ch. 2 Historical Issues, ch. 3 Legal Issues, ch. 4 Psychobiologic Bases of Behavior

A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group? A. A client in an acute care mental health facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who says he is becoming more anxious during group therapy D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months

A. A client in acute care who has been running and falling should be helped by the treatment team on her unit. B. CORRECT: An ACT group works with clients who are nonadherent with traditional therapy, such as the client in a home setting who keeps "forgetting" his injection. C. A client who has anxiety might be referred to his counselor or mental health provider. D. A client who is grieving for her husband who died 3 months ago is currently involved in an appropriate intervention.

A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms. C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of medications.

A. A ssisting with systematic desensitization therapy is a cognitive and behavioral, rather than a psychobiological intervention. B. T eaching appropriate coping mechanisms is a counseling or health teaching, rather than a psychobiological intervention. C. A ssessing for comorbid health conditions is health promotion and maintenance, rather than a psychobiological, intervention. D. CORRECT: Monitoring for adverse effects of medications is an example of a psychobiological intervention.

A nurse is told during change‑of‑shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect? A. The client arouses briefly in response to a sternal rub. B. The client has a Glasgow Coma Scale score less than 7. C. The client exhibits decorticate rigidity. D. The client is alert but disoriented to time and place

A. CORRECT: A client who is stuporous requires vigorous or painful stimuli to elicit a response. B. A GCS score of less than 7 indicates a comatose, rather than stuporous, level of consciousness. C. A bnormal posturing is associated with a comatose, rather than stuporous, level of consciousness. D. A client who is stuporous is not alert.

A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply.) A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents."

A. CORRECT: Counting backward by 7s is an appropriate technique to assess a client's cognitive ability. B. CORRECT: Observing a client's facial expression is appropriate when assessing affect. C. CORRECT: Writing a sentence is an indication of language ability. D. A sking the client to repeat a list of objects is appropriate to assess immediate, rather than remote, memory. E. A sking the client to identify recent presidents is appropriate to assess cognitive knowledge rather than abstract thinking.

A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply.) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy

A. CORRECT: Educational groups are services provided in a community mental health facility. B. CORRECT: Medication dispensing programs are services provided in a community mental health facility. C. CORRECT: Individual counseling programs are services provided in a community mental health facility. D. Detoxification programs are services provided in a partial hospitalization program. E. CORRECT: Family therapy is a service provided in a community mental health facility

A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. The client's wife works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow‑up care? A. Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visiting a community mental health center on a daily basis

A. Daily care provided by a home health aide will not provide adequate supervision for this client. B. Weekly visits from a case worker will not provide adequate care and supervision for this client. C. CORRECT: A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present. D. Daily visits to a community mental health center will not provide consistent supervision for this client.

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short‑staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery

A. I nvasion of privacy is the sharing or obtaining of the client's confidential information without the client's consent. B. CORRECT: A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the confining of a client to a specific area, such as a seclusion room, if the reason for such confinement is for the convenience of staff. C. A ssault is making a threat to the client's person. D. Justice involves the fair and equal treatment of clients

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services. B. Identify the client's perception of her mental health status. C. Include the client's family in the interview. D. Teach the client about her current mental health disorder.

A. I t is appropriate to coordinate holistic care for the client with social services as part of case management. However, it is not the highest priority action when using the nursing process approach to client care. B. CORRECT: Assessment is the priority action when using the nursing process approach to client care. Identifying the client's perception of her mental health status provides important information about the client's psychosocial history. C. I f the client wishes, it is appropriate to include the client's family in the interview. However, it is not the highest priority action when using the nursing process approach to client care. D. I t is appropriate to teach the client about her disorder. However, it is not the highest priority action when using the nursing process approach to client care

A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM‑5). Which of the following information is appropriate to include in the discussion? (Select all that apply.) A. The DSM‑5 includes client education handouts for mental health disorders. B. The DSM‑5 establishes diagnostic criteria for individual mental health disorders. C. The DSM‑5 indicates recommended pharmacological treatment for mental health disorders. D. The DSM‑5 assists nurses in planning care for client's who have mental health disorders. E. The DSM‑5 indicates expected assessment findings of mental health disorders.

A. T he DSM‑5 is used by mental health professionals. However, it does not include client education handouts. B. CORRECT: The DSM‑5 establishes diagnostic criteria for mental health disorders. C. T he DSM‑5 does not indicate pharmacological treatment for mental health disorders. D. CORRECT: Nurses use the DSM‑5 to plan, implement, and evaluate care for client's who have mental health disorders. E. CORRECT: The DSM‑5 identifies expected findings for mental health disorders.

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply.) A. "Client ate most of his breakfast." B. "Client was offered 8 oz of water every hr." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000." E. "Client acted out after lunch."

A. T he nurse should document objective information regarding intake in the client's medical record. B. CORRECT: How much water was offered and how often it was offered is objective data that the nurse should document when caring for a client in mechanical restraints. C. CORRECT: A description of the client's verbal communication is objective data that the nurse should document when caring for a client in mechanical restraints. D. CORRECT: The dosage and time of medication administration is objective data that the nurse should document when caring for a client in mechanical restraints E. T he nurse should document objective information regarding the client's behavior in the client's medical record.

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in‑service program about confidentiality. D. Complete an incident report.

A. T he nurse should notify the nurse manager if the client's right to privacy is violated. However, there is another action that the nurse should take first. B. CORRECT: The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a public place. The first action the nurse should take is to tell the newly licensed nurse to stop discussing the client's hallucinations in a public location. C. T he nurse should provide an in‑service program for staff about confidentiality. However, there is another action that the nurse should take first. D. T he nurse should complete an incident report about the violation of the client's right to privacy. However, there is another action that the nurse should take first.

