psych TB serious mental illness
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?
Encourage the consumer to discuss it at a meeting with everyone. Hire a professional cleaning service to clean the restrooms. Address the complaint at the next staff meeting. 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.
The sibling of a client who was diagnosed with a serious mental illness (SMI) asks why a case manager has been assigned. Which nurse's reply best cites the major advantage of the use of case management?
"The case manager can modify traditional psychotherapy for homeless clients so that it is more flexible." "Case managers coordinate services and help with accessing them, making sure the client's needs are met." "The case manager can focus on social skills training and esteem building in the real world where the client lives." "Having a case manager has been shown to reduce hospitalizations, which prevents disruption and saves money." ANS: B The case manager helps the client 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.
A client diagnosed with a serious mental illness (SMI) died suddenly at age 52. The client 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 certain number of people die young from undetected diseases, and it's just one of those sad things that sometimes happen." "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." "We will have to wait for the autopsy to know what happened. There were some medical problems, but we were not expecting death." "We are all surprised. The client 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 client 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.
A nurse's neighbor says, "My sister has been diagnosed with bipolar disorder but will not take her medication. I have tried to help her for over 20 years, but it seems like everything I do fails. Do you have any suggestions?" What is the nurse's best response?
"National Alliance on Mental Illness (NAMI) offers a family education series that you might find helpful." "Since your sister is noncompliant, perhaps it's time for her to be changed to injectable medication." "You have done all you can. Now it's time to put yourself first and move on with your life." "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 client.
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 client'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 client. Which response by the nurse would be most helpful?
Acknowledge their concerns and consult with the treatment team about ways to bring the client's symptoms under better control. 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. Refer them to crisis intervention services to learn ways to manage caregiver stress and provide titles of some helpful books for families. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the client become more independent. 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 client'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 client'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.
The nurse wants to enroll a client with poor social skills in a training program for clients diagnosed with schizophrenia. Which description accurately describes social skills training?
Clients learn to improve their attention and concentration. Group leaders provide support without challenging clients to change. Complex interpersonal skills are taught by breaking them into simpler behaviors. Clients learn social skills by practicing them in a supported employment setting. ANS: C In social skills training, complex interpersonal skills are taught by breaking them down into component behaviors that are covered in a stepwise fashion. Social skills training is not based in employment settings, although such skills can be addressed as part of supported employment services. The other distracters are less relevant to social skills training.
Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with serious mental illness (SMI)?
Clubhouse model Cognitive-behavioral therapy (CBT) Assertive community treatment (ACT) 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 client within his own environment.
Which nursing diagnosis is likely to apply to an individual diagnosed with a serious mental illness (SMI) who is homeless?
Insomnia Substance abuse Chronic low self-esteem 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 clients but is not a universal problem. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not seen in a majority of the homeless.
A client diagnosed with a serious mental illness (SMI) lives independently and attends a psychosocial rehabilitation program. The client presents at the emergency department seeking hospitalization. The client has no acute symptoms but says, "I have no money to pay my rent or refill my prescription." What is the nurse's best action?
Involve the client's case manager to provide crisis intervention. Send the client to a homeless shelter until housing can be arranged. Arrange for a short in-client admission and begin discharge planning. Explain that one must have active psychiatric symptoms to be admitted. ANS: A Impaired stress tolerance and problem-solving abilities can cause persons with SMI to experience relatively minor stressors as crises. This client has run out of money, and this has overwhelmed her ability to cope, resulting in a crisis for which crisis intervention would be an appropriate response. Inpatient care is not clinically indicated nor is the client homeless (although she may fear she is). Telling the client that she is not symptomatic enough to be admitted may prompt malingering.
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." What does the nurse suspect is the client's reason for medication nonadherence?
poor alliance with clinicians. inadequate discharge planning. dislike of medication side effects. thought disturbances associated with the illness. ANS: D The client's nonadherence is most closely related to thought disturbances associated with the illness. The client 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 client's nonadherence, the correct response is most likely.
After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This client 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 what factor?
side effects of antipsychotic medications. dependency caused by institutionalization. cognitive deterioration from schizophrenia. 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, clients become dependent on the institution to meet their needs and adapt to being cared for rather than caring for themselves. When these clients 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.
Many persons brought before a criminal court have mental illness, have committed minor offenses, and are non-medication adherent. 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?
"Sometimes a little time in jail makes a person rethink what they've been doing and puts them back on the right track." "Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses." "Arresting these people helps them in the long run. Sometimes we cannot hospitalize them, but in jail they will get their medication." "Research suggests that special mental health courts do not make much difference so far, but outpatient commitment does seem to help." ANS: B Research supports 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.
