Psych Exam 1 - Ch. 32 (Serious Mental Illness)
What is a popular misconception about the seriously mentally ill?
Violent and aggressive The seriously mentally are much more likely to be victims of violence than perpetrators of aggressive behavior. That the mentally ill are generally given the care they require, are likely to experience periods of remission, and usually are abandoned by their families are not true statements. p. 588
The nurse is teaching a group of nursing students about approaches to treating patients with severe mental illness. Which response by a student indicates effective learning regarding functions of assertive community treatment (ACT)?
"Treating patients in their environment reduces inpatient admission." Evidence-based treatment approaches can be used as an adjuvant treatment for patients with severe mental illness. ACT is given to patients who cannot avail themselves of the treatment because of low income and/or lack of awareness. A group of health care professionals form a team to provide the patient with complete care and treatment in their environment, and hospitalization is not required. The treatment of delusions and dementia is emphasized in cognitive and behavioral therapy, which focus on the thought processes of the patient to identify disoriented thinking and negative self-talk. In ACT, one of the members of the team is always available to provide 24-hour crisis intervention to the patient. In cognitive enhancement therapy, patients are given group exercises to improve their attention and memory. p. 592
How can a nurse advocate for consumers with serious mental illness in the community? (SATA)
-Educating law enforcement -Expanding community treatment -Assisting in establishing mental health courts The nurse can advocate for consumers with serious mental illness in the community by educating law enforcement, expanding community treatment, and assisting in the establishment of mental health courts. Deinstitutionalization may leave some patients without access to basic services such as housing, food, and mental health care. Trans-institutionalization is the shifting of a person or population from one kind of institution to another such as from a hospital to a jail. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten. p. 596
Why does the prognosis of a patient with serious mental illness seem threatened even though initially the patient does well? (SATA)
-Interruptions in treatment -Resistance to taking medications -Drug costs and increased co-pays Patients with chronic mental illness may have interruptions of treatment for several reasons, such as financial problems or shifting to some less costly neighborhood far from essential resources. They develop a resistance to taking medications because of anosognosia, or lack of awareness. This affects their health and prognosis. Mental illness drugs are very costly. The increasing co-pays create difficulties for unemployed persons. This also may be a reason for discontinuing treatment or treatment irregularity and the patient's prognosis is affected. The follow-up visits are effective for providing continuous treatment and care and for monitoring the disease. The medicines are properly regulated, and each batch is checked for quality before coming to the market. p. 595, Table 32.1,p. 589
A patient with mental illness and substance abuse is enrolled in vocational rehabilitation services. How does this help the patient improve his or her quality of life? (SATA)
-It encourages supported-employment services for the patients. -It combines the patient's employment with mental health services. Employers are given some financial incentives to employ a person with mental illness. Such supported-employment services are encouraged in vocational rehabilitation programs. Mental health services are combined with employment to help the patient socially and financially and also take care of the patient's health. Supportive psychotherapy is an approach that stresses anxiety reduction and therapeutic alliance when providing therapy for the current stage of the illness. Social skills training is an approach that teaches the patient different skills to negotiate or resolve conflict. This is not included as part of vocational rehabilitation services. The patients are trained to become independent so that they can take care of their own financial needs. They are not shifted to community homes. p. 593
The nurse is performing an assessment of a patient with severe mental illness. The nurse documents that the patient has the signs of indirect risk to others and self. On which factors does the nurse base this conclusion? (SATA)
-The patient is easily distracted. -The patient has no proper clothing. -The patient has inadequate nutrition. It is important to properly assess patients with severe mental illness. The nurse should check for signs of indirect risk to self or others. Inadequate nutrition, being distracted easily, and inadequate clothing are indications of this. Inadequate nutrition and improper clothing reflect that the patient cannot meet basic needs because of a lack of income. The patient may have chronic low self-esteem because of this and may develop suicidal intentions. The patient will be prone to accidents if easily distracted. Patients who are nonadherent to medications avoid discussing their problems with the nurse. Drug intoxication is an indication of psychiatric illness or caused by adverse drug interactions. p. 594
The case manager determines that the patient diagnosed with schizophrenia would profit from a structured environment and having simple responsibilities. Which community resource could provide this?
