Chapter 12: Caring for Clients With Mental Illness and Substance Use Disorders in General Practice Settings

The clinic nurse is triaging clients. The nurse should require which client with nonsuicidal self-injuring behavior to be seen immediately? 1.Is self-cutting in response to command hallucinations 2.Has a history of borderline personality disorder 3.Is on leave from the military 4.Has thoughts of being detached from the body

1.Is self-cutting in response to command hallucinations A client who exhibits nonsuicidal self-injuring behavior (self-cutting) in response to command hallucinations should be considered in need of immediate medical attention.

The client with a myocardial infarction tells the intensive care nurse, "You won't have to care for me pretty soon. I will not be a burden to you or others." Which initial action should the nurse take? 1.Screen the client for suicide 2.Transfer the client to the medical unit 3.Allow the client some private, quiet time 4.Teach the client that he or she will be able to care for himself or herself

1.Screen the client for suicide The nurse should screen the client for suicide as the initial action. Even though the client has a myocardial infarction and not a mental health disorder, the client's statement indicates possible depression and suicide. The nurse must remember that clients in all medical settings may not be forthcoming with thoughts of suicide unless specifically asked.

The nurse is working in a long-term care facility. Which action by the nurse demonstrates attention to a priority issue for screening for all clients in the facility? 1.Performing crisis intervention 2.Assessing a client for trauma 3.Determining presence of hallucinations 4.Monitoring for anxiety disorders

2.Assessing a client for trauma The nurse should assess for trauma. Three of the most important issue to screen for are trauma, suicide risk, and substance use disorders.

The nurse is working in an emergency department. With which client should the nurse use the screening, brief intervention, and referral to treatment approach (SBIRT)? 1.Has suicidal thoughts 2.Has nonsuicidal self-injuring behavior 3.Has an opioid addiction 4.Has been raped

3.Has an opioid addiction The client with an opioid addiction should be screened and cared for using the SBIRT approach. The SBIRT approach is an evidence-based approach that can be used in various settings for substance abuse and addiction.

What is the first step the nurse should take to reduce stigma of mental health clients? 1.Increase social contact with mental health clients 2.Attend on-the-job training about mental health clients 3.Have a willingness to interact with mental health clients 4.Understand the person as a mental health client

3.Have a willingness to interact with mental health clients The first step is to have a willingness to interact with mental health clients. The nurse should be willing to engage in meaningful relationships with people who have mental illnesses and addictions.

The nurse is caring for clients in a free community clinic. Which technique should the nurse use to conduct a trauma screening? 1.Quickly assessing the overall situation 2.Implementing a thorough head-to-toe assessment 3.Interviewing in a secluded area 4.Using empathy with the family members

3.Interviewing in a secluded area Interviewing in a secluded area is the technique the nurse should use during a trauma screening. It is critical that nurses conduct trauma screenings in private and communicate with a compassionate, nonjudgmental attitude.

The nurse is providing care to a depressed, introverted client who is receiving outpatient surgery for a fractured hip. Which action should the nurse take to provide patient-centered care? 1.Refer the client for involuntary hospitalization 2.Allow the client plenty of solitude time to prepare for surgery 3.Involve the client in choosing a blue or green gown to wear 4.Develop a partnership with the spouse who is not withdrawn

3.Involve the client in choosing a blue or green gown to wear Allowing the client to make decisions about their care (choosing a blue or green gown) is an indication of patient-centered care. Just because a client has a mental illness does not necessarily mean that they are incapable of making decisions.

The nurse in the emergency department (ED) is assessing a client who with a long history of depression. The nurse finds that the client has gained weight, has dry skin, and has cold sensitivity. The nurse determines the client's depression is exacerbating, further examination and testing reveal the client has hypothyroidism. Which phenomenon occurred? 1.Depression screening 2.Social distancing 3.Trauma-informed caring 4.Diagnostic overshadowing

4.Diagnostic overshadowing The nurse used diagnostic overshadowing, a phenomenon in which clients' physical symptoms are attributed to their mental illness. The nurse attributed the weight gain, dry skin, and cold sensitivity to the depression rather than to hypothyroidism.

