Ch 31 - Serious Mental Illness
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 needs is option A.REF: Page 588-589
The mother of a client with severe, persistent schizophrenia tells the nurse, "My son has slipped so far away from me over the past few years. We really don't have a relationship anymore. I miss him." The nursing diagnosis that best describes the mother's feelings is grieving. powerlessness. caregiver role strain. ineffective coping.
grieving. The mother is mourning the loss of her son as she formerly knew him. Grief is a common experience for families with mentally ill members.REF: 586-587
The nurse working with a client diagnosed with severe and persistent mental illness will implement rehabilitation principles by focusing assessment on the client's deficits. identifying and reinforcing the client's strengths. reviewing earlier treatment plans for errors. considering the need to lower expectations periodically.
identifying and reinforcing the client's strengths. Although deficits are assessed and addressed, implementation of rehabilitation is dependent on reinforcement of identified client strengths.REF: Page 585-586
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.REF: Page 585-586
Serious mental illness (SMI) affects how many people in the United States? 10% to 15% of the population 30% of the population 1% of the population 5% to 7% of the population
5% to 7% of the population
The case manager determines that the client diagnosed with schizophrenia would profit from a structured environment and having simple responsibilities. Which community resource could provide this? Inpatient hospitalization Supportive group therapy A psychosocial rehabilitation program Partial hospitalization
A psychosocial rehabilitation program Psychosocial rehabilitation programs are designed to provide daily structure for clients to promote socialization and vocational skills.REF: Page 588-589
The nurse working with a client in the partial hospitalization program seeks advice from the psychiatric clinical nurse specialist to help a client who has auditory hallucinations. The clinical nurse specialist would most likely suggest which of the following cognitive interventions for this client? Seclusion when escalation begins Physical restraints when the client is disruptive Distracting technique Giving as-needed medication for anxiety
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.REF: Page 590-591
Psychiatric nurses use basic nursing interventions in all settings. The basic nursing interventions include all but which of the following? Health teaching Crisis intervention Case management Housing access
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 clients: crisis intervention, psychobiological intervention, health teaching for clients and families, counseling, case management, milieu therapy, promotion of self-care activities, and psychiatric rehabilitation.REF: 589-590
A community mental health nurse assesses a client and obtains the information listed below. Which assessed data have the least priority? New-onset chewing movements Resting tremors of the hands are present. Muscle stiffness and rigidity are present. Reports of dry mouth and eyes
Reports of dry mouth and eyes Dry mouth and eyes are common anticholinergic side effects of antipsychotic medication. Although annoying, they are of little medical consequence. The other observations suggest the presence of tardive dyskinesia, a side effect requiring further assessment and possible discontinuance of the antipsychotic medication.REF: Page 588
Jeremiah is being discharged from the hospital. Which interventions and/or goals related to planning for discharge would support the recovery model of care? Jeremiah will attend groups that teach how to cope with his present illness. Jeremiah's parents will receive education on how to manage the patient's deficits. Interventions will focus on medication adherence. Interventions will focus on Jeremiah's stated wish for independent living.
Interventions will focus on Jeremiah'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.Cognitive Level: Analyze (Analysis)Nursing Process: PlanningNCLEX: Safe and Effective Care EnvironmentText page: 6
Which statement best reflects how 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 too busy thinking about their symptoms to worry about others.
Many feel stigmatized and alienated. Studies have shown that many clients experience stigmatization, alienation, loss of relationships, and loss of vocational opportunities.REF: 586-587
Which 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 with SMI, 60% also abuse substances. Smoking has declined in this population at the same rate as the general public.
Of those with SMI, 60% also abuse substances. 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 serious mental illness is higher than in the general population. Smoking has not declined in this population at the same rate as for the general public.Cognitive Level: Understand (Comprehension)Nursing Process: AssessmentNCLEX: Physiological IntegrityText page: 9
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.Cognitive Level: Apply (Application)Nursing Process: DiagnosisNCLEX: Psychosocial IntegrityText page: 4
The term dual diagnosis refers to having a severe mental illness and a substance abuse problem. medication noncompliance. a personality disorder. HIV infection.
