Mental Health Chapter 32: Serious Mental Illness (Week 13)

20. A homeless patient diagnosed with a SMI became suspicious and delusional. Depot antipsychotic medication began and housing was obtained in a local shelter. One month later, which statement by the patient indicates significant improvement? a. "They will not let me drink. They have many rules in the shelter." 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 patient's progress is made based on patient satisfaction with the new health status and the health care team's estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being "bothered" by others denotes improvement in the patient's condition. The other options suggest that the patient is in danger of relapse.

19. A person diagnosed with a SMI enters a shelter for the homeless. Which intervention should be the nurse'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. The first step in caring for health care needs is establishing rapport. Once a trusting relationship is established, the nurse pursues other interventions.

15. SMI is characterized as 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 the term "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 the course of the illness.

23. A consumer at a rehabilitative psychosocial program says to the nurse, "People are not cleaning up behind themselves in the bathrooms. The building is dirty and cluttered." How should the nurse respond? a. Encourage the consumer to discuss it at a meeting with everyone. b. Hire a professional cleaning service to clean the restrooms. c. Address the complaint at the next staff meeting. d. Tell the consumer, "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 the leadership of staff. See related audience response question.

10. A patient diagnosed with a SMI lives independently and attends a psychosocial rehabilitation program. The patient presents at the emergency department seeking hospitalization. The patient has no acute symptoms but says, "I have no money to pay my rent or refill my prescription." Select the nurse's best action. a. Involve the patient's case manager to provide crisis intervention. b. Send the patient to a homeless shelter until housing can be arranged. c. Arrange for a short in-patient 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 patient 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 the patient homeless (although she may fear she is). Telling the patient that she is not symptomatic enough to be admitted may prompt malingering.

5. An adult patient tells the case manager, "I don't have bipolar disorder anymore, so I don't need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends." Where should the nurse refer the patient? (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 patient does not understand the illness and need for adherence to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with SMI have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking the skill down into smaller verbal and nonverbal components. Work gives meaning and purpose to life, so vocational rehabilitation can assist with this aspect of care. The nurse case manager will function in the role of crisis stabilizer, so no related referral is needed. The patient presently has a home and does not require a homeless shelter.

6. Which statements most clearly indicate the speaker 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 the illness 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 the reality 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.

4. A patient diagnosed with SMI was living successfully in a group home but wanted an apartment. The prospective landlord said, "People like you have trouble getting along and paying their rent." The patient and nurse meet for a problem-solving session. Which options should the nurse endorse? (Select all that apply.) a. Coach the patient in ways to control symptoms effectively. b. Seek out landlords less affected by the stigma associated with mental illness. c. Threaten the landlord with legal action because of the discriminatory actions. d. Encourage the patient to remain in the group home until the illness is less obvious. e. Suggest that the patient list a false current address in the rental application. f. Have the case manager meet with the landlord 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 the most expeditious route to housing for this patient. Educating the landlord to reduce stigma might make him more receptive and give the case manager an opportunity to address some of his concerns (e.g., the case manager could arrange a payee to assure that the rent is paid each month). However, threatening a lawsuit would increase the landlord's defensiveness and would likely be a long and expensive undertaking. Delaying the patient's efforts to become more independent is not clinically necessary according to the data noted here; the problem is the landlord's bias and response, not the patient's illness. It would be unethical to encourage falsification and poor role modeling to do so; further, if falsification is discovered, it could permit the landlord to refuse or cancel her lease. See related audience response question.

2. The nurse manager of a mental health center wants to improve medication adherence among the seriously 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 the length 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 patients 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 patients 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 the cause 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 the regimen more difficult for the patient to remember.

1. After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This patient now requires continual direction to accomplish activities of daily living and expects others to provide meals and do laundry. The nurse assesses this behavior as the probable result of a. side effects of antipsychotic medications. b. dependency caused by institutionalization. c. cognitive deterioration from schizophrenia. d. stress associated with acclimation to the community.

