Chapter 32: Serious Mental Illness

A consumer at a rehabilitative psychosocial program says to thenurse, ―People are not cleaning up behind themselves in thebathrooms. thebuilding is dirty and cluttered.‖ How should thenurse respond? A. Encourage theconsumer to discuss it at a meeting with everyone. B. Hire a professional cleaning service to clean therestrooms. C. Address thecomplaint at thenext staff meeting. D. Tell theconsumer, ―That's not my problem.‖

ANS: A Consumer-run programs range from informal ―clubhouses,‖ which offer socialization and recreation, to competitive businesses, such as snack bars or janitorial services, which provide needed services and consumer employment while encouraging independence and building vocational skills. Consumers engage in problem solving under theleadership of staff. See related audience response question.

A nurse's neighbor says, ―My sister has been diagnosed with bipolar disorder but will not take her medication. I have tried to help her for over 20 years, but it seems like everything I do fails. Do you have any suggestions?‖ What is thenurse's best response? A. National Alliance on Mental Illness (NAMI) offers a family education series that you might find helpful.‖ B. Since your sister is noncompliant, perhaps it's time for her to be changed to injectable medication.‖ c. ―You have done all you can. Now it's time to put yourself first and move on with your life.‖ d. ―You cannot help her. Would it be better for you to discontinue your relationship?‖

ANS: A NAMI offers a family education series that assists with thestress caregivers and other family members often experience. thenurse should not give advice about injectable medication or encourage thefamily member to give up on theclient.

A client diagnosed with a serious mental illness (SMI) lives independently and attends a psychosocial rehabilitation program. theclient presents at theemergency department seeking hospitalization. theclient has no acute symptoms but says, ―I have no money to pay my rent or refill my prescription.‖ What is thenurse's best action? A. Involve theclient's case manager to provide crisis intervention. B. Send theclient to a homeless shelter until housing can be arranged. C. Arrange for a short in-client admission and begin discharge planning. D. Explain that one must have active psychiatric symptoms to be admitted.

ANS: A Impaired stress tolerance and problem-solving abilities can cause persons with SMI to experience relatively minor stressors as crises. This client has run out of money, and this has overwhelmed her ability to cope, resulting in a crisis for which crisis intervention would be an appropriate response. Inpatient care is not clinically indicated nor is theclient homeless (although she may fear she is). Telling theclient that she is not symptomatic enough to be admitted may prompt malingering.

An adult client tells thecase manager, ―I don't have bipolar disorder anymore, so I don't need medicine. After I was in thehospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends.‖ Where should thenurse refer theclient? (Select all that apply.) A. Psychoeducational classes B. Vocational rehabilitation C. Social skills training D. A homeless shelter E. Crisis intervention

ANS: A, B, C The client does not understand theillness and need for adherence to themedication regimen. Psychoeducation for theclient (and family) can address this lack of knowledge. theclient, who considers himself friendless, could also profit from social skills training to improve thequality of interpersonal relationships. Many clients with SMI have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking theskill down into smaller verbal and nonverbal components. Work gives meaning and purpose to life, so vocational rehabilitation can assist with this aspect of care. thenurse case manager will function in therole of crisis stabilizer, so no related referral is needed. theclient presently has a home and does not require a homeless shelter.

Which statements most clearly indicate thespeaker views mental illness with stigma? (Select all that apply.) A. We are all a little bit crazy.‖ B. If people with mental illness would go to church, their problems would be solved.‖ C. Many mental illnesses are genetically transmitted. It's no one's fault that theillness occurs.‖ D. Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people.‖ E. People with mental illness are lazy. They get government disability checks instead of working.‖

ANS: A, B, E Stigma is represented by judgmental remarks that discount thereality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame. See related audience response question.

