Chapter 32 Serious Mental Illness (Week 5)

supportive psychotherapy

Treatment that involves offering encouragement, support, and hope to patients facing difficult life transitions and events.

Which statement by a young client who has severe and persistent mental illness would alert the nurse to the need for psychoeducational intervention? "I like to watch cartoons every morning." "I hear that marijuana helps calm you down." "I am looking for a job washing dishes at a diner." "I hate having my thoughts so messed up all the time."

"I hear that marijuana helps calm you down." Clients with mental illness should receive information about the dangerous negative impact of using illegal drugs. None of the other options suggest situations that are unsafe for the client.

Which remark would signal to the nurse that there is a teaching need for the family of a client diagnosed with schizophrenia? "We always reprimand him whenever his behavior is bothersome." "We watch him closely for signs of illness associated with relapse." "We have taught him to use the bus so we do not have to drive him everywhere." "We give positive recognition to him whenever he does even simple things well."

"We always reprimand him whenever his behavior is bothersome." An important need of families caring for the severely and persistently mentally ill is psychoeducation to help them understand the disease process. Families need to be prepared to meet the many concerns related to safety, communication, medication compliance, and symptom management. Family interventions are now considered an evidence-based practice, with research showing improved outcomes of decreased relapses and rehospitalizations for clients whose families participate. The only negative approach to the client and his/her needs is reflected in the option that suggests reprimanding when bothersome.

Anosognosia

(uh-no-sog-NOH-zee-uh), the inability to recognize one's illness due to illness itself, affects most of those with SMI

Serious mental illness (SMI) affects how many adults in the United States? 11 million 8 million 4 million 1 million

4 million SMI affects about 10 million adults in the United States. The other options are incorrect percentages.DIF: Cognitive Level:

A 20-year-old Amish patient was diagnosed with paranoid schizophrenia 1 year ago who lives with his parents. When the nurse attempts to educate him about his diagnosis and the need for medication, the client persistently mumbles, "I don't have mental illness. No, I am not sick." What term is used to describe this response? Anosognosia Resistance Apathy Religiosity

Anosognosia Anosognosia is the inability to recognize one's deficits as a result of one's illness. In SMI, the brain, the organ one needs to have insight and make good decisions, is the organ that is diseased. An illness that makes one unable to recognize that illness can understandably cause one to be resistant to treatment. Although the patient may be resistive to treatment, it does not best describe the patient's denial of the illness. Apathy is lack of caring. Nothing in the scenario depicts the patient being preoccupied with religion at this time.

A client who has been prescribed an antipsychotic medication comes to the clinic 3 days after his scheduled visit and demonstrates evidence of restlessness and agitation. He states, "My medicine ran out, and I didn't remember where to get more." The client's case manager should initially implement which intervention to support medication adherence? Arrange to have the client's nursing care plan reflect the need for a medication change Arrange for the client to see his psychiatrist as soon as the psychiatrist has an open appointment. Arrange for the client to get to the nearest emergency department for treatment. Arrange for a dose of the client's medication immediately.

Arrange for a dose of the client's medication immediately. The role of the case manager is to coordinate access to psychiatric treatment, housing, rehabilitation or work setting, socialization, and medical care. The client's immediate need for medication is best addressed by arranging for an immediate dose.

The goal of a nurse working in psychiatric rehabilitation would be to help clients in the community achieve which outcome? Complete mental health Live comfortably in a psychiatric treatment facility Cope more effectively with their symptoms Learn to live with dependency

Cope more effectively with their symptoms The long-term outcomes of rehabilitation for severely mentally ill clients include the concepts of illness management and recovery. Illness management refers to the focus in the early stage of treatment that assists the client to gain control over symptoms. Clients are taught to collaborate with professionals in mental health treatment, reduce susceptibility to relapse, and cope more effectively with symptoms. Complete mental health is not always achievable.