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife. B. Keep the client's communication confidential, but watch the client and his roommate closely. C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others. D. Report the incident to the health care team, but do not inform the client of the intention to do so.

A. T he nurse should use therapeutic communication with the client. However, based on the nature of the information, the nurse cannot keep the information confidential from everyone despite the client's request. B. Based on the nature of the information, the nurse cannot keep the information confidential from everyone despite the client's request. C. CORRECT: The information presented by the client is a serious safety issue that the nurse must report to the health care team. Using the ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue. D. T he nurse should inform the if the information will be reported to the health care team.

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to himself

A. T he presence of delusions does not constitute a clear reason for a temporary emergency admission unless they present a danger for the client or others. B. C linical findings of depression do not constitute a clear reason for a temporary emergency admission unless the client is currently at risk for suicide. C. CORRECT: A client who is a current danger to self or others is a candidate for a temporary emergency admission. D. A client who is pacing does not constitute a clear reason for a temporary emergency admission.

A nurse is caring for several clients who are attending community‑based mental health programs. Which of the following clients should the nurse plan to visit first? A. A client who recently burned her arm while using a hot iron at home B. A client who requests that her antipsychotic medication be changed due to some new adverse effects C. A client who says he is hearing a voice that tells him he is not worthy of living anymore D. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview

A. T his client has needs that should be met, but there is another client whom the nurse should see first. B. T his client has needs that should be met, but there is another client whom the nurse should see first. C. CORRECT: A client who hears a voice telling him he is not worthy is at greatest risk for self‑harm, and the nurse should visit this client first. D. T his client has needs that should be met, but there is another client whom the nurse should see first.

A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression B. Performing screenings for depression at community health programs C. Establishing rehabilitation programs to decrease the effects of depression D. Providing support groups for clients at risk for depression

A. T his intervention is an example of primary prevention. B. T his intervention is an example of secondary prevention. C. CORRECT: Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness. D. T his intervention is an example of primary prevention.

A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period in which the patient was stable and competent. The nurse should: a. ensure that the directives are respected in treatment planning. b. review the directive with the patient to ensure that it is current. c. consider the directive only if there is a cardiac or respiratory arrest. d. realize that such directives address only the use of psychotropic medication.

ANS: A Advance directives for psychiatric care might be given by competent patients. They are considered binding and should be considered in planning treatment. Advance directives address several issues including psychotropic medication. Review is not required. A psychiatric advance directive relates specifically to mental health services, not cardiac or respiratory problems

A patient constantly interferes with activities on an inpatient unit. The nurse, speaking in a loud voice, tells the patient, "If you don't go to your room immediately, I will give you medication that will make you sleep." The nurse's behavior demonstrates: a. assault. b. battery. c. negligence. d. false imprisonment.

ANS: A Assault is defined as an act that creates a reasonable apprehension of harmful or offensive contact to another without consent of the other. The nurse has threatened the patient. Battery is unwanted touching. Negligence is failure to do what is reasonably prudent under the circumstances. False imprisonment is not evident.

To help preserve patients' rights to freedom from restraint and seclusion, the most important interventions that the nurse can use are based on which principle? a. Therapeutic management b. Reality-based communication c. Confidentiality of documentation d. Effective use of ancillary personnel

ANS: A Attention to the nurse-patient relationship, the therapeutic milieu, and principles of pharmacologic management can reduce the need for restrictive measures. The other options are important aspects of care but do not relate directly to the use of restraint and seclusion.

Freud's contribution to psychiatry that most affects current psychiatric nursing is: a. the challenge to look at humans objectively. b. recognition of the importance of human sexuality. c. theories about the importance of sleep and dreams. d. discoveries about the effectiveness of free association.

ANS: A Freud's work created a milieu for thinking about mental disorders in terms of the individual human mind. This called for therapists to look objectively at the individual, a principle that is basic to nursing. The correct answer is the most global response. Freud's theories of psychosexual development are an aspect of holistic nursing practice, but not the entire focus. Free association is not a pivotal issue in nursing practice.

A patient who experiences frequent panic attacks asks the nurse, "Why does this happen to me?" The nurse should explain that the problem might relate to a deficit of which brain chemical? a. GABA b. Serotonin c. Dopamine d. Glutamate

ANS: A Gamma-aminobutyric acid (GABA) is a neurotransmitter thought to exert a braking force on anxiety. A GABA deficit is implicated in generalized anxiety disorder and panic attacks. The other options have not been suggested as factors by research studies.

The nurse administers a medication that potentiates the action of GABA. Which finding would be expected? a. Reduced anxiety b. Improved memory c. More organized thinking d. Fewer sensory perceptual alterations

ANS: A Increased levels of GABA reduce anxiety; thus any potentiation of GABA action should result in anxiety reduction. Acetylcholine and substance P are associated with memory enhancement. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.

A crisis team led by a psychiatric nurse is called to a home because a patient with a history of paranoid schizophrenia is standing on the lawn shouting, "People are poisoning my water." The nurse should advise the police officer to institute procedures for: a. emergency care. b. long-term commitment. c. a probable-cause hearing. d. short-term observation and treatment.

ANS: A Individuals who are deemed to be dangerous to self, dangerous to others, or gravely disabled can be detained involuntarily for evaluation and emergency treatment for a specified period of time (often for 72 hours). Long-term commitment might be unnecessary. A probable-cause hearing is needed only for short-term observation and treatment.