A client diagnosed with serious mental illness (SMI) was living successfully in a group home but wanted an apartment. theprospective landlord said, ―People like you have trouble getting along and paying their rent.‖ theclient and nurse meet for a problem-solving session. Which options should thenurse endorse? (Select all that apply.) A. Coach theclient in ways to control symptoms effectively. B. Seek out landlords less affected by thestigma associated with mental illness. C. Threaten thelandlord with legal action because of thediscriminatory actions. D. Encourage theclient to remain in thegroup home until theillness is less obvious. E. Suggest that theclient list a false current address in therental application. F. Have thecase manager meet with thelandlord to provide education about mental illness.

ANS: A, B, F Managing symptoms so that they are less obvious or socially disruptive can reduce negative reactions and reduce rejection due to stigma. Seeking a more receptive landlord might be themost expeditious route to housing for this client. Educating thelandlord to reduce stigma mightmake him more receptive and give thecase manager an opportunity to address some of his concerns (e.g., thecase manager could arrange a payee to assure that therent is paid each month). However, threatening a lawsuit would increase thelandlord's defensiveness and would likely be a long and expensive undertaking. Delaying theclient's efforts to become more independent is not clinically necessary according to thedata noted here; theproblem is the landlord's bias and response, not theclient's illness. It would be unethical to encourage falsification and poor role modeling to do so; further, if falsification is discovered, it could permit thelandlord to refuse or cancel her lease. See related audience response question.

The nurse manager of a mental health center wants to improve medication adherence among theseriously mentally ill persons treated there. Which interventions are likely to help achieve this goal? (Select all that apply.) A. Maintain stable and consistent staff. B. Increase thelength of medication education groups. C. Stress that without treatment, illnesses will worsen. D. Prescribe drugs in smaller but more frequent dosages. E. Make it easier to access prescribers and pay for drugs. F. Require adherence in order to participate in programming.

ANS: A, E Trust in one's providers is a key factor in treatment adherence, and mentally ill persons can sometimes take a very long time to develop such trust; therefore, interventions which stabilize staffing allow clients to have more time with staff to develop these bonds. Ready access to prescribers allows medicine-related concerns to be addressed quickly, reducing obstacles to adherence such as side effects or ineffective dosages. Medication costs can be obstacles to adherence as well. Many SMI clients have anosognosia and do not adhere to treatment because they believe they are not ill, so telling them nonadherence will worsen an illness they do not believe they have is unlikely to be helpful. Increasing medication education is helpful only when thecause of nonadherence is a knowledge deficit. Other issues that reduce adherence, particularly anosognosia and side effects, are seldom helped by longer medication education.Requiring medication adherence to participate in other programs is coercive and unethical. Smaller, more frequent doses do not reduce side effects and make theregimen more difficult for theclient to remember.

A person diagnosed with a serious mental illness (SMI) enters a shelter for thehomeless. Which intervention should be thenurse's initial priority? A. Find supported employment. B. Develop a trusting relationship. C. Administer prescribed medication. D. Teach appropriate health care practices.

ANS: B Basic psychosocial needs do not change because a person is homeless. thefirst step in caring for health care needs is establishing rapport. Once a trusting relationship is established, thenurse pursues other interventions.

A homeless client diagnosed with a serious mental illness (SMI) became suspicious and delusional. Depot antipsychotic medication is prescribed and housing is obtained in a local shelter. One month later, which statement by theclient indicates significant improvement? A. They will not let me drink. They have many rules in theshelter.‖ B. I feel comfortable here. Nobody bothers me.‖ C. Those shots make my arm very sore.‖ D. Those people watch me a lot.‖

ANS: B Evaluation of a client's progress is made based on client satisfaction with thenew health status and thehealth care team's estimation of improvement. For a formerly delusional client to admit to feeling comfortable and free of being ―bothered‖ by others denotes improvement in the client's condition. theother options suggest that theclient is in danger of relapse.

After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to thecommunity. This client now requires continual direction to accomplish activities of daily livingand expects others to provide meals and do laundry. thenurse assesses this behavior as theprobable result of what factor? A. side effects of antipsychotic medications. B. dependency caused by institutionalization. C. cognitive deterioration from schizophrenia. D. stress associated with acclimation to thecommunity.