supported employment model

Elements of this approach include: 1. Financial incentives to employers to employ people with SMI 2. Rapid placement in a competitive job preferred by the patient 3. Continuing individualized support on the job (e.g., a coach at the worker's side providing support, guidance, and training in coordination with supervisors) 4. Integration of mental health and employment services

The clinical nurse specialist should suggest which cognitive intervention initially for a client experiencing auditory hallucinations? Seclusion when escalation begins Physical restraints when the client is disruptive Initiating a distracting technique Giving as-needed medication for anxiety

Initiating a distracting technique Strategies have been successfully applied to treat hallucinations, delusions, and negative symptoms, making cognitive interventions an evidence-based practice. For example, distraction techniques can be taught when auditory hallucinations occur, such as listening to music or humming. The remaining options should only be considered when less restrictive interventions, like distraction, prove to be ineffective and the client is at risk for injury to self or to others.

Which interventions and/or goals related to planning for discharge of a client diagnosed with a SMI would support the recovery model of care? Attending groups that teach how to cope with one's present illness. The client's parents will receive education on how to manage the patient's deficits. Care plan interventions will focus on medication adherence. Interventions will focus on the client's stated wish for independent living.

Interventions will focus on the client's stated wish for independent living. The recovery model is patient centered, instills hope and empowerment, emphasizes the person and the future, encourages independence and self-determination, and focuses on achieving goals of the patient's choosing and meaningful living. The National Alliance on Mental Illness (NAMI) and the President's New Freedom Commission on Mental Health (2003) both support the recovery model of care rather than the rehabilitation model, which focuses on the illness and the present. The other options all follow the rehabilitation model, focusing on the illness.

Which statement best reflects the way clients who are severely and persistently mentally ill generally perceive how others in the community see them? Many feel stigmatized and alienated. Most feel undersupported by family and friends. A large number are intensely hostile toward others. The majority are incapable of such self-reflective thought.

Many feel stigmatized and alienated. Studies have shown that many clients experience stigmatization, alienation, loss of relationships, and loss of vocational opportunities. While some clients may have the perceptions described in the other options, none are as generally expressed as feeling stigmatized and alienated.

National Alliance on Mental Illness

National Alliance on Mental Illness is a support and advocacy organization for those with SMI and those who care about them. It has national, state, and local chapters and provides a wealth of educational materials and services.

Which statement is true of the relationship between SMI and substance abuse? Substance abuse rarely occurs within this population. Substance abuse occurs at approximately the same rate as in the general population. Of those diagnosed with SMI, substance abuse is high. Smoking has declined in this population at the same rate as the general public.

Of those diagnosed with SMI, substance abuse is high. Comorbid substance abuse occurs in 60% of those with SMI. It may be a form of self-medication, countering the dysphoria or other symptoms caused by illness or its treatment (e.g., the sedation caused by one's medications) or a maladaptive response to boredom. Nicotine use has always been higher in the population of those with SMI and is not declining as it has been in the general population. Substance abuse contributes to comorbid physical health problems, reduced quality of life, incarceration, relapse, and reduced effectiveness of medications. Substance abuse in those with SMI is higher than in the general population. Smoking has not declined in this population at the same rate as for the general public.DIF: Cognitive Level:

Institutionalization leads to what specific type of behaviors in adults old enough to have been confined to institutions before deinstitutionalization? Anger and aggression Passivity and dependence Assertiveness and candor Fearfulness and paranoia

Passivity and dependence Medical paternalism, in which the health care provider made all decisions for patients with SMIs, was pervasive at the time of common institutionalization for mental illness. As a result, patients became dependent on the services and structure of institutions and unable to function independently outside such institutions. It was difficult to distinguish whether behaviors such as regression were the result of the illness or institutionalization. The other options are incorrect regarding the common resulting behavior of institutionalized patients.

insurance parity

Providing mental healthcare coverage equal to that for physical healthcare or insurance parity is required under the Affordable Care Act

The nurse working with a client diagnosed with severe and persistent mental illness will implement rehabilitation principles by concentrating on which intervention? Assessment on the client's deficits Reinforcing the client's strengths Reviewing earlier treatment plans for errors Considering the need to lower expectations periodically

Reinforcing the client's strengths Although deficits are assessed and addressed, implementation of rehabilitation is dependent on reinforcement of identified client strengths. Neither of the remaining options is fundamental to the rehab process.

