Chapter 27: Community Mental Health Nursing

Mrs. W, a 78-year-old depressed widow, says to her home health nurse, "What's the use? I don't have anything to live for anymore." Which is the best response on the part of the nurse? a. "Of course you do, Mrs. W. Why would you say such a thing?" b. "You seem so sad. I'm going to do my best to cheer you up." c. "Let's talk about why you are feeling this way." d. "Have you been thinking about harming yourself in any way?"

D. "Have you been thinking about harming yourself in any way?"

John, a homeless person, has a history of schizophrenia and noncompliance with medications. Which of the following medications might be the best choice for John? a. Haldol b. Navane c. Lithium carbonate d. Prolixin decanoate

D. Prolixin decanoate

The physician orders trazadone (Desyrel) for Mrs. W, a 78-year-old widow with depression, 150 mg to take at bedtime. Which of the following statements about this medication would be appropriate for the home health nurse to make in teaching Mrs. W about trazadone? A. "You may feel dizzy when you stand up, so go slowly when you get up from sitting or lying down." B. "You must be sure and not eat any chocolate while you are taking this medicine." C. "We will need to draw a sample of blood to send to the lab every month while you are on this medication." D. "If you don't feel better right away with this medicine, the doctor can order a different kind for you."

A. "You may feel dizzy when you stand up, so go slowly when you get up from sitting or lying down."

Which of the following represents a nursing intervention at the tertiary level of prevention? A. Serving as case manager for a mentally ill homeless client B. Leading a support group for newly retired men C. Teaching prepared childbirth classes D. Caring for a depressed widow in the hospital

A. Serving as case manager for a mentally ill homeless client

Which of the following represents a nursing intervention at the primary level of prevention? A. Teaching a class in parent effectiveness training B. Leading a group of adolescents in drug rehabilitation C, Referring a married couple for sex therapy D. Leading a support group for battered women

A. Teaching a class in parent effectiveness training

A school nurse provides education on drug abuse to a high school class. This nursing action is an example of which level of preventive care? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Primary intervention

ANS: 1 Page: 726 Feedback 1 Providing nursing education on drug abuse to a high school class is an example of primary prevention. Primary prevention services are aimed at reducing the incidence of mental health disorders within the population. 2 Secondary prevention is aimed at early detection and prompt intervention. 3 Tertiary prevention is aimed at reduction of symptoms. 4 Primary intervention is not a term associated with the public health model.

Which of the following issues have been identified as contributing to the rise in the population of those who are homeless? Select all that apply. A. Poverty B. Lack of affordable health care C. Substance abuse D. Severe and persistent mental illness E. Growth in the number of family members living together

A, B, C, D A. Poverty B. Lack of affordable health care C. Substance abuse D. Severe and persistent mental illness

A client at the mental health clinic tells the case manager, "I can't think about living another day, but don't tell anyone about the way I feel. I know you are obligated to protect my confidentiality." Which case manager response is most appropriate? 1. "The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care." 2. "Let's discuss steps that will resolve negative lifestyle choices that may have increased your suicidal risk." 3. "You seem to be preoccupied with self. You should concentrate on hope for the future." 4. "This information is secure with me because of client confidentiality."

ANS: 1 Page: 739 Feedback 1 The most appropriate response by the case manager is to explain that sharing the information with the treatment team is critical to the client's care. This case manager's priority is to ensure client safety and to inform others on the treatment team of the client's suicidal ideation. 2 Stating "Let's discuss steps that will resolve negative lifestyle choices that may have increased your suicidal risk" does not protect the client's safety, which is the priority. 3 Stating "You seem to be preoccupied with self. You should concentrate on hope for the future" does not protect the client's safety, which is the priority. 4 Stating "This information is secure with me because of client confidentiality" does not protect the client's safety, which is the priority.

Which of the following have been assessed as the most common types of mental illness identified among homeless individuals? (Select all that apply.) 1. Schizophrenia 2. Body dysmorphic disorder 3. Antisocial personality disorder 4. Neurocognitive disorder 5. Conversion disorder

ANS: 1, 3, 4 Page: 745-750 Feedback 1. A number of studies have been conducted, primarily in large, urban areas, which have addressed the most common types of mental illness identified among homeless individuals. Schizophrenia is frequently described as the most common diagnosis. 2. Body dysmorphic disorder is not among the most common types of mental illnesses among homeless individuals. 3. Other prevalent disorders include personality disorders, such as antisocial personality disorder. 4. Other prevalent disorders include neurocognitive disorders. 5. Conversion disorder is not among the most common types of mental illnesses among homeless individuals.