ANS: B Institutions tend to impede independent functioning; for example, daily activities are planned and directed by staff; others provide meals and only at set times. Over time, clients become dependent on theinstitution to meet their needs and adapt to being cared for rather than caring for themselves. When these clients return to thecommunity, many continue to demonstrate passive behaviors despite efforts to promote. Cognitive dysfunction and antipsychotic side effects can make planning and carrying out activities more difficult, but thequestion is more suggestive of adjustment to institutional care and difficulty readjusting to independence instead.

Many persons brought before a criminal court have mental illness, have committed minor offenses, and are non-medication adherent. thejudge consults thenurse at thelocal community mental health center for guidance about how to respond when handling such cases. Which advice from thenurse would be most appropriate? A. Sometimes a little time in jail makes a person rethink what they've been doing and puts them back on theright track.‖ B. Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses.‖ C. Arresting these people helps them in thelong run. Sometimes we cannot hospitalize them, but in jail they will get their medication.‖ D. Research suggests that special mental health courts do not make much difference so far, but outpatient commitment does seem to help.‖

ANS: B Research supports theuse of special mental health courts that can sentence mentally ill persons to treatment instead of jail. Jail exposes vulnerable mentally ill persons to criminals, victimization, and high levels of stimulation and stress. Incarceration can also interrupt eligibility for benefits or lead to theloss of housing and often provides lower-quality mental health treatment in other settings. Recidivism rates for both mentally ill and non-mentally ill offenders are relatively high, so it does not appear that incarceration necessarily leads people to behave more appropriately. In addition, a criminal record can leave them more desperate and with fewer options after release. Research indicates that outpatient commitment is less effective at improving themental health of mentally ill persons than was expected.

For clients diagnosed with serious mental illness (SMI), what is themajor advantage of case management? A. The case manager can modify traditional psychotherapy. B. With one coordinator of services, resources can be more efficiently used. C. The case manager can focus on social skills training and esteem building. D. Case managers bring groups of clients together to discuss common problems.

ANS: B The case manager coordinates thecare and multiple referrals that so often confuse theseriously mentally ill client and theclient's family. Case management promotes efficient use of services. theother options are lesser advantages or are irrelevant.

The sibling of a client who was diagnosed with a serious mental illness (SMI) asks why a case manager has been assigned. Which nurse's reply best cites themajor advantage of theuse of case management? A. The case manager can modify traditional psychotherapy for homeless clients so that it is more flexible.‖ B. Case managers coordinate services and help with accessing them, making sure the client's needs are met.‖ c. ―The case manager can focus on social skills training and esteem building in thereal world where theclient lives.‖ d. ―Having a case manager has been shown to reduce hospitalizations, which prevents disruption and saves money.‖

ANS: B The case manager helps theclient gain entrance into thesystem of care, can coordinate multiple referrals that so often confuse theseriously mentally ill person and his family, and can help overcome obstacles to access and treatment participation. Case managers do not usually possess thecredentials needed to provide psychotherapy or function as therapists. Case management promotes efficient use of services in general, but only ACT programming has been shown to reduce hospitalization (which thesibling might see as a disadvantage). Case managers operate in thecommunity, but this is not theprimary advantage of their services.

A client diagnosed with a serious mental illness (SMI) died suddenly at age 52. theclient lived in thecommunity for 5 years without relapse and held supported employment thepast 6 months. thedistressed family asks, ―How could this happen?‖ Which response by thenurse accurately reflects research and addresses thefamily's question? A. A certain number of people die young from undetected diseases, and it's just one of those sad things that sometimes happen.‖ B. Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, smoke more, or are overweight.‖ C. We will have to wait for theautopsy to know what happened. There were some medical problems, but we were not expecting death.‖ D. We are all surprised. theclient had been doing so well and saw thenurse every other week.‖

