for crisis or emergency psychiatric interventions from time to time.

ANS: D Patients with serious mental illness are rarely considered cured at the time of hospital discharge. Decompensation is likely from time to time, even when good community support is provided. While the remaining options are appropriate, none will affect relapse manage more than an understanding that relapse care will likely be necessary.

1. A newly licensed asks a nursing recruiter for a description of nursing practice in the psychiatric setting. What is the nurse recruiter's best response? a. "The nurse primarily serves in a supportive role to members of the health care delivery team." b. "The multidisciplinary approach eliminates the need to clearly define the responsibilities of nursing in such a setting." c. "Nursing actions are identified by the institution that distinguishes nursing from other mental health professions." d. "Nursing offers unique contributions to the psychotherapeutic management of psychiatric patients."

ANS: D Professional role overlap cannot be denied; however, nursing is unique in its focus on and application of psychotherapeutic management. Neither the facility nor the multidisciplinary team define the professional responsibilities of its members but rather utilizes their unique skills to provide holistic care. Ideally, all team members support each other and have functions within the team.

7. A patient tells the nurse, "When I get out, I'm going to get even with a lot of people." With respect to the nurse's duty to warn, what priority action should the nurse take? a. Discuss the consequences of such actions with the client. b. Notify local law enforcement officials of the threat. c. Warn close relatives and significant other as required by law. d. Document and discuss the threat with the clinical team.

ANS: D The Tarasoff ruling specifies that a specific threat to a readily identifiable person or persons must be made. In this situation, the threat is nonspecific. The prudent action is to document and discuss with the clinical team to determine the need for providing a warning to third parties and to notify the police. While discussing the consequences of acting on the threat is not inappropriate, it is not the priority intervention required.

9. Which nursing intervention is associated with a shift in the psychiatric nursing focus during the community mental health period of the 1960s? a. De-emphasizing the high numbers of people seeking treatment b. Making substance abuse the primary focus of care c. Focusing services on persons with serious mental illness d. Assessing the client's potential for improvement

ANS: D The community mental health movement brought with it a broadening of areas of concern to the psychiatric nurse. It became acceptable, even desirable, for psychiatric nurses to focus on what was called the worried well, as opposed to providing care for acutely ill psychotic individuals. Neither disillusionment with the numbers seeking treatment nor providing more services to those with severe mental illness occurred.

15. A patient backs into a corner of the room and shouts at the nurse, "Stay away from me." What is the nurse's best initial nursing intervention in this situation? a. Obtain an order for seclusion. b. Administer a PRN antipsychotic drug. c. Call for assistance to physically restrain the patient. d. Talk to the patient in a calm, nonthreatening manner.

ANS: D Verbal intervention provides the least restrictive alternative in this situation. Verbal intervention might halt escalation and prevent the need for medication or the use of restraint or seclusion. Seclusion, restraint, and medication usage are all more restrictive than verbal intervention.

2. A community mental health nurse works in a mental health services system that is undergoing change to become a seamless system. To promote integrity of the new system, the nurse should focus on: (Select all that apply.) a. psychopathology. b. symptom stabilization. c. medication management. d. patient and family psychoeducation. e. patient reintegration into the community. f. holistic issues relating to patient care.

ANS: D, E, F A seamless system of mental health services will require new conceptualizations. Nurses will need to focus more on recovery and reintegration than on symptom stabilization and more on holistic issues such as finances and housing than on medication management. Consumers and family members will also need to be provided with extensive psychoeducation.

An adult with paranoid schizophrenia is hospitalized. This patient has frequent auditory hallucinations and walks about the unit, muttering. To use psychotherapeutic management effectively, it is most important for the nurse to: a. understand the disease process of schizophrenia. b. minimize contact between this patient and other patients. c. administer PRN medication before interacting with the patient. d. use behavior modification to decrease the frequency of hallucinations.

a. understand the disease process of schizophrenia. An understanding of psychopathology is the foundation on which the three components of psychotherapeutic management rest; it facilitates therapeutic communication and provides a basis for understanding psychopharmacology and milieu management. Minimizing contact between the patient and others and administering PRN medication indiscriminately are nontherapeutic interventions. Using behavior modification to decrease the frequency of hallucinations would need to be incorporated into the plan of care.

most prevalent mental disorder

anxiety

about half of all mental disorders begin

at mid-teens

Which guideline should a nurse use when applying the components of psychotherapeutic management to the care of a patient with mental illness? a. The nurse's role in milieu management is secondary to that of social work. b. Omitting any one component usually will result in less effective treatment. c. The most important element of psychotherapeutic management is drug therapy. d. A therapeutic nurse-patient relationship is the most important aspect of treatment.

b. Omitting any one component usually will result in less effective treatment. The three components listed as choices a, c, and d above work together to provide the best treatment outcomes. When one element is missing, treatment is usually compromised. No single element is more important than the others; however, patients' needs govern the application of the components and permit judicious use.

A patient attends outpatient programs at a community mental health center and meets with the primary nurse regularly. Last week, the patient's haloperidol (Haldol) dose was reduced from 5 mg to 2 mg daily to decrease side effects. The nurse will need to monitor changes in: a. the activity schedule at the center. b. the nature of the patient's symptoms. c. attention given to the patient by other staff. d. balance among psychotherapeutic management elements.

b. the nature of the patient's symptoms. It will be necessary for the nurse to assess for exacerbation of the patient's symptoms of psychosis as well as for an amelioration of side effects. Dosage decrease might lead to the return or worsening of positive symptoms such as hallucinations and delusions, and negative symptoms such as blunted affect, social withdrawal, and poor grooming.

The primary element required to match individual patient needs with appropriate services is proper: a. planning. b. evaluation. c. assessment. d. implementation.

c. assessment Proper assessment is critical for being able to determine the appropriate level of services that will provide the patient with optimal care at the lowest cost. The decision tree for the continuum of care establishes this fact.

Select the best description of nursing practice in the psychiatric setting. a. The nurse primarily serves in a supportive role to other members of the team. b. The multidisciplinary approach eliminates the need to clearly define the responsibility of nursing. c. Clearly differentiated nursing actions have been identified that distinguish nursing from other professions. d. Although professional role overlap exists, nursing offers unique contributions to psycho-therapeutic management.

d. Although professional role overlap exists, nursing offers unique contributions to psychotherapeutic managemnet. Professional role overlap cannot be denied; however, nursing is unique in its focus on and application of psychotherapeutic management. Psychiatric social workers do not have expertise in physical care. Ideally, all team members support each other.

A depressed adult is hospitalized after a suicide attempt. The patient receives an antidepressant medication, is closely supervised, attends a variety of group therapies and activities, watches television during free time, and talks to visitors in the evening. Which additional intervention is needed in the patient's care? a. Milieu therapy b. Adequate drug therapy c. Increased contact with significant others d. Meaningful communication with nursing staff

d. meaningful communication with the nursing staff. Two of the three elements of psychotherapeutic management are present: psychopharmacology and milieu management. There is no evidence that the psychotherapeutic nurse-patient relationship exists. Maintaining contact with significant others is not considered an element of the psychotherapeutic management model.

deinstitutionalization

depopulating of state mental hospitals

most prevalent of specific mental illness

major depression

four of the top medical disorders causing disability

major depression, schizophrenia, bipolar disorder, alcohol abuse

where individuals outside of institutions may be living

nursing homes, prisons/jails, state hospitals, homeless, home with families (group or board-and-care homes, or on own)

key element in facilitation of less restrictive treatment setting

psychotropic meds