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, patients become dependent on the institution to meet their needs and adapt to being cared for rather than caring for themselves. When these patients return to the community, 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 the question is more suggestive of adjustment to institutional care and difficulty readjusting to independence instead.

13. Many persons brought before a criminal court have mental illness, have committed minor offenses, and are off medications. The judge consults the nurse at the local community mental health center for guidance about how to respond when handling such cases. Which advice from the nurse 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 the right 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 the long run. Sometimes we cannot hospitalize them, but in jail they will get their medication." d. "Research suggests that speciaNlUmReSnINtaGl ThBea.CltOhMcourts do not make much difference so far, but outpatient commitment does seem to help."

ANS: B Research supports the use 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 the loss 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 the mental health of mentally ill persons than was expected.{ 14. 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?" Select the nurse's best response. a. "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 the stress caregivers and other family members often experience. The nurse should not give advice about injectable medication or encourage the family member to give up on the patient.

21. For patients diagnosed with SMI, what is the major 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 patients together to discuss common problems.

ANS: B The case manager coordinates the care and multiple referrals that so often confuse the seriously mentally ill patient and the patient's family. Case management promotes efficient use of services. The other options are lesser advantages or are irrelevant.

8. The sibling of a patient who was diagnosed with a SMI asks why a case manager has been assigned. The nurse's reply should cite the major advantage of the use of case management as: a. "The case manager can modify traditional psychotherapy for homeless patients so that it is more flexible." b. "Case managers coordinate services and help with accessing them, making sure the patient's needs are met." c. "The case manager can focus on social skills training and esteem building in the real world where the patient lives." d. "Having a case manager has been shown to reduce hospitalizations, which prevents disruption and saves money."

ANS: B The case manager helps the patient gain entrance into the system of care, can coordinate multiple referrals that so often confuse the seriously mentally ill person and his family, and can help overcome obstacles to access and treatment participation. Case managers do not usually possess the credentials 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 the sibling might see as a disadvantage). Case managers operate in the community, but this is not the primary advantage of their services.

12. A patient diagnosed with a SMI died suddenly at age 52. The patient lived in the community for 5 years without relapse and held supported employment the past 6 months. The distressed family asks, "How could this happen?" Which response by the nurse accurately reflects research and addresses the family'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 the autopsy to know what happened. There were some medical problems, but we were not expecting death." d. "We are all surprised. The patient had been doing so well and saw the nurse 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. The most 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 the patient died prematurely, and they would not attribute his death to random, undetected medical problems. Although the cause of death will not be reliably established until the autopsy, this response fails to address the family's need for information.

18. A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, "You cause too much trouble." What problem is the patient 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 daNmUaRgSeItNoGrTeBp.uCtOatMion, shame, and ridicule society places on mental illness. Data are not present to identify grief as a patient problem. Data do not suggest that the patient is actually homeless. See relationship to audience response question.

3. A person diagnosed with SMI has frequent relapses, usually precipitated by situational stressors such as running out of money or the absence of key staff at the mental health center. Which interventions would the nurse suggest to reduce the risk 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 the patient remember what to do in a crisis. c. Help the patient identify and anticipate events that are likely to be overwhelming. d. Encourage health-promoting activities such as exercise and getting adequate rest. e. Accompany the patient to a 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 the name 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 the patient 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.

3. Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with 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 the team is available 24 hours a day for crisis needs, and the emphasis is on treating the patient within his own environment.

11. The nurse wants to enroll a patient with poor social skills in a training program for patients diagnosed with schizophrenia. Which description accurately describes social skills training? a. Patients learn to improve their attention and concentration. b. Group leaders provide support without challenging patients to change. c. Complex interpersonal skills are taught by breaking them into simpler behaviors. d. Patients 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. The other distracters are less relevant to social skills training.

16. Which nursing diagnosis is likely to apply to an individual diagnosed with a 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 the street or in a shelter has a negative influence on the individual's self-esteem, making this nursing diagnosis 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 patients but is not a universal problem. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not seen in a majority of the homeless.