A psychosocial rehabilitation program Psychosocial rehabilitation programs are designed to provide daily structure for patients to promote socialization and vocational skills. p. 591
A nurse is planning discharge care for a patient with serious mental illness experiencing multiple hospitalizations over the past year. Which evidence-based approach will provide the most support for the patient after discharge?
Assertive community treatment (ACT) ACT will offer the most support for the patient after discharge from the hospital. It involves consumers working with a multidisciplinary team that provides a comprehensive array of services including a team member that is available 24 hours a day for crisis care. CBT is effective in helping individuals with serious mental issues reduce and cope with symptoms such as delusion and impaired social functioning. Community outreach programs are designed to focus on homeless individuals or people who do not seek care on their own. Family support and services provide support to families that are experiencing stress related to the mental illness of a loved one. p. 592
Which nursing intervention reflects the recovery model of care for a patient with serious mental illness?
Encouraging the patient to focus on achieving goals Encouraging the patient to focus on achieving goals reflects the recovery model of care, which is centered on the consumer and on actively partnering with the consumer to improve his or her quality of life. The focus is not on stabilization of the disability, managing deficits, or on present illness in this model. p. 586
What is the most appropriate description of the rehabilitation model of care for mental illnesses?
Focuses on skills to learn to live with illnesses Rehabilitation focuses on the patient's deficits and how to develop skills to learn to live with the illness. It is not empowering to the patients as it just focuses on managing the illness and the impacts of the illness. In the rehabilitation facility, the care provider helps the patient to overcome weaknesses and disabilities. It does not teach patients any social coping skills and does not work on building confidence and self-esteem. This is unlike the recovery model, which focuses on improving the quality of life rather than on living with the disability. p. 586
Psychiatric nurses use basic nursing interventions in all settings. The basic nursing interventions include all but which of the following?
Housing access Nurses encounter the severely mentally ill in the acute psychiatric setting, community treatment, and medical-surgical units and clinics. All psychiatric nurses use the following basic interventions with these patients: crisis intervention, psychobiological intervention, health teaching for patients and families, counseling, case management, milieu therapy, promotion of self-care activities, and psychiatric rehabilitation. pp. 590-591
How will the nurse working with a patient diagnosed with severe and persistent mental illness implement rehabilitation principles?
Identifying and reinforcing the patient's strengths Although deficits are assessed and addressed, implementation of rehabilitation is dependent on reinforcement of identified patient strengths. p. 587
A patient diagnosed with schizophrenia is being discharged from the hospital. Which interventions or goals related to planning for discharge would support the recovery model of care?
Interventions will focus on the patient'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. Attending groups, education on how to manage the patient's deficits, and medication adherence all follow the rehabilitation model, focusing on the illness. pp. 586-587
The nurse finds that a patient with severe mental illness also has substance abuse. The primary health care provider prescribes a medication for treating substance abuse. Which drug does the nurse anticipate in the patient's prescription?
Methadone Substance abuse can be seen in patients with severe mental illness. These patients are prescribed detoxification drugs such as methadone, a synthetic opioid drug. It is used to reduce opioid dependency in patients who have substance abuse. Carbamazepine is an antiepileptic drug used to treat epilepsy. Acetaminophen is prescribed to relieve pain such as headaches and backaches. Dextroamphetamine is a central nervous system stimulant prescribed to enhance alertness and wakefulness in the patient. p. 591
A patient diagnosed with serious mental illness lives in the community. The patient says to the nurse, "I want to get a job. My disability check is not enough money for me to live on." What is the nurse's best action?
Refer the patient to participate in a prevocational training group. Prevocational training, the fundamentals needed before one can be employed successfully, includes interviewing, dressing for work, and interacting professionally with co-workers. The nurse should encourage the patient's message of motivation rather than reinforcing limitations associated with the illness. Assisting the patient to prepare a resume and obtain references is premature. p. 591
An issue for severely and persistently mentally ill patients living in the community is inadequate long-term medication monitoring by community mental health workers. What is a remedy for this?
Shift follow-up from social workers to the assertive community treatment (ACT) model Adequate monitoring of medication effects by the community-based health care provider is often difficult but more achievable when the patient is being monitored by the ACT model. Discontinuing antipsychotics, developing tools to predict relapse and assess the potential for violence, and using patient empowerment techniques do not provide the needed level of monitoring. p. 591
A patient 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 the others in the group home. It's better when I just stay by myself." The nurse should consider which nursing diagnosis?