A client diagnosed with a severe and persistent mental illness tells the case manager, "I think people are laughing at me behind my back. I get real upset and anxious when I have to be around others in the group home. It's better when I just stay by myself." The nurse should consider which nursing diagnosis to address the client's concerns? Acute confusion Social isolation Risk for activity intolerance Impaired comfort

Social isolation Social isolation is aloneness experienced by the individual and perceived as imposed by others. None of the other options would be supported by the information provided in the question.

vocational rehabilitation

Vocational services, or vocational rehabilitation, typically include training skills to enhance employment and financial support for attaining employment.

Which functions are often simultaneously impaired when a patient is experiencing a serious mental illness? Select all that apply. a. Cognition b. Emotions c. Perceptions d. Social interactions e. Self-care

a,b,c,d,e

Psychiatric advance directives

are legal documents that allow an individual whose disorder is in remission to direct how to manage treatment if judgment becomes impaired during a relapse. For example, when well, a consumer can agree to accept hospitalization or medications should he or she experience a relapse.

Charlie is coping well with a severe mental illness diagnosis. He and his 91-year-old father live together on the family farm. This stable and secluded life has allowed Charlie to live with minimal stimulation, and his relapses have been few. Charlie's caseworker makes a visit to open up a conversation on where Charlie will live when his father can no longer care for him. By bringing up the topic now, the caseworker is hoping to: a. Arrange housing for Charlie for when his father dies. b. Avert a relapse and preserve stability in Charlie's life. c. Rescue Charlie when the crisis occurs. d. Make Charlie realize he will soon live independently.

b

Isadora is a middle-aged woman living in a group home after being discharged from a psychiatric institution nearly 20 year ago. Isadora keeps to herself, stays in her room most of the day, and only ventures out for meals. Cassandra, the house manager, encourages Isadora to: a. Begin looking for a job b. Join a day program clubhouse c. Assist in the kitchen washing dishes d. Take on a roommate so as not to be alone

b

Jimmy has been hospitalized three times for schizophrenia. Typically, he is very disorganized, spends his money irresponsibly, and loses his housing when he does not pay the rent. In turn, Jimmy cannot be located by his case manager, which leads to treatment nonadherence and relapse. Which response would be most therapeutic? Select all that apply. a. Advise Jimmy that if he does not pay his rent, he will be placed in a group home instead of independent housing. b. Discuss with Jimmy the option of having a guardian who will ensure that the rent is paid and that his money is managed to meet his basic needs. c. Suggest to Jimmy and his prescribing clinician that he be placed on a long-acting injectable form of antipsychotic medication to improve treatment nonadherence. d. Encourage Jimmy's case manager to hold him responsible for the outcomes of his poor decisions by allowing periods of homelessness to serve as a natural consequence.J

b,c

1. Which statement made by a patient diagnosed with a serious mental illness reflects a common situation associated with this disorder in today's healthcare system? Select all that apply. a. "I have been in a state institution most of my life." b. "I've been homeless for years." c. "Once a care provider knows my psychiatric history, my physical problems are not taken seriously." d. "No one wants to hire a person with mental issues." e. "My family doesn't want to be around me because I hear voices."

b,c,d &e

A 73-year-old man was diagnosed with a serious mental illness at age 20. Subsequently, he was frequently hospitalized. Two years ago, he was transferred to a group home. When considering the effects of institutionalization, which behavior demonstrates adaptation to the new environment? a. Willingly takes his medications b. Keeps his room neat and clean c. Makes himself lunch when he is hungry d. Enjoys spending the afternoon watching television

c

Due to the need to self-medicate for anxiety, a patient diagnosed with schizophrenia smokes two packs of cigarettes a day. What unique risk does nicotine pose to this patient's health? a. Lung cancer b. Cardiovascular constriction c. Impaired psychotropic medication therapy d. Increased incidence of lung-reacted disorders

c

What is the primary reason the nurse should include the family of a patient with a serious mental illness in treatment planning? a. They know the patient better than anyone. b. The patient is likely willing to listen to them. c. They are likely the patient's support system. d. The patient will turn to them first when needing help.