A client diagnosed with schizophrenia is hospitalized owing to an exacerbation of psychosis related to nonadherence with antipsychotic medications. Which level of care does the client's hospitalization reflect? 1. Primary prevention level of care 2. Secondary prevention level of care 3. Tertiary prevention level of care 4. Case management level of care

ANS: 2 Page: 731 Feedback 1 Primary prevention aims are preventing the need of services. 2 The client's hospitalization reflects the secondary prevention level of care. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment. 3 Tertiary prevention aims at reducing the symptoms of a disease or illness. 4 Case management level of care is not a term associated with the public health model.

A nursing instructor is teaching about case management. What student statement indicates that learning has occurred? 1. "Case management is a method used to achieve independent client care." 2. "Case management provides coordination of services required to meet client needs." 3. "Case management exists mainly to facilitate client admission to needed inpatient services." 4. "Case management is a method to facilitate physician reimbursement."

ANS: 2 Page: 739 Feedback 1 This statement indicates that further education is needed. 2 The instructor evaluates that learning has occurred when a student defines case management as providing coordination of services required to meet client needs. Case management strives to organize client care so that specific outcomes are achieved within allotted time frames. 3 This statement indicates that learning has not occurred. 4 This statement indicates that further teaching is required.

A homeless client comes to an emergency department reporting cough, night sweats, weight loss, and blood-tinged sputum. Which disease, which has recently become more prevalent among the homeless community, should a nurse suspect? 1. Meningitis 2. Tuberculosis 3. Encephalopathy 4. Mononucleosis

ANS: 2 Page: 745-750 Feedback 1 Meningitis has not recently become more prevalent. 2 The nurse should suspect that the homeless client has contracted tuberculosis. Tuberculosis is a growing problem among individuals who are homeless, owing to being in crowded shelters, which are ideal conditions for the spread of respiratory tuberculosis. Prevalence of alcoholism, drug addiction, HIV infection, and poor nutrition also impact the increase of contracted cases of tuberculosis. 3 Encephalopathy has not recently become more prevalent. 4 Mononucleosis has not recently become more prevalent.

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ANS: 2, 3, 1. Page: 724-725 Feedback The premise of the model of public health is based largely on the concepts set forth by Gerald Caplan (1964) during the initial community mental health movement. They include primary prevention, secondary prevention, and tertiary prevention. 1. Primary prevention is aimed at reducing the incidence of mental disorders within the population. 2. Secondary prevention is aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness. 3. Tertiary prevention is aimed at providing services that reduce the residual defects that are associated with severe and persistent mental illness.

Which of the following are characteristics of a Program of Assertive Community Treatment (PACT), as described by the National Alliance on Mental Illness (NAMI)? (Select all that apply.) 1. PACT offers nationally based treatment to people with serious and persistent mental illnesses. 2. PACT is a type of case-management program. 3. The PACT team provides services 24 hours a day, 7 days a week, 365 days a year. 4. The PACT team provides highly individualized services directly to consumers. 5. PACT is a multidisciplinary team approach.

ANS: 2, 3, 4, 5 Page: 739-740 Feedback 1. NAMI defines PACT as a service-delivery model that provides comprehensive, locally, not nationally, based treatment to people with serious and persistent mental illnesses. 2. PACT is a type of case-management program. 3. The PACT team provides these services 24 hours a day, 7 days a week, 365 days a year. 4. PACT is a type of case-management program that provides highly individualized services directly to consumers. 5. It is a team approach and includes members from psychiatry, social work, nursing, substance abuse, and vocational rehabilitation.