ANS: B The family is in distress. Because they do not understand his death, they are less able to accept it and seek specific information to help them understand what happened. Persons with SMI die an average of 25 years prematurely. Contributing factors include failing to provide for their own health needs (e.g., forgetting to take medicine), inability to access or pay for care, higher rates of smoking, poor diet, criminal victimization, and stigma. themost accurate answer indicates that seriously mentally ill people are at much higher risk of premature death for a variety of reasons. Staff would not have been surprised that theclient died prematurely, and they would not attribute his death to random, undetected medical problems. Although thecause of death will not be reliably established until theautopsy, this response fails to address thefamily's need for information.

A client living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, theclient was prohibited from returning to theapartment. thelandlord said, ―You cause too much trouble.‖ What problem is theclient experiencing? a. Grief b. Stigma c. Homelessness d. Nonadherence

ANS: B The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a client problem. Data do not suggest that theclient is actually homeless. See relationship to audience response question.

How is serious mental illness (SMI) characterized? A. any mental illness of more than 2 weeks' duration. B. a major long-term mental illness marked by significant functional impairments. C. a mental illness accompanied by physical impairment and severe social problems. D. a major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities.

ANS: B ―Serious mental illness‖ has replaced theterm ―chronic mental illness.‖ Global impairments in function are evident, particularly social. Physical impairments may be present. SMI can be treated, but remissions and exacerbations are part of thecourse of theillness.

A person diagnosed with serious mental illness (SMI) has frequent relapses, usually precipitated by situational stressors such as running out of money or theabsence of key staff at themental health center. Which interventions would thenurse suggest to reduce therisk of stressors to cause relapse? (Select all that apply.) A. Discourage potentially stressful activities such as groups or volunteer work. B. Develop written plans that will help theclient remember what to do in a crisis. C. Help theclient identify and anticipate events that are likely to be overwhelming. D. Encourage health-promoting activities such as exercise and getting adequate rest. E. Accompany theclient to a National Alliance on Mental Illness (NAMI) support group.

ANS: B, C, D, E Basic interventions for coping with crises involve anticipating crises where possible and then developing a plan with specific actions to take when faced with an overwhelming stressor. Written plans are helpful; it can be difficult for anyone, especially a person with cognitive or memory impairments, to develop or remember steps to take when under overwhelming stress. Health-promoting activities enhance a person's ability to cope with stress. As thename suggests,support groups help a person develop a support system, and they provide practical guidance from peers who learned from experience how to deal with issues theclient may be facing. Groups and volunteer work may involve a measure of stress but also provide benefits that help persons cope and should not be discouraged unless they are being done to excess.

Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with serious mental illness (SMI)? A. Clubhouse model B. Cognitive-behavioral therapy (CBT) c. Assertive community treatment (ACT) d. Cognitive enhancement therapy (CET)

ANS: C ACT involves consumers working with a multidisciplinary team that provides a comprehensive array of services. At least one member of theteam is available 24 hours a day for crisis needs, and theemphasis is on treating theclient within his own environment.

The nurse wants to enroll a client with poor social skills in a training program for clients diagnosed with schizophrenia. Which description accurately describes social skills training? A, Clients learn to improve their attention and concentration. B. Group leaders provide support without challenging clients to change. C. Complex interpersonal skills are taught by breaking them into simpler behaviors. D. Clients learn social skills by practicing them in a supported employment setting.

ANS: C In social skills training, complex interpersonal skills are taught by breaking them down into component behaviors that are covered in a stepwise fashion. Social skills training is not based in employment settings, although such skills can be addressed as part of supported employment services. theother distracters are less relevant to social skills training.

Which nursing diagnosis is likely to apply to an individual diagnosed with a serious mental illness (SMI) who is homeless? A. Insomnia B. Substance abuse C. Chronic low self-esteem D. Impaired environmental interpretation syndrome

ANS: C Many individuals with SMI do not live with their families and become homeless. Life on thestreet or in a shelter has a negative influence on theindividual's self-esteem, making this nursingdiagnosis one that should be considered. Substance abuse is not an approved North American Nursing Diagnosis Association (NANDA)-International diagnosis. Insomnia may be noted in some clients but is not a universal problem. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not seen in a majority of thehomeless.