An example of a breach of a patient's right to privacy occurred when a nurse: a. released information to the patient's employer without consent. b. documented the patient's daily behaviors during hospitalization. c. discussed the patient's history with other staff during care planning. d. asked a family to share information about a patient's behavior prior to admission.

ANS: A Release of information without patient authorization violates the patient's right to privacy. The other options are acceptable nursing practices.

The parent of an adopted infant tells the nurse, "Our baby was abused before the adoption. I read an article online that said this experience causes problems as a child grows up. What we should be watching for?" Select the nurse's best response. a. "Early trauma sometimes causes learning difficulties, anxiety, and difficulty handling stress later in life." b. "Early abuse causes the myelin covering of the nerves to overgrow, which leads to high anxiety and mood instability." c. "Many individuals who experience early trauma and abuse develop symptoms of schizophrenia." d. "Your child will be normal. Information in online articles is not reliable."

ANS: A Stress increases cortisol levels. Excessive cortisol levels can cause hippocampal atrophy, leading to memory and learning difficulty. Elevated cortisol level is also associated with hypersensitivity of the hypothalamic-pituitary-adrenal (HPA) system, leading to overreaction to stress and possibly a propensity to depression and anxiety. Myelin continues to grow after birth, but overgrowth is not likely as a result of abuse. Stating that the individual is at risk for schizophrenia is incorrect. Online articles may or may not be reliable. The nurse should not give false reassurance about the child's development.

A patient demonstrates visual aphasia. The nurse can project that there is dysfunction in which cerebral lobe? a. Temporal b. Parietal c. Occipital d. Frontal

ANS: A Temporal lobe lesion of the visual association area would result in visual aphasia, the inability to recognize previously known words. A parietal lobe lesion would involve sensory interpretation or association. An occipital lobe lesion would produce loss of vision. Problems with the frontal lobe would produce motor problems or changes in thought or personality.

When assessing a patient, the nurse elicits the Babinski reflex on the left foot. The nurse knows this response can indicate the existence of: a. an upper motor neuron lesion on the right side. b. an upper motor neuron lesion on the left side. c. a lower motor neuron lesion on the right side. d. a lower motor neuron lesion on the left side.

ANS: A The Babinski sign is the result of an upper motor neuron lesion on the opposite (contralateral) side of the body. Lower motor neuron lesions normally result in flaccid paralysis.

A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient's insurance form. Which resource should the nurse use to discern the criteria used to establish this diagnosis? a. The Diagnostic and Statistical Manual of Mental Disorders (DSM) b. Nursing Diagnosis Manual c. A psychiatric nursing textbook d. A behavioral health reference manual

ANS: A The DSM gives the criteria used to diagnose each mental disorder. The distracters do not contain diagnostic criteria for mental illness.

When a nurse working in a well-child clinic asks a parent's address, the parent responds, "My children and I are homeless." The nurse can assess this response as: a. a common occurrence, because 1 out of 50 children are homeless. b. a signal to investigate the possibility that the parent has severe mental illness. c. evidence of child abuse or neglect that should be reported to social service agencies. d. unusual because most homeless individuals have severe mental illness or substance abuse problems.

ANS: A The current belief is that the homeless are people (including entire families) who have been displaced by social policies over which they have no control. One out of 50 children is homeless. Although homelessness might be associated with serious mental illness, it might also be the result of having a weak support system and of social policies over which the individual or family has no control. Clinic users come from all socioeconomic backgrounds.

A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot injection) to a patient diagnosed with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop. I don't want to take that medicine anymore. I hate the side effects." Select the nurse's first action. a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Proceed with the injection but explain to the patient that there are medications that may help reduce the unpleasant side effects. c. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose." d. Notify other staff to report to the room for a show of force, and proceed with the injection, using restraint if necessary.

ANS: A The nurse, as an advocate and educator, should seek more information about the patient's decision and should not force the medication. Patients with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. It is not reasonable to promise a reduction in side effects without first discussing them, nor is it appropriate to pressure the patient into taking the medication. The medication cannot be given without the patient's informed consent.

A patient's insurance will not pay for continuing hospitalization at a private facility, so the family considers transferring the patient to a public psychiatric hospital. They express concern that the patient will "never get any treatment." Select the nurse's most helpful reply. a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern, because the right to treatment extends only to provision of food, shelter, and safety." c. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse."

ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals under federal law. The remaining statements do not accurately describe that right.

Which skill is most important to a nurse working as a member of a community mental health team that strives to use a seamless continuum of care? a. Case management b. Diagnostic ability c. Physical assessment skills d. Patients' rights advocacy

ANS: A To effectively use a seamless continuum of care, a nurse must have case management skills with which he or she can coordinate care using available and appropriate community resources. Psychosocial assessment and physical assessment are functions that can be fulfilled by another health care worker. Patients' rights advocacy is one aspect of case management. `

A patient is diagnosed with severe depression. The nurse will prepare a plan to teach the patient about medications that improve brain availability of which neurotransmitter? Select all that apply. a. Serotonin b. Dopamine c. Norepinephrine d. Acetylcholine e. Substance P

ANS: A, C Two neurotransmitters believed to be in low concentration at brain synapses of patients with depression are norepinephrine and serotonin. Most antidepressants act to increase availability of one or both of these neurotransmitters. Dopamine is implicated in schizophrenia; acetylcholine is implicated in Alzheimer's disease. Substance P modulates pain.