a substance abuse problem
Jeremiah is a 20-year-old Amish patient who was diagnosed with paranoid schizophrenia 1 year ago and who lives with his parents. He is admitted to the psychiatric unit with psychosis because of nonadherence to his medication regime. When you are attempting to educate him about his diagnosis and the need for medication, Jeremiah persistently mumbles, "I don't have mental illness. No, I am not sick." You recognize that Jeremiah may be exhibiting: 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. Cognitive Level: Apply (Application) Nursing Process: Diagnosis NCLEX: Psychosocial Integrity Text page: 13
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 will change the client's nursing care plan to 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 and make necessary changes to his plan of care.
arrange for a dose of the client's medication immediately and make necessary changes to his plan of care. The role of the case manager is to coordinate access to psychiatric treatment, housing, rehabilitation or work setting, socialization, and medical care.REF: 589-590
A nurse preparing an education plan includes a component designed to help the client access and use community supports. The nurse can consider the educational component successful when the client identifies stressful events. remains medication compliant. can discuss early signs of relapse. arranges to attend a money management workshop.
arranges to attend a money management workshop. Although each outcome is desirable, only option D relates directly to accessing and using community supports.REF: Page 588-589
One of the roles of a case manager working with severely and persistently mentally ill clients who are homeless is to administer medication. coordinate needed services and provide outreach. ensure that the clients are not rehospitalized. teach the clients to function independently.
coordinate needed services and provide outreach. Community mental health services are designed to provide outreach and case management for severely mentally ill persons who are homeless. Client participation in the program is voluntary. Community outreach programs send professional and nonprofessional workers into streets, parks, temporary shelters, bus stations, soup kitchens, and anywhere else the mentally ill may be found. A team approach is used to gain access to clients and connect them with the various services available to meet their needs. The role of the outreach worker is to be an advocate in all areas of client need and to foster client self-care.REF: 590-591
The goal of a nurse working in psychiatric rehabilitation would be to help clients in the community achieve complete mental health. continue to live comfortably in a psychiatric treatment facility. cope more effectively with their symptoms. learn to live with dependency and be content with fewer opportunities.
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.REF: Page 585-586
A client diagnosed with a severe mental illness and institutionalized for most of his adult life has recently been transferred to a supervised community-based residential home that houses several other adult men. The client is resistant to going to day therapy and has begun to socially isolate if allowed. He has an apparent weight loss and has become uncooperative. The most likely reason for these changes is that he has begun exhibiting lack of desire to attend the day program. is lazy now that he is not on a regular schedule. is experiencing a decreased sense of self. has begun showing signs of independence.
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. Clients 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.REF: Page 585
An issue for severely and persistently mentally ill clients living in the community is inadequate long-term medication monitoring by community mental health workers. A remedy for this is to discontinue antipsychotics that cause untoward side effects. develop tools to predict relapse and assess the potential for violence. shift follow-up from social workers to the ACT model. use client empowerment techniques to increase client autonomy.
shift follow-up from social workers to the ACT model. Adequate monitoring of medication effects by the community-based health care provider is often difficult but more achievable when the client is being monitored by the assertive community treatment (ACT) model.REF: 589
An understanding of the burden borne by a family with a mentally ill family member is best demonstrated by the nurse who shows respect and support for the client and family. respects confidentiality for the client and family. is highly intellectual and can problem-solve readily. is able to provide crisis intervention.
shows respect and support for the client and family. The need to provide multiple types of support for families cannot be overemphasized. Dealing with a family member who has a mental illness is a major crisis for the family that pervades all aspects of family life. Professionals must recognize the problems facing the family and identify the strengths from which the family can plan support. Often the family becomes the most accurate source of information for use in diagnosis and client management. Cooperative planning and respect for family members are essential in providing individualized client care, as well as support for the caregivers.REF: 593-594
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 the nursing diagnosis of 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.REF: Page 587
Severely mentally ill clients often express a strong desire to be employed. According to the evidence-based research, the most effective model of employment for these clients is vocational rehabilitation. productive employment. a placement program of rehabilitation. supported employment.
supported employment. In the past, vocational rehabilitation programs required extensive evaluation procedures and training before attempting job placement. However, these programs were unsuccessful at helping severely mentally ill clients to maintain jobs. Research efforts have identified a more productive model called
A popular misconception about the seriously mentally ill is that they are violent and aggressive. generally given the care they require. likely to experience periods of remission. usually abandoned by their families.
violent and aggressive. The seriously mentally are much more likely to be victims of violence than perpetrators of aggressive behavior.REF: 586-587