The clinic nurse is caring for a client with ulcerative colitis who has signs of depression. Which additional conditions should the nurse assess for in this client? (Select all that apply.) 1. Mania 2. Cardiovascular disease 3. Metabolic syndrome 4. Diabetes 5. Emphysema

ANS: 1, 2, 3, 4

The nurse is preparing a staff development presentation to improve the screening, intervention, and referral process for clients in the geriatric community center. Which information should the nurse identify as barriers to this initiative? (Select all that apply.) 1. Patient concerns about privacy 2. Competing workload demands 3. New nurses 4. The staff's attitude 5. Changing screening requirements

ANS: 1, 2, 3, 4

The nurse is a manager of a pediatric unit. Which actions should the nurse manager take to equip staff to address neuropsychiatric symptoms in pediatric clients? (Select all that apply.) 1. Encourage use of screening tools 2. Provide education of staff members 3. Keep referrals to a minimum 4. Increase social contact with individuals with mental illness 5. Promote defensive medicine

ANS: 1, 2, 4

The client has extensive mental health problems that require medication and counseling. To which mental health-care professional should the nurse refer the client? 1. Psychologist 2. Psychiatrist 3. Licensed independent social worker 4. Peer support specialist

ANS: 2 The nurse should refer the client to a psychiatrist. Psychiatrists provide diagnostic, medication management, and counseling services to clients.

In which setting should the nurse be aware that the client with a substance use disorder would most likely seek initial treatment? 1. Psychiatric hospital 2. Addiction treatment center 3. Urgent care clinic 4. Inpatient psychiatric unit

ANS: 3 Clients with substance use disorders commonly seek care first in general medical and community practice settings, like an urgent care clinic, before being treated in psychiatric or substance abuse treatment settings.

A home care nurse notices the client who startles easily is exhibiting signs of posttraumatic stress disorder. The nurse asks, "Have you ever made a suicide attempt?" to which the client responds, "Yes, I have." Which response should the nurse make next? 1. Notify the primary care provider 2. Gently touch the client's arm 3. Say, "Why would you do that? I am here to help you." 4. Ask, "Are you having thoughts of suicide right now?"

ANS: 4 A "yes" response to either question ("In the past month, have you had thoughts about suicide?" and "Have you ever made a suicide attempt?") should prompt the nurse to ask a third question, "Are you having thoughts of suicide right now?"

17. Which observation seen in a teenage patient supports the suspicion of anabolic steroid abuse? A. Lack of facial hair B. Ritualized hand washing C. Stealing and hiding a magazine belonging to another patient D. Throwing a chair when told it was time to turn off the television

ANS: D For all individuals abusing anabolic steroids, extreme mood swings occur, and these may be accompanied by violent behaviors. Obsessive-compulsive behaviors and stealing are not generally associated with this disorder. The increased hormone presence would result not in a lack, but rather an increase, in facial hair.

9. Which nursing intervention best demonstrates an understanding of the relationship between confirmed intravenous drug abuse and specific infections? A. Screening the patient for hepatitis B virus (HBV) B. Assessing the patient for potentially infected injection sites C. Determining if the patient has ever been tested for human immunodeficiency virus (HIV) D. Evaluating the patients understanding of the increased risk for developing sexually transmitted diseases

ANS: A Injecting drug users have one of the highest HBV rates among all risk groups and account for at least half of all new HCV cases, so screening for such infections demonstrates that the nurse understands the severity of the problem. Although the other options reflect potential infection risks, they are not as commonly seen in patients with this diagnosis.

16. Which question is most appropriate when assessing a patient who is exhibiting symptoms of a systemic infection including a fever of unknown origin? A. Are you an intravenous drug user? B. Have you been told that you drink too much alcohol? C. Have you been diagnosed with an acute bacterial infection before? D. Are you familiar with an infection of the heart called endocarditis?

ANS: A Intravenous drug users are at risk for subacute bacterial endocarditis and other circulatory compromise created by foreign substances introduced during the process of intravenous use. Regardless of the setting, nurses need to ask about intravenous drug use whenever a patient presents with fever of unexplained origin. Assessing the patients knowledge related to bacterial infections and endocarditis will not address the possible cause of the fever. Alcohol consumption is not relevant in this situation.

1. When asked, What causes alcoholism? the nurses response will be based on the fact that: A. The response to alcohol is a result of a brain-based disorder. B. Alcoholism is believed to be an allergic response to the alcohol. C. Every individual has the same susceptibility for developing alcoholism. D. It is a physical response to alcohol but its etiology is not fully understood.

ANS: A It has been determined that alcoholism is not an allergy but rather it is recognized as a partial brain-based disorder that some brains are more susceptible to than others.