Which interventions apply to the care plan of a patient being secluded? Select all that apply. a. Seclusion instituted when verbal intervention ineffective in stopping threatening behavior b. Written medical order obtained within 2 hours c. Patient debriefed when seclusion discontinued d. Patient offered bathroom privileges hourly e. Fluids offered every 4 hours

ANS: A, C, D The correct interventions meet Medicare and Medicaid guidelines for the psychiatric setting. Other guidelines exist and should also be observed so that care can be evaluated as safe and effective. Fluids should be offered more often than every 4 hours, and a medical order must be secured within 1 hour.

A newcomer to a community support meeting asks a nurse, "Why aren't people with mental illnesses treated at state institutions anymore?" What would be the nurse's accurate responses? Select all that apply. a. "Funding for treatment of mental illness now focuses on community treatment." b. "Psychiatric institutions are no longer accepted because of negative stories in the press." c. "There are less restrictive settings available now to care for individuals with mental illness." d. "Our nation has fewer people with mental illness; therefore, fewer hospital beds are needed." e. "Better drugs now make it possible for many persons with mental illness to live in their communities."

ANS: A, C, E Deinstitutionalization and changes in funding shifted care for persons with mental illness to the community rather than large institutions. Care provided in a community setting, closer to family and significant others, is preferable. Improvements in medications to treat serious mental illness made it possible for more patients to live in their home communities. Prevalence rates for serious mental illness have not decreased. Although the national perspectives on institutional care did become negative, that was not the reason many institutions closed.

An individual is experiencing problems associated with speech and communication. Which cerebral structures are most likely to be involved in this deficit? Select all that apply. a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe e. Basal ganglia

ANS: A, D The frontal and temporal lobes of the cerebrum play a key role in the reception of messages and speech. The occipital lobe is predominantly involved with vision. The basal ganglia influence integration of physical movement as well as some thoughts and emotions, whereas the parietal lobe is involved with sensory reception.

A patient who is admitted involuntarily with bipolar disorder, manic phase, refuses a prescribed dose of lithium. The nurse assembles a show of force and intimidates the patient into taking the medication. As an outcome of this action, the patient: a. will experience lessened mania. b. can bring civil suit for assault and battery. c. can sue the hospital for false imprisonment. d. has no recourse, because the medication is in the interest of the patient's welfare.

ANS: B A nurse who forces a patient to accept treatment or take medication in a nonemergency situation against the patient's wishes can be found liable for assault (threatening) and battery (nonconsenting touching) in civil court, even if the nurse had the best interest of the patient in mind. Diminished symptoms of mania are not likely to be related to a single dose of lithium. The scenario does not describe the conditions of false imprisonment. Actions taken in the best interest of the patient that violate the patient's rights are cause for civil action.

The broadened scope of psychiatric nursing practice is attributable primarily to: a. increased use of psychotropic drugs. b. opening of community mental health centers. c. legislation that changed nurse practice acts across the country. d. recidivism of seriously mentally ill patients in public mental hospitals.

ANS: B Community mental health centers were designed and organized to provide services in addition to inpatient hospitalization, thus giving nurses opportunities to practice in a variety of treatment settings (e.g., emergency rooms, partial hospitalization settings, outpatient care) and to have new roles, such as consultant, liaison, and case manager. Increased use of psychotropic drugs is not as important a factor as are community mental health centers. Legislation changing nurse practice acts broadened the scope of practice for nurse practitioners only by allowing prescriptive privileges. Recidivism is not a relevant factor.

A patient with mental illness was initially treated in an outpatient setting and then hospitalized for a week when the disorder became acute. After discharge to a halfway house, this patient's care was managed by a community mental health nurse. Which inference applies to this community? a. Additional mental health services should be made available for the severely mentally ill. b. A seamless continuum of services is in place to serve persons with severe mental illness. c. Case management services should be expanded to care for acute as well as long-term system consumers. d. There are insufficient data to make a conclusion.

ANS: B Data are sufficient to suggest that a seamless continuum of service is in place, because the individual is able to move between continuum treatment sources and is given the services of a case manager to coordinate care. Data provided are insufficient to warrant any of the other assessments.

A former pediatric nurse begins working in a clinic housed in a homeless shelter. The nurse asks the clinic director, "What topic should I review to improve my effectiveness as I begin my new job?" Which topic should the clinic director suggest? a. Care of school-age children b. Psychiatric and substance abuse assessment c. Communicable disease prevention strategies d. Sexually transmitted disease signs and symptoms

ANS: B It is estimated that significant numbers of the homeless population have a serious mental illness and/or suffer from substance abuse or dependence. Although the other conditions may exist, the numbers are not as significant.

A patient diagnosed with paranoid schizophrenia believes that evil spirits are being stirred by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. What is the basis for this action? a. Information cannot be released without proper authorization. b. There is a duty to warn and protect. c. No action can violate the patient's confidentiality. d. Charges of malpractice must be avoided.

ANS: B It is the health care professional's duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not considered a violation of confidentiality or an example of malpractice.

A male patient is diagnosed with mitochondrial encephalopathy. The patient's daughter asks, "Since this is a genetic disorder, am I at risk for having it too?" Select the nurse's best response. a. "Your risk is related to exposure to environmental toxins." b. "No, this problem is only passed on by the mother." c. "You must be feeling very worried." d. "Your risk is not predictable."

ANS: B Mitochondria are passed to the ovum only by the mother, so the patient is not at risk for receiving it from the father. It is important to provide information in response to the daughter's question.

A patient denies hunger despite ingesting fewer than 400 calories daily. The patient's problem might be associated with dysfunction of which structure? a. Parietal lobe b. Hypothalamus c. Medulla oblongata d. Reticular activating system

ANS: B Research has shown that the hypothalamus is involved with eating and satiety, so dysfunction might be a factor in anorexia nervosa. Research has not implicated any of the other brain structures listed in anorexia nervosa.