An adult diagnosed with a serious mental illness (SMI) says, ―I do not need help with money management. I have excellent ideas about investments.‖ This client usually does not have money to buy groceries by themiddle of themonth. thenurse assesses theclient as demonstrating what defense mechanism? a. rationalization. b. identification. c. anosognosia. d. projection.

ANS: C The client scenario describes anosognosia, theinability to recognize one's deficits due to one's illness. theclient is not projecting an undesirable thought or emotion from himself onto others. He is not justifying his behavior via rationalization and is not identifying with another.

A person diagnosed with a serious mental illness (SMI) living in thecommunity was punched, pushed to theground, and robbed of $7 during theday on a public street. Which statements about violence and SMI in general are accurate? (Select all that apply.) A. Persons with SMI are more likely to be violent. B. SMI persons are more likely to commit crimes than to be thevictims of crime. C. Impaired judgment and social skills can provoke hostile or assaultive behavior. D. Lower incomes force SMI persons to live in high-crime areas, increasing risk. E. SMI persons experience higher rates of sexual assault and victimization than others. F. Criminals may believe SMI persons are less likely to resist or testify against them.

ANS: C, D, E, F Mentally ill persons are more likely to be victims of crime than perpetrators of criminal acts. They are often victims of criminal behavior, including sexual crimes, at a higher rate than others. When a mentally ill person commits a crime, it is usually nonviolent. Mental illnesses interfere with employment and are associated with poverty, limiting SMI persons to living in inexpensive areas that also tend to be higher-crime areas. SMI persons may inadvertently provoke others because of poor judgment or socially inappropriate behavior, or they may be victimized because they are perceived as passive, less likely to resist, and less likely to be believed as witnesses. See related audience response question.

A homeless individual diagnosed with serious mental illness (SMI) and a history of persistent treatment nonadherence plans to begin attending theday program at a community mental health center. Which intervention should be theteam's initial focus? A. Teach appropriate health maintenance and prevention practices. B. Educate theclient about theimportance of treatment adherence. C. Help theclient obtain employment in a local sheltered workshop. D. Interact regularly and supportively without trying to change theclient.

ANS: D Given thehistory of treatment nonadherence and thedifficulty achieving other goals until psychiatrically stable and adherent, getting theclient to accept and adhere to treatment is thefundamental goal to address. theintervention most likely to help meet that goal at this stage is developing a trusting relationship with theclient. Interacting regularly, supportively, and without demands is likely to build thenecessary trust and relationships that will be thefoundation for all other interventions later on. No data here suggest theclient is in crisis, so it is possible to proceed slowly and build this foundation of trust.

A hospitalized client diagnosed with schizophrenia has a history of multiple relapses. theclient usually responds quickly to antipsychotic medication but soon discontinues themedication. Discharge plans include follow-up at themental health center, group home placement, and a psychosocial day program. Which strategy should apply first as theclient transitions from hospital to community? A. Administer a second-generation antipsychotic to help negative symptoms. B. Use a quick-dissolving medication formulation to reduce ―cheeking.‖ C. Prescribe a long-acting intramuscular antipsychotic medication. D. Involve theclient in decisions about which medication is best.

ANS: D Persons with schizophrenia are at high risk for treatment nonadherence, so thestrategy needs primarily to address that risk. Of theoptions here, involving theclient in thedecision is best because it will build trust and help establish a therapeutic alliance with care providers, an essential foundation to adherence. Intramuscular depot medications can be helpful for promoting adherence if other alternatives have been unsuccessful, but IM medications are painful and may jeopardize theclient's acceptance. All of theother strategies also apply but are secondary to trust and bonding with providers.