A homeless client diagnosed with a serious mental illness (SMI) became suspicious and delusional. Depot antipsychotic medication is prescribed and housing is obtained in a local shelter. One month later, which statement by the client indicates significant improvement?
"They will not let me drink. They have many rules in the shelter." "I feel comfortable here. Nobody bothers me." "Those shots make my arm very sore." "Those people watch me a lot." ANS: B Evaluation of a client's progress is made based on client satisfaction with the new health status and the health care team's estimation of improvement. For a formerly delusional client to admit to feeling comfortable and free of being "bothered" by others denotes improvement in the client's condition. The other options suggest that the client is in danger of relapse.
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?
"We make this referral to continue eligibility for federal funding." "Are you concerned that we're trying to make your child too independent?" "If you think the program would be detrimental, we can postpone it for a time." "Most clients are capable of employment at some level, competitive or supported." ANS: D Studies have shown that most clients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression.
An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The client says, "I threw away the pills because they keep me from hearing God." Which response by the nurse would most likely to benefit this client?
"You need your medicine. Your schizophrenia will get worse without it." "Do you want to be hospitalized again? You must take your medication." "I would like you to come to the medication education group every Thursday." "I noticed that when you take the medicine, you are able to keep the job you wanted." ANS: D The client appears not to understand that he has an illness. He has stopped his medication because it interferes with a symptom that he finds desirable (auditory hallucinations—the voice of God). Connecting medication adherence to one of the client's goals (the job) can serve to motivate the client to take the medication and override concerns about losing the hallucinations. Exhorting a client to take medication because it is needed to control his illness is unlikely to be successful; he does not believe he has an illness. Medication psychoeducation would be appropriate if the cause of nonadherence was a knowledge deficit.
A hospitalized client diagnosed with schizophrenia has a history of multiple relapses. The client 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 client transitions from hospital to community?
Administer a second-generation antipsychotic to help negative symptoms. Use a quick-dissolving medication formulation to reduce "cheeking." Prescribe a long-acting intramuscular antipsychotic medication. Involve the client 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 client 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 client's acceptance. All of the other strategies also apply but are secondary to trust and bonding with providers.
A person diagnosed with a serious mental illness (SMI) enters a shelter for the homeless. Which intervention should be the nurse's initial priority?
Find supported employment. Develop a trusting relationship. Administer prescribed medication. 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.
A homeless individual diagnosed with serious mental illness (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?
Teach appropriate health maintenance and prevention practices. Educate the client about the importance of treatment adherence. Help the client obtain employment in a local sheltered workshop. Interact regularly and supportively without trying to change the client. ANS: D Given the history of treatment nonadherence and the difficulty achieving other goals until psychiatrically stable and adherent, getting the client 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 client. 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 client is in crisis, so it is possible to proceed slowly and build this foundation of trust.
For clients diagnosed with serious mental illness (SMI), what is the major advantage of case management?
The case manager can modify traditional psychotherapy. With one coordinator of services, resources can be more efficiently used. The case manager can focus on social skills training and esteem building. Case managers bring groups of clients together to discuss common problems. ANS: B The case manager coordinates the care and multiple referrals that so often confuse the seriously mentally ill client and the client's family. Case management promotes efficient use of services. The other options are lesser advantages or are irrelevant.
A client living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the client was prohibited from returning to the apartment. The landlord said, "You cause too much trouble." What problem is the client experiencing?
a. Grief b. Stigma c. Homelessness d. Nonadherence ANS: B The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a client problem. Data do not suggest that the client is actually homeless. See relationship to audience response question.
An adult diagnosed with a serious mental illness (SMI) says, "I do not need help with money management. I have excellent ideas about investments." This client usually does not have money to buy groceries by the middle of the month. The nurse assesses the client as demonstrating what defense mechanism?
a. rationalization . b. identification. c. anosognosia. d. projection. ANS: C The client scenario describes anosognosia, the inability to recognize one's deficits due to one's illness. The client 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.
How is serious mental illness (SMI) characterized?
any mental illness of more than 2 weeks' duration. a major long-term mental illness marked by significant functional impairments. a mental illness accompanied by physical impairment and severe social problems. 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.
A client diagnosed with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." How should the nurse identify the etiology of the client's ineffective management of the medication regime?
inadequate discharge planning. poor therapeutic alliance with clinicians. dislike of antipsychotic medication side effects. impaired reasoning secondary to the schizophrenia. ANS: D The client's ineffective management of the medication regime is most closely related to impaired reasoning associated with the thought disturbances of schizophrenia. The client 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.