A patient was restrained after assaulting a staff member. Which nursing measure has priority? a. Monitor the patient every 30 minutes. b. Maintain constant supervision of the patient. c. Administer a sedating medication after applying the restraints. d. Distract the patient at frequent intervals while restraints are in use.

ANS: B Restrained patients must be constantly observed, with documentation of physical safety and comfort interventions occurring at 15-minute intervals. Medication may be administered, but this is not the priority action. Distraction is not an effective technique to use when a patient is in restraints, because minimal stimulation is preferred.

A key factor motivating passage of the Community Mental Health Centers Act in 1963 was that mentally ill individuals had been: a. hospitalized only if they demonstrated violent behavior. b. geographically isolated from family and community. c. discharged before receiving adequate treatment. d. used as subjects in pharmacologic research.

ANS: B State hospitals were often located a great distance from the patients' homes, making family visits difficult during hospitalization. The Community Mental Health Centers Act in 1963 served as the impetus for deinstitutionalization, allowing patients and families to receive care close to home. Admission only for behavior that endangers self or others is more consistent with current admission criteria. Early discharge rarely occurred before the community mental health movement. Unethical pharmacologic research was not a major issue leading to community mental health legislation.

Considering that a state uses the M'Naghten Rule when an individual is on trial for a crime, what would be most important to document for a nurse caring for a patient who will soon be tried on murder charges? a. The patient's participation in treatment planning b. The patient's comments about commission of the crime c. Examples of behaviors that support psychiatric diagnoses d. The patient's perceptions of the need for hospitalization and treatment

ANS: B The M'Naghten Rule states that to be held legally accountable for his or her actions, a person with mental illness must be able to understand the nature and implications of the crime. Although each of the options refers to data that should be documented, the patient's comments about the crime would be of most importance to the trial.

Which individual should the nurse assess as having the highest risk for homelessness? a. An older adult woman with mild dementia who resides in an assisted-living facility b. An adult with serious mental illness and no family c. An adolescent with an eating disorder d. A married person with alcoholism

ANS: B The adult has both a serious mental illness and a potentially weak support system. Both are risk factors for homelessness. The other individuals have psychiatric disorders but have better established support systems

A patient is recovering from surgery to remove a tumor in the cerebellum. Which assessment finding is most attributable to this diagnosis? a. The patient complains of limited taste and smell. b. The patient demonstrates poor balance and coordination. c. The patient has limited ability to learn and poor memory. d. The patient has poor emotional control and low motivation.

ANS: B The cerebellum coordinates muscle synergy and is responsible for the maintenance of equilibrium. The limbic system plays a role in taste, smell, memory, learning, emotional control, and motivation.

The nurse assesses a patient diagnosed with Parkinson's disease. When will tremors be most pronounced? a. When sleeping b. When sitting quietly c. When focusing intently d. When reaching for something

ANS: B The tremor of Parkinson's disease, a disease that affects the extrapyramidal system, is most pronounced when the patient is at rest. In Parkinson's disease, tremor is absent during sleep and diminished when concentrating or with intentional movement.

A patient tells the nurse, "You better take good care of me or I'll sue you using the precedent established in Wyatt v. Stickney." The nurse can interpret this as: a. intellectualization. b. concern about rights to adequate treatment. c. a warning about being coerced into treatment. d. a request for immediate discharge from the facility.

ANS: B Wyatt v. Stickney was a case in which the court ruled that patients had the right to adequate treatment while hospitalized. Intellectualizing is a defense mechanism. Right to refuse treatment and commitment issues were not the focus of Wyatt v. Stickney.

Which changes in psychiatric nursing practice are directly attributable to events occurring during the Decade of the Brain? Select all that apply. a. Homeless shelters became practice sites. b. Nurses upgraded knowledge of psychopharmacology. c. Nurses provided psychoeducation to patients and families. d. Nurses viewed psychiatric symptoms as resulting from brain irregularities. e. Nurses were more likely to advocate for patients' rights related to involuntary commitment.

ANS: B, C, D Psychobiologic research relating to brain structure and function made it possible for psychiatric nurses to view symptoms as brain irregularities and made it necessary for them to become knowledgeable about psychotropic medications to make appropriate assessments regarding desired outcomes and side and toxic effects of therapy. With hospital stays shortened, it became necessary for nurses to provide psychoeducation to patients and families who would need to monitor outcomes, symptoms of relapse, and side and toxic effects of medication. Homeless shelters became practice sites with the onset of deinstitutionalization. Advocacy for patients' rights relating to hospitalization and commitment became an ethical issue before the Decade of the Brain.

An adult with serious mental illness is being admitted to a community behavioral health inpatient unit. Recognizing current trends in hospitalization, this patient is likely to: a. comply readily with the prescribed treatment. b. have a clear understanding of the illness. c. display aggressive behavior. d. stabilize within 24 hours.

ANS: C Compared with patients of the 1960s and 1970s, today's patients are likely to display more aggressive behavior. This understanding is critical to making astute assessments that lead to planning for the provision of safety for patients and staff. Treatment compliance, understanding of the illness process, and discharge against medical advice are possible issues with which the nurse might deal, but these are less relevant when admission assessment is performed.

A patient excitedly tells the nurse, "Look what I made in arts and crafts! I did a good job. I want to make some other things too." The nurse may conclude that which part of the patient's nervous system is responsible for processing this reaction? a. Brainstem b. Occipital lobe c. Limbic system d. Corpus callosum

ANS: C Feelings of pleasure are generated in the brain's limbic system. The exact mechanisms of generating emotions and motivation, however, are unclear. The other structures are not involved in pleasure or motivation processing.