2. 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 patient usually does not have money to buy groceries by the middle of the month. The nurse assesses the patient as demonstrating a. rationalization. b. identification. c. anosognosia. d. projection.

ANS: C The patient scenario describes anosognosia, the inability to recognize one's deficits due to one's illness. The patient 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.

1. A person diagnosed with a SMI living in the community was punched, pushed to the ground, and robbed of $7 during the day 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 the victims of crime. c. Impaired judgment and socialNskUiRllSsINcaGnTpBr.CoOvoMke 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.

6. A homeless individual diagnosed with SMI and a history of persistent treatment nonadherence plans to begin attending the day program at a community mental health center. Which intervention should be the team's initial focus? a. Teach appropriate health maintenance and prevention practices. b. Educate the patient about the importance of treatment adherence. c. Help the patient obtain employment in a local sheltered workshop. d. Interact regularly and supportively without trying to change the patient.

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

7. A hospitalized patient diagnosed with schizophrenia has a history of multiple relapses. The patient usually responds quickly to antipsychotic medication but soon discontinues the medication. Discharge plans include follow-up at the mental health center, group home placement, and a psychosocial day program. Which strategy should apply first as the patient 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 the patient in decisions about which medication is best.

ANS: D Persons with schizophrenia are at high risk for treatment nonadherence, so the strategy needs primarily to address that risk. Of the options here, involving the patient in the decision 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 the patient's acceptance. All of the other strategies also apply but are secondary to trust and bonding with providers.

22. The parent of a seriously mentally ill adult asks the nurse, "Why are you making a referral to a vocational rehabilitation program? My child won't ever be able to hold a job." Which is the nurse'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 the program would be detrimental, we can postpone it for a time." d. "Most patients are capable of employment at some level, competitive or supported."

ANS: D Studies have shown that most patients 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.

9. A family discusses the impact of a seriously mental ill member. Insurance partially covers treatment expenses, but the family spends much of their savings for care. The patient's sibling says, "My parents have no time for me." The parents are concerned that when they are older, there will be no one to care for the patient. Which response by the nurse would be most helpful? a. Acknowledge their concerns and consult with the treatment team about ways to bring the patient'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 the patient become more

ANS: D The family has raised a number of concerns, but the major issues appear to be the effects caregiving has had on the family and their concerns about the patient's future. NAMI offers support, education, resources, and access to other families who have experience with the issues now facing this family. NAMI can help address caregiver burden and planning for the future needs of SMI persons. Improving the patient'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. The family will need more than financial planning; their issues go beyond financial. The family is distressed but not in crisis. Crisis intervention is not an appropriate resource for the longer-term issues and needs affecting this family.

5. An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, "I threw away the pills because they keep me from hearing God." Which response by the nurse would most likely to benefit this patient? 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 the medication education group every Thursday." d. "I noticed that when you take the medicine, you are able to keep the job you wanted."

ANS: D The patient 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 the patient's goals (the job) can serve to motivate the patient to take the medication and override concerns about losing the hallucinations. Exhorting a patient 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 the cause of nonadherence was a knowledge deficit.

17. A patient diagnosed with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." The nurse identifies the etiology of the patient's ineffective management of the medication regime as 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 patient's ineffective management of the medication regime is most closely related to impaired reasoning associated with the thought disturbances of schizophrenia. The patient believes in being an 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 the other factors often related to medication nonadherence.

4. An outpatient diagnosed with schizophrenia tells the nurse, "I am here to save the world. I threw away the pills because they make God go away." The nurse identifies the patient's reason for medication nonadherence as 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 patient's nonadherence is most closely related to thought disturbances associated with the illness. The patient 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 the distracters may play a part in the patient's nonadherence, the correct response is most likely.