3. A substance use disorder (SUD) is a likely comorbid mental illness in which patient? A. The soldier diagnosed with posttraumatic stress disorder B. The teenager demonstrating symptoms of poor impulse control C. The older adult diagnosed with early stage Alzheimers disease D. The new mother exhibiting symptoms of postpartum depression

ANS: A Posttraumatic stress disorder creates a risk for substance use or relapse. A total of 30% to 60% of persons with SUDs meet the criteria for comorbid posttraumatic stress disorder. The remaining options have not shown such a prevalence of comorbid relationship with SUDs.

18. A patients wife has chronic alcoholism, and the husband is concerned about the possibility that their children may develop the disease. He asks the nurse what the risk is. The nurses best response is: A. The risk for developing alcoholism is increased if there is a family history of alcoholism. B. Studies have confirmed that individuals with dependent personality traits are at high risk for this disease. C. Cultures that include alcohol as part of the ritualized behavior have a higher rate of alcoholism. D. Twin studies have indicated that the environment of a person is more important than the biologic influences of parents.

ANS: A Problems with alcohol increase with the number of relatives with alcoholism. No unique personality profile is prone to addiction. Ritualized use of alcohol does not predispose to alcoholism and twin studies indicate a significant genetic contribution to susceptibility to alcoholism.

14. Which protocol should guide the nurse responsible for administering pharmacologic interventions for a patient who is experiencing alcohol intoxication? A. Medication interventions are based on the presence of withdrawal symptoms. B. Medications are prescribed at appropriate intervals for at least one full week. C. Symptoms are managed with medications for only the initial 24 hours of hospitalization. D. Medications are introduced to treat grand mal seizures that may accompany withdrawal symptoms.

ANS: A The course of intoxication is usually self-limiting to approximately 24 hours, after which withdrawal symptoms can occur for a time period unique to each patient. Treatment is directed by the symptoms the patient is experiencing, which generally emerge during the withdrawal stage. Seizures are among several serious symptoms that can occur during the withdrawal stage.

4. Which group would be the target population for educational material on the dangers of binge drinking? A. Full-time college students B. Blue-collared young adults C. Older widows and widowers D. High school juniors and seniors

ANS: A The highest prevalence of binge and heavy drinking is among young adults between the ages of 18 and 25 years, with the majority being full-time college students.

8. Which sociological aspect, vital to relapse prevention, is greatly affected when a patient is found to have a dual diagnosis of psychosis and alcoholism? A. Ability to afford the cost of outpatient services B. A supportive, reliable, accessible support system C. Protection from both physical and emotional abuse D. Access to reasonable housing and employment opportunities

ANS: B Often individuals with this type of diagnosis have lost their support systems as a result of chronic mistreatment of their family and friends and an inability to maintain and recognize the importance of this aspect to their treatment plan. Although the remaining options impact relapse prevention, they are generally available when the patient is being supported appropriately.

19. Which observation best supports the patients success with achieving long-term sobriety? A. Asking a family member to, get rid of all the alcohol before I come home B. Identifying all the problems alcoholism has caused the family over the years C. Being able to discuss the importance of attending a support group for alcoholics D. Promising to, stop the drinking so I can be a good parent and raise a good child

ANS: B One of the most prominent factors that leads an individual to recovery is the patients recognition that substance use has caused or influenced his or her lifes problems and interrupted his or her functioning. The remaining options lack that element of self-reflection.

2. Which patient response would support the conclusion that the patient has moved into the dark side of a narcotic addition? A. Ive been abusing drugs for at least 10 years. B. Drugs makes me feel good; that why I use them. C. I dont like the way I feel when I dont use drugs. D. Drugs are something that I can either take or leave

ANS: C During beginning use (the light side), the feel good effects are dominant. As the individual becomes habituated to the drug, tolerance and withdrawal symptoms develop; this constitutes the dark side. The remaining options do not describe effects of drug use.

12. Which nursing intervention demonstrates an understanding regarding the primary form of substance use disorder among older adults? A. Assessing the patients hands and feet for the presence of both numbness and tingling B. Having the patient, describe your relationship with you adult children, co- workers, and friends. C. Asking, Please identify for me all the medications both prescribed and over the counter you regularly take. D. Evaluate the patients understanding of the possible health risks that alcohol and medication abuse has on ones health

ANS: C Misuse of prescription medications is the most common form of drug abuse among older adults. This population is especially vulnerable because of the multiple drugs that are often prescribed for medical conditions. The remaining options do not help identify the presence of multiple medications.