Which of the following clients should a nurse recommend for a structured day program? (Select all that apply.) 1. An acutely suicidal teenager 2. A chronically mentally ill woman who has a history of medication nonadherence 3. A socially isolated older individual 4. A depressed individual who is able to contract for safety 5. A client who is hearing voices that tell the client to harm s

ANS: 2, 4 Page: 740-741 Feedback 1. A suicidal teenager is not an appropriate candidate for a structured day program. 2. The nurse should recommend a structured day program for a chronically mental ill woman who has a history of medication non-adherence. 3. A socially isolated older adult is not an appropriate candidate for a structured day program. 4. The nurse should recommend a structured day program for a depressed individual who is able to contract for safety. 5. A client hearing voices is not an appropriate candidate for a structured day program.

A nursing instructor is teaching about the Community Health Centers Act of 1963. What was a deterring factor to the proper implementation of this act? 1. Many prospective clients did not meet criteria for mental illness diagnostic-related groups. 2. Zoning laws discouraged the development of community mental health centers. 3. States could not match federal funds to establish community mental health centers. 4. There was not a sufficient employment pool to staff community mental health centers.

ANS: 3 Page: 723 Feedback 1 A client who did not meet criteria for mental illness was not a deterring factor. 2 Zoning laws were not a deterring factor. 3 A deterring factor to the proper implementation of the Community Mental Health Centers Act of 1963 was that states could not match federal funds to establish community mental health centers. This act called for the construction of comprehensive community mental health centers to offset the effect of deinstitutionalization, the closing of state mental health hospitals. 4 Insufficient staffing was not a deterring factor.

A nurse is implementing care within the parameters of tertiary prevention. Which nursing action is an example of this type of care? 1. Teaching an adolescent about pregnancy prevention 2. Teaching a client the reportable side effects of a newly prescribed neuroleptic medication 3. Teaching a client to cook meals, make a grocery list, and establish a budget 4. Teaching a client about his or her new diagnosis of bipolar disorder

ANS: 3 Page: 725 Feedback 1 Teaching about pregnancy prevention is primary prevention. 2 Teaching about side effects of a new medication and bipolar disorder is secondary prevention. 3 The nurse who teaches a client to cook meals, make a grocery list, and establish a budget is implementing care within the parameters of tertiary prevention. Tertiary prevention consists of services aimed at reducing the residual effects that are associated with severe and persistent mental illness. It is accomplished by preventing complications of the illness and promoting rehabilitation that is directed toward achievement of maximum functioning. 4 Teaching about bipolar disorder to a newly diagnosed client is secondary prevention.

When a home health nurse administers an outpatient's injection of haloperidol decanoate (Haldol decanoate), which level of care is the nurse providing? 1. Primary prevention level of care 2. Secondary prevention level of care 3. Tertiary prevention level of care 4. Case management level of care

ANS: 3 Page: 739 Feedback 1 Primary prevention is aimed at preventing services before they are needed. 2 Secondary prevention is aimed at early detection and fast intervention. 3 When administering medication in an outpatient setting, the nurse is providing a tertiary prevention level of care. Tertiary prevention services are aimed at reducing the residual effects that are associated with severe and persistent mental illness. It is accomplished by preventing complications of the illness and promoting rehabilitation that is directed toward achievement of maximum functioning. 4 Case management level of care is not a term associated with the public health model.

A newly admitted homeless client diagnosed with schizophrenia states, "I have been living in a cardboard box for two weeks. Why did the government let me down?" Which is an appropriate nursing response? 1. "Your discharge from the state hospital was done prematurely. Had you remained in the state hospital longer, you would not be homeless." 2. "Your premature discharge from the state hospital was not intended for patients diagnosed with chronic schizophrenia." 3. "Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success." 4. "Your discharge from the state hospital was based on presumed family support, and this was not forthcoming."

ANS: 3 Page: 745-750 Feedback 1 This is inaccurate because the client was not discharged prematurely. 2 This is inaccurate because the client was not discharged prematurely due to schizophrenia. 3 The most accurate nursing response is to explain to the client that the resources were not available to make transitioning out of a state hospital a success. There are several factors that are thought to contribute to homelessness among the mentally ill: deinstitutionalization, poverty, lack of affordable housing, lack of affordable health care, domestic violence, and addiction disorders. 4 This statement is not accurate based on the client's situation.