A person says, "Now that many state hospitals are closed, patients with psychiatric problems are free in our community. It is not safe for me." The nurse's reply should be based on knowledge that: a. depressed patients are nonviolent. b. state hospitals are no longer needed. c. major depression is very prevalent. d. bizarre behavior is viewed as sensational.

ANS: C Four of the top medical disorders causing disability are psychiatric disorders (i.e., major depression, schizophrenia, bipolar disorder, and alcohol abuse). The other options are not true statements.

Which patient should be considered for involuntary commitment for psychiatric treatment? a. A patient who is noncompliant with the treatment regimen b. A patient who sold and distributed illegal drugs c. A patient who threatens to harm self and others d. A patient who fraudulently filed for bankruptcy

ANS: C Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

A patient tells the nurse, "I still have suicidal thoughts, but don't tell anyone because I am supposed to be discharged today." Select the nurse's best course of action. a. Have the patient sign a "no suicide" contract. b. Respect the patient's request related to confidentiality. c. Inform the health care provider and other team members. d. Search the patient's belongings for potentially hazardous items.

ANS: C Patient right to confidentiality never includes keeping important clinical information secret, especially information related to patient safety. Patients should be informed that all relevant information will be shared with the health care team. None of the other options sufficiently address the safety issue presented by a patient who expresses suicidal thoughts.

A patient shouts, "I'm holding you responsible for mistreatment based on Rogers v. Orkin." The nurse can conclude that the patient is objecting to: a. loss of privileges to leave the unit. b. inability to make phone calls. c. taking medication. d. hospitalization.

ANS: C Rogers v. Orkin was a case in which the court ruled that nonviolent patients could not be forced to take medication. It did not have implications related to hospitalization or application of patient privileges.

The greatest impact in the care of the mentally ill over the past 50 years has resulted from progress and improvement in which area? a. Self-help groups b. Outpatient therapy c. Psychotropic drugs d. Patients' rights awareness

ANS: C The advent of psychotropic drugs allowed patients to normalize thinking and feeling. As psychosis diminished, the individual became accessible for psychotherapeutic interventions. Hospital stays were shortened. Hospital milieus improved. Though important, none of the other choices has had such a significant impact.

The nurse plans discharge teaching for a patient who experienced a stroke involving the hippocampus. The nurse should adapt the teaching plan to account for possible problems with: a. visual acuity. b. expressive aphasia. c. short-term memory. d. balance and coordination.

ANS: C The limbic system is crucial to memory. Damage to the hippocampus, a part of the limbic system, causes problems converting short-term to long-term memory, making learning difficult. Aphasia is a temporal lobe problem. Blindness is an occipital lobe problem. Balance and coordination are affected by damage to the cerebellum.

An involuntarily admitted inpatient with paranoid schizophrenia repeatedly calls the local mayor. The patient verbally abuses the person who answers the phone as well as the mayor. Select the most appropriate initial nursing intervention. a. Allow the patient to continue to use the phone. b. Include the patient in a social skills building group. c. Suspend the patient's phone privileges temporarily, and document the reason. d. Ask the patient advocate to review the limits of the patient's rights with the patient.

ANS: C The nurse should document that the patient's calls violated the rights of others, thus providing a basis for temporary suspension of the right to make phone calls to the mayor's office. Allowing continued calls violates the rights of others. It might require several days for the advocate to meet with the patient.

Although a patient appears to have recovered from a head injury resulting from an auto accident 3 months ago, the family reports changes in the patient's personality and behavior. The nurse should explain that these changes are probably associated with injury to which structure? a. Pons b. Parietal lobe c. Prefrontal area d. Caudate nucleus

ANS: C The prefrontal area is the seat of personality. It is responsible for thought, goal-oriented behavior, and inhibition. The other structures have less significant roles in personality change.

What concerns were shared by society during both the Period of Enlightenment and the Period of Community Mental Health? a. Moving patients out of asylums b. Studying brain structure and function c. Meeting basic human needs humanely d. Providing medication to control symptoms

ANS: C The use of asylums signaled concern for meeting basic needs of the mentally ill, who in earlier times often wandered the countryside. With deinstitutionalization, many patients who were poorly equipped to provide for their own needs were returned to the community. The current system must now concern itself with ensuring that patients have such basic needs as food, shelter, and clothing. Studying brain structure and function is more a concern of modern times, as is the provision of medication.

To reduce the risk of a lawsuit based on false imprisonment, mental health nurses must give the highest priority to which intervention? a. Educating patients about unit protocols b. Providing adequate treatment during hospitalization c. Selecting the least restrictive treatment environment that will be effective d. Ensuring that patients have probable-cause hearings within 24 hours of admission

ANS: C Treating a patient in the least restrictive environment that will be effective lessens the threat of the patient bringing civil suit for false imprisonment. In the least restrictive environment the disruption to patient rights is minimized. Providing information about unit rules and providing adequate treatments are of less immediate importance than ensuring the least restrictive alternative. Probable-cause hearings are necessary only in certain cases.

A patient diagnosed with bipolar disorder is admitted involuntarily during a manic phase. Lithium 300 mg PO t.i.d. is prescribed. The patient refuses the morning dose. What are the nurse's best actions? Select all that apply. a. Get the prescription changed to an elixir, and administer it in juice. b. Assemble adequate help to force the patient to take the medication. c. Educate the patient about the importance of lithium in stabilizing the mood. d. Allow the patient to refuse the medication, and document the patient's comments. e. Inform the patient that unit privileges are contingent on taking prescribed medications.