10. Which assessment data would bring into question a patients statement that, I have only a few drinks on special occasions.? A. History of treatment for glaucoma B. Fasting serum blood glucose level of 182 mg/dL C. Patient reports numbness in hands and feet bilaterally D. Red rash observed over neck, shoulders, and upper chest

ANS: C Peripheral nerve deterioration in both hands and feet result from chronic alcohol intake. Peripheral neuropathy occurs in about 10% of alcoholics after years of heavy drinking causing the nurse to question the patients statement. The remaining options do not reflect symptomology generally associated with alcoholism.

15. A patient recently discharged from an alcohol rehabilitation program is brought to the hospital in a state of prostration with severe throbbing headache, tachycardia, a beet-red face, dyspnea, and continuous vomiting. The patients significant other states the patient got sick about 15 minutes after drinking a glass of wine. The nurse should be guided in assessment by the suspicion that the patient: A. Is having a stroke B. Has alcohol intoxication C. Is reacting to disulfiram (Antabuse) D. Is exhibiting symptoms of cross-dependence

ANS: C The alcohol deterrent drug, Antabuse, commonly prescribed in recovering alcoholic treatment, causes this reaction when taken in combination with alcohol. Alcohol intoxication, stroke, and cross-dependence do not present with the listed prostration symptoms.

6. Which assessment data poses the greatest risk for injury in a patient who abuses alcohol? A. Takes a baby aspirin each morning B. Uses over-the-counter antihistamines for seasonal allergies C. Has been taking a tricyclic antidepressant for more than 2 years D. Took a narcotic for 1 week to manage postdental surgery pain

ANS: C Tricyclic antidepressants are strictly contraindicated with alcohol consumption because of their potential effect on cardiac function. Although aspirin increases bleeding times and antihistamines and narcotics increase sedation, the outcome of combining alcohol and these drugs is not as dangerous as that of the correct option.

7. If an individual is admitted with a diagnosis of Wernicke-Korsakoffs syndrome, the nurse would expect to assess: A. Peptic ulcer B. Vivid illusions C. Cognitive deficits D. Auditory hallucinations

ANS: C Wernicke-Korsakoffs syndrome includes a severe form of amnesia and an inability to learn new skills which reflects a cognitive impairment. The other options are not associated with the syndrome.

11. Which intervention has priority when a nurse suspects a staff member of providing patient care while being impaired by alcohol or drugs? A. Asking the staff member to explain their suspicious behavior B. Adjust the staff members assignment to minimize patient contact C. Providing the staff member with material regarding alcohol abuse and treatment D. Reporting the staff members suspicious behavior to the nursing supervisor on duty

ANS: D It is a professional obligation to report suspected impaired practice. The remaining options do not have prior in this situation since the concern is patient safety.

20. Which principle of recovery is the basis of the nurses response when a patient relapses and is hospitalized for alcohol detox treatment? A. Alcoholism requires a lifelong commitment to control. B. Most people who are serious about treatment achieve sobriety. C. Relapsing is an expected occurrence for the patient diagnosed with alcohol abuse. D. Rehabilitation generally involves several relapses before true sobriety is achieved.

ANS: D Sobriety is the goal of complete abstention from drugs, alcohol, and addictive behaviors. Sobriety often involves several attempts, and many patients relapse 9 or 10 times before achieving and sustaining sobriety. This information is the basis for the physical and emotional support provided by the nurse. Although citing that a relapse is not a failure but an expected part of the recovery process, this option does not include the needed information of the frequency of the possible relapses. The remaining options are not focused on relapsing.

13. Which assessment demonstrates the nurses understanding of the relationship between substance abuse and the development of symptoms characteristic of delirium? A. Determining the patients age and gender B. Evaluating the patients food and fluid intake over the last 48 hours C. Observing the patient for fine tremors of the hands, especially the fingers D. Determining the amount of caffeine the patient ingested in the last 24 hours

ANS: D Some people who ingest large amounts of caffeine develop delirium. The remaining options are not relevant to caffeine ingestion or the abuse of any other substance.

5. Which social factor has the greatest impact on the changing nature of alcohol abuse treatment? A. Development of new pharmaceutical treatment options B. Dramatic increase of alcoholism among young adult males C. Raising cost of both inpatient and outpatient treatment programs D. Womens substance abuse only recently acknowledge by society

ANS: D The existence of an alcohol abuse problem among women has only been recently recognized and this has dramatically affected treatments and services being provided. Although the other options are true, they do not have the impact on treatment modalities as much as the correct option.