Social isolation Social isolation is aloneness experienced by the individual and perceived as imposed by others. pp. 588, 595, Table 32.1
The nurse includes the recovery model in the treatment plan of a patient with a serious mental illness. Which appropriate action does the nurse follow while caring for this patient?
The nurse focuses on the existing strengths of the patient. According to the recovery model, the nurse focuses on the strengths and abilities of the patient. The nurse should encourage the patient to realize strengths and to practice them in problem solving. It instills the hope of effective recovery and better response. Focusing on the dysfunction and disabilities of the patient can make the patient feel helpless. The nurse should emphasize the patient's future treatment outcomes rather than the present illness. The nurse should encourage the patient to become independent and self-determined by allowing the patient to make decisions. Having the staff help make decisions hinders the improvement of the patient's decision-making skills. p. 587
A patient with a serious mental illness gives an advance directive during a period of remission. What does this action indicate?
The patient directs the future management of therapy if patient's judgment is impaired. During periods of remission, the patient may give advance directives. This provides clarity about the future management of treatment needs in case the patient's judgment is impaired. The patients are always given the opportunity to participate in their own treatment plans. This scenario does not imply that the patient is adamant. The treatment plan is managed according to the health care programs, but the patient may express the wish to follow particular advice or not. The primary care provider decides what is of the best benefit to the patient's health, but the patient's wish is always respected. The health care professional does not make all the decisions about managing the therapy. p. 593
The nurse diagnoses a patient with severe mental illness as having impaired social interaction. What outcome shown by the patient indicates effective treatment?
The patient starts cooperating with others in group tasks. The patient with impaired social interaction has withdrawal and social discomfort. Following effective treatment, patients cooperate with members of the group by involving themselves in tasks such as discussion of common topics of interest. They appear relaxed and are able to cooperate well in such group tasks. Effective participation in the health care decision is an outcome for nonadherence. Expressing feelings of self-worth is an outcome for chronic low self-esteem. Sharing their feelings on spirituality is an outcome for spiritual distress, which is seen in depressed patients. p. 595, Table 32.1
Why is there a requirement for integrating mental and physical health care into a single setting?
The patient's description of a serious symptom may be misunderstood. Patients with mental illness are unable to communicate properly. This may lead to a misunderstanding by the primary care provider. He or she may not be able to understand a serious symptom. Integration of mental health care will reduce such incidents. Patients with mental illnesses are usually not violent, but they communicate in a different way that may not be understandable to the physical health care providers. Insurance coverage for the patient depends on the patient's employment condition. There are different models for the integration. Sometimes mental health centers partner with primary health care providers for the physical health care while mental health care is provided by the center. p. 587
An adult diagnosed with mental illness was brought by police to the emergency department. The adult was wandering in the community, wearing provocative clothing, yelling obscenities, and threatening to shoot the mayor. Which behavior most clearly meets criteria for involuntary hospitalization of this adult?
Threats to shoot the mayor Threatening to shoot the mayor indicates dangerousness to others, which fulfills criteria for involuntary care. Yelling obscenities, wandering in the community, and wearing provocative clothing show poor judgment, but may or may not be associated with dangerousness. p. 596
The nurse is caring for a patient with severe mental illness. What nursing interventions does the nurse follow to improve the patient's adherence to the treatment? (SATA)
-Monitor the patient for side effects of medications. -Identify resources for financial support for the patient. Patients with severe mental illness often do not adhere to treatment because of side effects and the high cost of medication. Antipsychotic medications are often costly, and a patient may require financial assistance through health insurance and other health care policies. The nurse should monitor and record the side effects of medications. This helps to revise the treatment plan and regimen of the patient to provide an effective treatment. Not considering the cultural beliefs of the patient leads to mistrust and rejection of the treatment by the patient. Making a treatment plan to achieve the goals of the patient helps to improve the patient's condition and avoid rehospitalization. The nurse should talk with the patient for a few minutes after administering the drug to ensure that the patient has swallowed the oral medications. pp. 590-591
Which intervention supports the recovery model of care for patients with serious mental illness (SMI)? (SATA)
-Provide remedial English and math courses. -Assist patients in creating long-term educational goals. -Provide patients with choices regarding their employment needs. The recovery model is characterized by emphasizing the person and the future rather than the illness and the present by focusing on strengths and abilities rather than dysfunction and disability. This model encourages independence and self-determination and focuses on achieving goals of the patient's choosing (not the staff's) to facilitate productive and meaningful lives for those with SMI. The concept of rehabilitation focuses on managing patients' deficits and helping them learn to live with their illnesses. Staff direct the treatment and focus on helping patients to function in their daily roles. pp. 586-587
A patient has relapses of mental illness several times and is known to be nonadherent to treatment. What interventions can make the patient compliant to medication? (SATA)
-Side effects are actively managed to minimize or avoid distress. -Simple treatment regimens, understandable to the patient, are put in place. -Effective and well-tolerated medications, acceptable to the patient, are prescribed. The side effects of medications should be managed actively so that the patient does not feel distressed from taking them. A simple treatment regimen should be in place so that it is not complicated for the patient to follow regularly. The nurse should discuss with the patient about effective, well-tolerated medicines he or she should be prescribed. Long-acting medications should be used so that the patient does not have to take them as frequently. The nurse should provide culturally sensitive care; otherwise patients may refuse to accept a process of treatment that conflicts with their culture beliefs and practices. p. 590, Box 32.2
Serious mental illness (SMI) affects how many people in the United States?