ANS: C, D Patients have the right to refuse consent to treatment, including medication administration. The courts have ruled that neither voluntary nor involuntary patients can be forced to take psychotropic medication. Hiding the medication in food or fluids is not ethical. Assembling a show of force implies that forcible administration will occur. Making privileges contingent on medication ingestion is coercion.

Which situation is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient's admission. b. An advanced-practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patient's admission status is changed from involuntary to voluntary after the patient's hallucinations subside. d. A nurse gives a PRN dose of an antipsychotic drug to a patient to prevent violent acting out because the unit is short staffed.

ANS: D A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify torts.

An adolescent is hospitalized after a violent physical outburst and tells the nurse, "I'm going to kill my parents, but you can't tell them." Select the nurse's initial response. a. "You're right. Federal law requires me to keep information private." b. "Those kinds of threats will make your hospitalization longer." c. "You really should share this thought with your psychiatrist." d. "I am required to talk to the treatment team about your threats."

ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances, because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the patient's parents of the risk for harm.

How many violations of Medicare and Medicaid guidelines are evident in this documentation? Patient assaulted nurse in hall at 1730. Staff provided verbal intervention, but patient continued to strike out. Patient placed in seclusion at 1745. Observation instituted at hourly intervals. Order received from physician at 1930. Patient sleeping soundly at 2100. Patient released from seclusion at 2230 and returned to own room. a. Two b. Three c. Four d. Five

ANS: D Constant observation of a secluded individual is necessary, with attention given at frequent intervals for safety and comfort interventions. No mention is made of providing fluids or bathroom privileges. Seclusion requires a written order posted within 1 hour. Seclusion must be terminated when patient behavior permits. If the patient is calm enough to sleep, the need for seclusion should be reevaluated. The patient should be debriefed after the seclusion.

When a nurse administers an anticholinergic drug, it is important to assess for symptoms associated with inhibition of: a. spinal nerve function. b. the central nervous system. c. the sympathetic nervous system. d. the parasympathetic nervous system.

ANS: D Drugs with anticholinergic properties block parasympathetic function of certain cranial nerves, resulting in dilated pupils, decreased tearing, dry mouth, tachycardia, and a slowed gastrointestinal system. Anticholinergics do not affect spinal nerve function or function associated with the central or sympathetic nervous systems.

A gravely disabled psychiatric patient has a guardian. What is the essential implication for nursing care? a. The patient can override the guardian's judgment at any time. b. Guardianship is a legal matter that does not affect clinical care. c. The guardian's rights apply only to a patient's financial interests. d. The guardian participates in treatment planning on behalf of the patient.

ANS: D Guardians make decisions on behalf of the patient and represent the patient in treatment planning meetings. Guardianship affects clinical care, as previously mentioned. The guardian has the right to refuse treatment for the patient. The patient cannot override the guardian's judgment, because the patient is considered incompetent.

Which individual would be the most likely candidate to have a guardian appointed? a. A patient with panic attacks b. A bipolar patient who refuses medication c. A patient with frequent admissions for drug abuse d. A gravely disabled patient with paranoid schizophrenia

ANS: D Guardians or conservators are appointed by the courts to manage the affairs of mentally ill individuals found to be incompetent and unable to manage their own affairs appropriately. A gravely disabled patient with schizophrenia would be in need of a conservator or guardian, whereas the other individuals would more likely be judged competent.

Ventricular enlargement noted in brain studies of patients diagnosed with Alzheimer's disease is most likely attributable to: a. narrowing of the subarachnoid space. b. overproduction of cerebrospinal fluid. c. blockage of cerebrospinal fluid outflow. d. brain atrophy associated with cellular degeneration.

ANS: D In Alzheimer's disease, when brain cells degenerate, the brain atrophies and the ventricles enlarge to fill the existing space. Planning should consider the fact that the patient has fewer functioning brain cells, thus explaining cognitive symptoms and problems such as incontinence and difficulty in swallowing.

Select the most accurate characterization of treatment of the mentally ill prior to the Period of Enlightenment. a. Large asylums provided custodial care. b. Care for the mentally ill was more compassionate. c. Care focused on reducing stress and meeting basic human needs. d. Patients were banished from communities or displayed for public amusement.

ANS: D In the 1700s it was common practice for caretakers to display mentally ill patients for the amusement of the paying public. The creation of large asylums took place during the Period of Enlightenment. Mental illness was first studied during the Period of Scientific Study. Dealing with stress and meeting basic needs are concerns of the modern era.

A nurse could anticipate that the treatment plan for a patient experiencing memory difficulties might include medications designed to: a. inhibit GABA. b. increase dopamine at receptor sites. c. decrease dopamine at receptor sites. d. prevent destruction of acetylcholine.

ANS: D Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory. GABA is known to affect anxiety level rather than memory. Increased dopamine would cause symptoms associated with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinson's disease rather than improving memory.

The patient is tense, hypervigilant, and reports, "My heart is racing." The nurse understands that the primary neurotransmitter associated with these complaints is: a. serotonin. b. glutamate. c. acetylcholine. d. norepinephrine.

ANS: D Norepinephrine is a catecholamine. It is released in response to sympathetic stimulation and causes increased heart rate and blood pressure and other symptoms of anxiety. Glutamate, serotonin, and acetylcholine are not associated with sympathetic nervous system stimulation.

A nurse in a community mental health center receives a call asking for information about a patient. Under which condition can the nurse release information to the caller? a. The caller is related to the patient. b. The psychiatrist approves the request. c. The caller is a mental health professional. d. The patient has given written consent for release of information.