When intervening with a married couple experiencing relationship discord, which nursing action reflects an intervention at the secondary level of prevention? 1. Teaching assertiveness skills in order to meet assessed needs 2. Supplying the couple with guidelines related to marital seminar leadership 3. Teaching the couple about various methods of birth control 4. Counseling the couple related to open and honest communication skills

ANS: 4 Page: 726-727 Feedback 1 Teaching assertiveness skills in order to meet assessed needs is tertiary prevention. 2 Supplying the couple with guidelines related to marital seminar leadership is primary prevention. 3 Teaching the couple about various methods of birth control is primary prevention. 4 Counseling the couple related to open and honest communication skills is a reflection of a nursing intervention at the secondary level of prevention. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment.

An instructor is teaching nursing students about the difference between partial and inpatient hospitalization. In what way does partial hospitalization differ from traditional inpatient hospitalization? 1. Partial hospitalization does not provide medication administration and monitoring. 2. Partial hospitalization does not use an interdisciplinary team. 3. Partial hospitalization does not offer a comprehensive treatment plan. 4. Partial hospitalization does not provide supervision 24 hours a day.

ANS: 4 Page: 740-741 Feedback 1 Partial hospitalization provides medication administration and monitoring. 2 Partial hospitalization uses an interdisciplinary team. 3 Partial hospitalization offers a comprehensive treatment plan. 4 The instructor should explain that partial hospitalization does not provide supervision 24 hours a day. Partial hospitalization programs generally offer a comprehensive treatment plan formulated by an interdisciplinary team, including medication administration. They have proved to be an effective method of preventing hospitalization.

When attempting to provide health-care services to the homeless, what should be a realistic concern for a nurse? 1. Most individuals that are homeless reject help. 2. Most individuals that are homeless are suspicious of anyone who offers help. 3. Most individuals that are homeless are proud and will often refuse charity. 4. Most individuals that are homeless relocate frequently.

ANS: 4 Page: 745-750 Feedback 1 It is inaccurate to state that most homeless reject help. 2 It is inaccurate to state that most homeless are suspicious of those who offer help. 3 It is inaccurate to state that most homeless refuse charity. 4 A realistic concern in the provision of health-care services to the homeless is that individuals who are homeless relocate frequently. Frequent relocation confounds service delivery and interferes with providers' efforts to ensure appropriate care.

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ANS: deinstitutionalization Page: 723 Feedback The deinstitutionalization movement closed state mental hospitals and caused the discharge of individuals with mental illness. Congress passed the Mental Retardation Facilities and Community Mental Health Centers Construction Act (often called the Community Mental Health Centers Act) in 1963. This act called for the construction of comprehensive community health centers, the cost of which would be shared by federal and state governments. Unfortunately, many state governments did not have the capability to match the federal funds required for the establishment of these mental health centers.

Ann is a psychiatric home health nurse. She has just received an order to begin regular visits to Mrs. W, a 78-year-old widow who lives alone. Mrs. W's primary care physician has diagnosed her as depressed. Which of the following criteria would qualify Mrs. W for home health visits? a. Mrs. W never learned to drive and has to depend on others for her transportation. b. Mrs. W is physically too weak to travel without risk of injury. c. Mrs. W refuses to seek assistance as suggested by her physician because "I don't have a psychiatric problem." d. Mrs. W says she would prefer to have home visits than go to the physician's office.

B. Mrs. W is physically too weak to travel without risk of injury.

Which of the following represents a nursing intervention at the secondary level of prevention? A. Teaching a class about menopause to middle-aged women B. Providing support in the emergency room to a rape victim C. Leading a support group for women in transition D. Making monthly visits to the home of a client with schizophrenia to ensure medication compliance

B. Providing support in the emergency room to a rape victim

Ann is a psychiatric home health nurse. She has just received an order to begin regular visits to Mrs. W, a 78-year-old widow who lives alone. Mrs. W's primary care physician has diagnosed her as depressed. Which of these potential problems is a priority to evaluate during the first home visit? A. Complicated grieving B. Social isolation C. Risk for injury D. Sleep pattern disturbance

C. Risk for injury

John, a homeless person, has just come to live in the shelter. The shelter nurse is assigned to his care. Which of the following is a priority intervention on the part of the nurse? a. referring John to a social worker b. Developing a plan of care for John c. conducting a behavioral and needs assessment on John d. helping John apply for social security benefits

C. conducting a behavioral and needs assessment on John