4% of the population SMI affects 4% of the United States population. The other options are incorrect percentages. p. 585, Figure 32.1
A nurse is caring for a patient diagnosed with bipolar disorder who was brought in by the family after not sleeping for several days. The patient states to the nurse, "There is nothing wrong with me. I don't belong here." What treatment issue is the patient experiencing?
Anosognosia The patient is experiencing anosognosia, the inability to recognize one's own illness due to the illness itself. A patient with acute mental illness may not possess the insight or awareness to think clearly enough to consciously be in denial. Nonadherence may result from the patient's inability to recognize his or her own mental illness or may result from a multitude of other factors. Treatment inadequacy is the inability of the patient to receive sufficient treatment. p. 454
A patient diagnosed with serious mental illness and who lives in the community says to the nurse, "You try to be so helpful to me but I'm not worth your energy. You should spend your time helping other patients who have a chance to get well." Which nursing diagnosis applies?
Chronic low self-esteem Self-negating verbalizations, lack of success in life events, hesitancy to try new situations, indecisive behavior, lack of eye contract, and nonassertive behavior are indicators of chronic low self-esteem. Many persons with serious mental illness have problems with self-esteem, which can contribute to depression. The patient's thought processes are intact. There is no evidence of anxiety or problems with personal identity. p. 595, Table 32.1
A male patient diagnosed with a severe mental illness and institutionalized for most of his adult life recently has been transferred to a supervised community-based residential home that houses several other adult men. The patient is resistant to going to day therapy and has begun to socially isolate if allowed. He has apparent weight loss and has become uncooperative. What is the most likely reason for these changes?
Is experiencing a decreased sense of self Before deinstitutionalization of the severely mentally ill beginning in 1975, psychiatric hospitals were the long-term residences for many people. Medical paternalism was a pervasive philosophical stance at that time. The health care approach to severely mentally ill persons was that of making all their decisions. Patients became institutionalized, that is, they could not think independently and lost the ability to problem solve. Much of a person's behavior became a combination of the disease process and the decreased sense of self that resulted from the lack of autonomy. p. 596
The nurse maintains a record of regular supplies of hot meals, clothing, transportation, and mailing addresses of patients with severe mental illness. Which community service (or program) can the nurse use to perform these functions?
Multiservice centers There are many community services and programs for the effective treatment and care of patients with severe mental illness. Multiservice centers work in collaboration with the other services listed to supply hot meals, clothing, and mailing address to the patient. Housing services are provided to patients who have committed an offense while suffering from severe mental illness. It helps the patient to maintain stability and live independently without depending on others. In partial hospital programs, the patient is given treatment similar to that provided to an inpatient of a psychiatric ward. Patients from inpatient units are referred to partial hospitalization programs after effective treatment. These programs help to stabilize the patient within the community and their surroundings. In guardianship, a person is appointed to make treatment decisions for a patient with impaired judgment. p. 591
The nurse conducting a group session provides patients the opportunity to role play in a job interview situation. Which evidence-based treatment approach is the nurse using?