The role of a case manager working with severely and persistently mentally ill clients who are homeless would include which intervention? A. Coordinate needed services B. Administer medication C. Teach the clients to function independently D. Ensure that the clients are not re-hospitalized

Answer: A Community mental health services are designed to provide outreach and case management for severely mentally ill persons who are homeless. 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. The role of the case manager does not include any of the other options.

Which statement is true of the relationship between serious mental illnesses (SMIs) and substance abuse? A. Of those diagnosed with SMI, substance abuse is high B. Substance abuse occurs at approximately the same rate as in the general population C. Substance abuse rarely occurs within this population D. Smoking has declined in this population at the same rate as the general public

Answer: A Comorbid substance abuse occurs in 30% 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.

The term dual diagnosis refers to having a severe mental illness and what other dysfunctional behavior? A. A substance abuse problem B. Medication noncompliance C. HIV infection D. A personality disorder

Answer: A Dual diagnosis is the term used to identify a client with severe mental illness and a substance abuse problem. Both problems must be treated if the client is to be successfully rehabilitated. None of the other options reflect an accurate description of the term dual diagnosis.

Serious mental illness (SMI) affects how many adults in the United States? A. 11 million B. 8 Million C. 4 Million D. 1 million

Answer: A SMI affects about 11.4 million adults in the United States. The other options are incorrect percentages.

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

Answer: A 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 serious mental illness (SMI) would support the recovery model of care? A. Interventions will focus on the client's stated wish for independent living B. Care plan interventions will focus on medication adherence C. The clients' parents will receive education on how to manage the patient's deficits D. Attending groups that teach how to cope with one's present illness

Answer: A 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.

An issue for severely and persistently mentally ill clients living in the community is inadequate long-term medication monitoring by community mental health workers. What is a remedy for this problem? A. Use client empowerment techniques to increase client autonomy B. Shift follow-up from social workers to the ACT model C. Develop tools to predict relapse and assess the potential for violence D. Discontinue antipsychotics that cause untoward side effects

Answer: B 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. None of the other options present an effective remedy for this problem.

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

Answer: B 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.

A client who has been prescribed an antipsychotic medication comes to the clinic 3 days after a 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? A. Arrange for the client to get to the nearest emergency department for treatment B. Arrange for a dose of the client's medication immediately C. Arrange to have the client's nursing care plan reflect the need for a medication change D. Arrange for the client to see his psychiatrist as soon as the psychiatrist has an open appointment

Answer: B 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. None of the other options addresses the client's needs as effectively.

A 20-year-old Amish client 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? A. Religiosity B. Apathy C. Anosognosia D. Resistance

Answer: C Anosognosia is the inability to recognize one's deficits as a result of one's illness. In serious mental illnesses (SMIs), 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.

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

Answer: C 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.

Severely mentally ill (SMI) clients often express a strong desire to be employed. According to the evidence-based research, what is the most effective model of employment for these clients? A. Vocational rehabilitation B. A placement program of rehabilitation C. Supported employment D. Productive employment

Answer: C 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 supported employment.

Institutionalization leads to what specific type of behaviors in adults old enough to have been confined to institutions before deinstitutionalization? A. Assertiveness and condor B. Fearfulness and paranoia C. Passivity and dependance D. Anger and aggression

Answer: C Medical paternalism, in which the health care provider made all decisions for patients with serious mental illnesses (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.

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? A. Acute confusion B. Risk for activity intolerance C. Social isolation D. Impaired comfort

Answer: C 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.

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

Answer: C 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.

The mother of a client with severe, persistent schizophrenia tells the nurse, "My child has slipped so far away from me over the past few years. We really don't have a relationship anymore. I miss my child terribly." The nursing diagnosis that best describes the mother's feelings using which term? A. Ineffective coping B. Caregiver role strain C. Grieving D. Powerlessness

Answer: C 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. The statement does not support any of the other options.

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

Answer: D Although deficits are assessed and addressed, implementation of rehabilitation is dependent on reinforcement of identified client strengths. None of the remaining options is fundamental to the rehab process.

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

Answer: D 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.