ANS: D Patient information is privileged. Information cannot be released without consent signed by the patient. None of the other conditions is sufficient.

An adult with schizophrenia is discharged from a state mental hospital after 20 years of institutionalization. When planning care in the community, which premise applies? This patient is likely to: a. independently find support services to aid transition from hospitalization to community. b. adjust smoothly to the community if provided with sufficient support services. c. self-administer antipsychotic medications correctly if provided with education. d. need crisis or emergency psychiatric interventions from time to time.

ANS: D Patients with serious mental illness are rarely considered cured at the time of hospital discharge. Decompensation is likely from time to time, even when good community support is provided. The emergency room may become a first-line resource in the continuum of care designed to prevent rehospitalization. Unfortunately, transitional services are not always readily available. Adjustment to a community environment after long institutionalization is often a slow process.

A patient who abuses heroin says, "I have willpower to manage my life in other areas, but I feel helpless to control my craving for heroin." The nurse's response should be based on research findings suggesting that addictive behavior is related to changes in: a. cortisol secretion. b. the substantia nigra. c. mitochondrial DNA. d. the nucleus accumbens.

ANS: D Research has implicated the nucleus accumbens as having a role in addictive behaviors. The substantia nigra is concerned with dopamine production. Excessive cortisol secretion has its primary effect on the hippocampus. Mitochondrial DNA mutation has not been implicated in addiction risk.

A patient tells the nurse, "When I get out, I'm going to get even with a lot of people." With respect to the nurse's duty to warn, the nurse should: a. take no action on a general threat. b. notify local law enforcement officials. c. warn close relatives and significant other. d. document and discuss the threat with the clinical team.

ANS: D The Tarasoff ruling specifies that a specific threat to a readily identifiable person or persons must be made. In this situation, the threat is nonspecific. The prudent action is to document and discuss with the clinical team to determine the need for providing a warning to third parties.

Dysfunction in which structure should lead the nurse to consider institution of fall precautions? a. Wernicke's area b. Hippocampus c. Amygdala d. Cerebellum

ANS: D The cerebellum is responsible for the maintenance of equilibrium. When equilibrium is impaired, fall prevention becomes a priority. Problems in Wernicke's area are associated with impaired comprehension of the spoken word. Problems with the hippocampus or amygdala are associated with impaired memory formation.

A shift in the psychiatric nursing focus during the community mental health period of the 1960s resulted in: a. disillusionment with the high numbers of people seeking treatment. b. focusing more attention on complications associated with substance abuse. c. spending more time providing services to persons with serious mental illness. d. shifting focus away from the most acutely ill and to persons with a perceived greater potential for improvement.

ANS: D The community mental health movement brought with it a broadening of areas of concern to the psychiatric nurse. It became acceptable, even desirable, for psychiatric nurses to focus on what was called the worried well, as opposed to providing care for acutely ill psychotic individuals. Neither disillusionment with the numbers seeking treatment nor providing more services to those with severe mental illness occurred.

A patient diagnosed with split-brain syndrome has damage to which structure of the brain? a. Amygdala b. Hippocampus c. Pyramidal tract d. Corpus callosum

ANS: D The corpus callosum connects the two brain hemispheres. When this communication pathway is severed, split-brain syndrome develops. None of the other structures is implicated in this disorder.

A patient has disorganized thinking associated with schizophrenia. Neuroimaging studies will most likely show dysfunction in which part of the brain? a. Temporal lobe b. Cerebellum c. Brainstem d. Frontal lobe

ANS: D The frontal lobe is responsible for intellectual functioning. The temporal lobe is responsible for the sensation of hearing. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

A patient reports an inability to sleep because of too much noise and light, even though the environment is quiet with soft lighting. The nurse knows such reports support dysfunction of which organ? a. Basal ganglia b. Pituitary gland c. Substantia nigra d. Reticular activating system

ANS: D The reticular activating system (RAS) serves as a screen that allows individuals to tune out some stimuli and attend to others. When RAS disruption occurs and the individual is unable to tune out stimuli, the individual is unable to sleep. Lack of sleep can produce psychotic symptoms. The other structures are not involved in perception of sensory stimuli.

A patient backs into a corner of the room and shouts at the nurse, "Stay away from me." Select the best initial nursing intervention in this situation. a. Obtain an order for seclusion. b. Administer a PRN antipsychotic drug. c. Call for assistance to physically restrain the patient. d. Talk to the patient in a calm, nonthreatening manner.

ANS: D Verbal intervention provides the least restrictive alternative in this situation. Verbal intervention might halt escalation and prevent the need for medication or the use of restraint or seclusion. Seclusion, restraint, and medication usage are all more restrictive than verbal intervention.

A community mental health nurse works in a mental health services system that is undergoing change to become a seamless system. To promote integrity of the new system, the nurse should focus on (select all that apply) a. psychopathology. b. symptom stabilization. c. medication management. d. patient and family psychoeducation. e. patient reintegration into the community. f. holistic issues relating to patient care.

ANS: D, E, F A seamless system of mental health services will require new conceptualizations. Nurses will need to focus more on recovery and reintegration than on symptom stabilization and more on holistic issues such as finances and housing than on medication management. Consumers and family members will also need to be provided with extensive psychoeducation.

Put these services in order from least to most intensive. a. Day treatment b. Hospitalization c. Scheduled visits at a community mental health center

The continuum of care represents treatment services along a range of intensity. Hospitalization is the most intensive, progressing to day treatment, and finally to routine visits at a community mental health center.