Social skills training The evidence-based treatment approach used by the nurse providing an opportunity to role play in a job interview is social skills training. Social skills training focuses on teaching a wide variety of social and activities of daily living skills. Vocational rehabilitation includes providing job training skills to enhance employment and financial support for attaining employment. Cognitive enhancement therapy is focused on the principle of neuroplasticity, that healthier areas of the brain can assume neurological function for compromised areas of the brain. The supportive employment model is an approach to vocational rehabilitation that provides structure to integrate a patient into community-based employment. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 592
The nurse is performing an assessment of a patient with serious mental illness. The nurse documents that the patient has impaired verbal communication. Which appropriate symptom does the nurse find in the patient?
The patient has difficulty expressing thoughts. Patients with impaired verbal communication may have difficulty expressing thoughts. Inappropriate verbalization may hinder communication and prevent the expression of thoughts. Patients with serious mental illness are fearful and have reduced social interaction, so they rarely make eye contact. A preoccupied thought is a symptom of social isolation. Social discomfort, lack of belonging, and withdrawal are symptoms of impaired social interaction. p. 595, Table 32.1
When caring for a person with major depression, the nurse documents a nursing diagnosis of social isolation. What is the reason for the nurse's decision?
The patient is preoccupied with his or her own thoughts. The nurse makes a nursing diagnosis of social isolation when the patient is preoccupied with his or her own thoughts. The patient spends much of his or her time in deep thought and stays away from any kind of intimacy or social interaction. When the patient has difficulty expressing his or her thoughts, the nursing diagnosis is impaired verbal communication. The patient has difficulty putting words and sentences together to express thoughts. When the patient shows inappropriate interpersonal behaviors, the nursing diagnosis is impaired social interaction. Unlike in social isolation, such a person wants to interact but is unable to interact effectively with others. When the patient says he or she is no good anymore, it indicates self-negating verbalization. The nursing diagnosis in such a case is chronic low self-esteem. p. 595, Table 32.1
What is the nurse's understanding of a psychiatric advance directive?
The patient maintains control over treatment when in remission. A psychiatric advanced directive is a legal document that allows the individual whose disorder is in remission to direct how to manage treatment if judgment becomes impaired during a relapse. It allows the consumer to accept treatment and medication during a relapse and avoid the need for involuntary admission and court involvement. Guardianship involves the appointment of a person to make decisions for the consumer during times when judgment is impaired. The guardian's authority may encompass financial and/or treatment decisions. A patient has the right to refuse treatment if deemed competent and not a danger to him- or herself or others. p. 593
A nurse is caring for a patient who has been readmitted to the mental health unit due to medication noncompliance. What intervention can the nurse employ to ensure the patient is taking the medication?
Administering a long-acting form of medication When other interventions have been unsuccessful, the use of medication monitoring and long-acting forms of medication can be utilized to increase the likelihood that the needed medication will be in the patient's system. Simplifying the patient's medication regimen may be more acceptable to the patient when the patient is discharged from the unit. Checking the patient's mouth or engaging the patient in a conversation after administering the medication is of limited benefit, as the patient may still be able to hide pills. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly, and see if it completely covers the material the question asks; and (3) narrow the choices by immediately eliminating answers you know are incorrect. p. 590
Why is suicide common among patients with serious mental illness (SMI)?
Chronic grief and loss The chronic nature of mental illness and its impacts on daily life prevent patients from returning to normal lives. Patients with mental illness experience chronic grief and loss, which causes depression and suicidality. Patients with SMIs are misunderstood easily, and due to their conditions, normal people avoid them. Due to this and also the illness, they develop an indifference to life. This may or may not be associated with increased suicidal tendencies but is not a direct cause of suicidality. They suffer from comorbid conditions that require special attention from the primary health care providers. They lose confidence to go outside and interact with peers because of the social stigma attached to mental illness. p. 587
A patient with severe mental illness says to the nurse, "I haven't been successful in any job interview; I will not attend any job interviews from now on." What appropriate diagnosis should the nurse make based on the patient's response?
Chronic low self-esteem Patients with severe mental illness have chronic low self-esteem, which is characterized by a lack of success in life events such as attending a job interview or graduating from college. The patient may avoid eye contact and will be hesitant to try new situations. Impaired social interaction is characterized by inappropriate interpersonal behavior and social discomfort. Social isolation is characterized by the absence of significant support from others, behavior that is not accepted by dominant cultural groups, and feeling different from others. Caregiver role strain is characterized by lack of time to meet personal needs, anger, stress, and frustration. p. 595, Table 32.1