c

Assertive Community Treatment (ACT)

community-based programs that provide many of the services that are necessary for successful community living; includes case management, problem-solving, social skills training, support, teaching on a 24/7 basis.

A female consumer with severe and recurrent mania argues with outpatient staff about her medication. She does not believe she has a mental illness. Although she takes medication during hospitalizations, she stops taking them after discharge. Which intervention is most helpful in promoting medication adherence? a. Assign a new outpatient staff to reduce the conflicts she is experiencing with her current providers. b. Explain that the medications will help her and that all medications have side effects, but she can learn to live with these. c. Involve her in a medication group that will teach her the types and names of psychotropic medications, their purpose, and possible side effects. d. Explore her perceptions and experiences regarding medication and help her to connect taking medications with achieving her goals.

d

Individuals with severe mental illness (SMI) diagnoses can suffer from ineffective healthcare. Providers may be unaccustomed to working with this population or not comprehend obscure details described by the person seeking medical attention. This hurdle can be overcome by: a. Seeking medical attention at the emergency department. b. Having a community clinic in the area where the SMI live. c. Medicate the patient before a medical examination. d. Integrating mental and physical health in one setting.

d

psychoeducation

groups (educating about mental health topics [e.g., psychotropic drugs] and skills [e.g., conflict resolution])

Guardianship

involves the appointment of a person (guardian) to make decisions for the consumer during times when judgment is impaired or is disabled with anosognosia.

Social skills training

is an evidence-based practice that focuses on teaching a wide variety of social and ADL skills. People with SMI often have social deficits that cause functional impairment. For example, a person may not realize that standing too close causes discomfort to others and can lead to negative outcomes such as rejection or a poor job evaluation.

Stigma

is the perception that an individual is flawed. The perception is covertly or overtly linked to some personal defect in the person being stigmatized. A lack of understanding and incorrect beliefs about mental illness result in stigma about SMI. For example, some may believe that people with SMI are violent when in fact violence is rare.

Transinstitutionalization

is the shifting of a person or population from one kind of institution to another such as a state hospital, jail, prison, nursing home, or shelter. For example, people who were discharged from state hospitals ended up homeless

consumer-run programs

may be informal clubhouses, which offer socialization, recreation, and sometimes other services. Community mental health centers typically have consumer-run programming as part of day programs.

severe mental illness (SMI)

refers to a group of psychiatric disorders, most of which are primarily biological in origin, that can significantly affect functioning and one's quality of life, especially if they go untreated.

Peer support specialists

that is, other consumers who are in recovery, may provide some of the services.

Deinstitutionalization

the mass shift of patients from state hospitals into the community, began in the 1960s and has continued since. However, planned systems of community care needed by individuals with SMI did not always materialize, leaving them to fend for themselves without access to the services they needed.

Outpatient commitment

which provides mandatory treatment in the community, is relatively new. Typically ordered by a court when a patient leaves a hospital or prison, it is for people who would otherwise be unlikely to continue treatment, resulting in their becoming a danger to self or society.

The recovery model

• Is patient/consumer-centered. • Is hopeful and empowering. • Emphasizes the person and the future rather than the illness and the present. • Involves an active partnership between patient and care providers. • Focuses on strengths and abilities rather than dysfunction and disability. • Encourages independence and self-determination. • Focuses on achieving goals of the patient's choosing (not staff's). • Emphasizes staff working collaboratively with consumers, building on strengths to help consumers achieve the highest possible quality of life. • Aims for increasingly productive and meaningful lives for those with SMI.