The parent of a seriously mentally ill adult asks thenurse, ―Why are you making a referral to a vocational rehabilitation program? My child won't ever be able to hold a job.‖ Which is thenurse's best reply? A. We make this referral to continue eligibility for federal funding.‖ B. Are you concerned that we're trying to make your child too independent?‖ C. If you think theprogram would be detrimental, we can postpone it for a time.‖ D. Most clients are capable of employment at some level, competitive or supported.‖

ANS: D Studies have shown that most clients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression.

An outpatient diagnosed with schizophrenia attends programming at a community mental health center. theclient says, ―I threw away thepills because they keep me from hearing God.‖ Which response by thenurse would most likely to benefit this client? A. You need your medicine. Your schizophrenia will get worse without it.‖ B. Do you want to be hospitalized again? You must take your medication.‖ C. I would like you to come to themedication education group every Thursday.‖ D. I noticed that when you take themedicine, you are able to keep thejob you wanted.‖

ANS: D The client appears not to understand that he has an illness. He has stopped his medication because it interferes with a symptom that he finds desirable (auditory hallucinations—the voice of God). Connecting medication adherence to one of theclient's goals (the job) can serve to motivate theclient to take themedication and override concerns about losing thehallucinations. Exhorting a client to take medication because it is needed to control his illness is unlikely to be successful; he does not believe he has an illness. Medication psychoeducation would be appropriate if thecause of nonadherence was a knowledge deficit.

A client diagnosed with schizophrenia tells thecommunity mental health nurse, ―I threw away my pills because they interfere with God's voice.‖ How should thenurse identify theetiology of theclient's ineffective management of themedication regime? A. inadequate discharge planning. B. poor therapeutic alliance with clinicians. C. dislike of antipsychotic medication side effects. D. impaired reasoning secondary to the schizophrenia.

ANS: D The client's ineffective management of themedication regime is most closely related to impaired reasoning associated with thethought disturbances of schizophrenia. theclient believes in beingan exalted personage who hears God's voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest any of theother factors often related to medication nonadherence.

An outpatient diagnosed with schizophrenia tells thenurse, ―I am here to save theworld. I threw away thepills because they make God go away.‖ What does thenurse suspect is theclient's reason for medication nonadherence? A. poor alliance with clinicians. B. inadequate discharge planning. C. dislike of medication side effects. D. thought disturbances associated with the illness.

ANS: D The client's nonadherence is most closely related to thought disturbances associated with theillness. theclient believes he is an exalted personage who hears God's voice rather than an individual with a serious mental disorder who needs medication to control his symptoms. While thedistracters may play a part in theclient's nonadherence, thecorrect response is most likely.

A family discusses theimpact of a seriously mental ill member. Insurance partially covers treatment expenses, but thefamily spends much of their savings for care. theclient's sibling says, ―My parents have no time for me.‖ theparents are concerned that when they are older, there will be no one to care for theclient. Which response by thenurse would be most helpful? A. Acknowledge their concerns and consult with thetreatment team about ways to bring theclient's symptoms under better control. B. Give them names of financial advisors that could help them save or borrow sufficient funds to leave a trust fund to care for their loved one. C. Refer them to crisis intervention services to learn ways to manage caregiver stress and provide titles of some helpful books for families. D. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help theclient become more independent.

ANS: D The family has raised a number of concerns, but themajor issues appear to be theeffects caregiving has had on thefamily and their concerns about theclient's future. NAMI offers support, education, resources, and access to other families who have experience with theissues now facing this family. NAMI can help address caregiver burden and planning for thefuture needs of SMI persons. Improving theclient's symptom control and general functioning can help reduce caregiver burden but would likely be a slow process, whereas NAMI involvement could benefit them on a number of fronts, possibly in a shorter time period. thefamily will need more than financial planning; their issues go beyond financial. thefamily is distressed but not in crisis. Crisis intervention is not an appropriate resource for thelonger-term issues and needs affecting this family.