Varcarolis Ch. 32: Serious Mental Illness

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

a. Encourage the consumer to discuss it at a meeting with everyone. 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 592-593 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

4. A patient diagnosed with serious mental illness was living successfully in a group home but wanted an apartment. The prospective landlord said, People like you have trouble getting along and paying their rent. The patient and nurse meet for a problem-solving session. Which options should the nurse endorse? Select all that apply. a. Coach the patient in ways to control symptoms effectively. b. Seek out landlords less affected by the stigma associated with mental illness. c. Threaten the landlord with legal action because of the discriminatory actions. d. Encourage the patient to remain in the group home until the illness is less obvious. e. Suggest that the patient list a false current address in the rental application. f. Have the case manager meet with the landlord to provide education about mental illness.

a. Coach the patient in ways to control symptoms effectively. b. Seek out landlords less affected by the stigma associated with mental illness. f. Have the case manager meet with the landlord to provide education about mental illness. Managing symptoms so that they are less obvious or socially disruptive can reduce negative reactions and reduce rejection due to stigma. Seeking a more receptive landlord might be the most expeditious route to housing for this patient. Educating the landlord to reduce stigma might make him more receptive and give the case manager an opportunity to address some of his concerns (e.g., the case manager could arrange a payee to assure that the rent is paid each month). However, threatening a lawsuit would increase the landlords defensiveness and would likely be a long and expensive undertaking. Delaying the patients efforts to become more independent is not clinically necessary according to the data noted here, the problem is the landlords bias and response, not the patients illness. It would be unethical to encourage falsification and poor role modeling to do so, further, if falsification is discovered, it could permit the landlord to refuse or cancel her lease. See related audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 586-587 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

19. A person diagnosed with a serious mental illness enters a shelter for the homeless. Which intervention should be the nurses initial priority? a. Find supported employment. b. Develop a trusting relationship. c. Administer prescribed medication. d. Teach appropriate health care practices.

b. Develop a trusting relationship. 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 593 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

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

c. Complex interpersonal skills are taught by breaking them into simpler behaviors. 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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 594 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

3. Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with serious mental illness? a. Clubhouse model b. Cognitive Behavioral Therapy (CBT) c. Assertive Community Treatment (ACT) d. Cognitive Enhancement Therapy (CET)

c. Assertive Community Treatment (ACT) Assertive community treatment (ACT) involves consumers working with a multidisciplinary team that provides a comprehensive array of services. At least one member of the team is available 24 hours a day for crisis needs, and the emphasis is on treating the patient within his own environment. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 590-591 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

2. An adult diagnosed with a serious mental illness says, I do not need help with money management. I have excellent ideas about investments. This patient usually does not have money to buy groceries by the middle of the month. The nurse assesses the patient as demonstrating: a. rationalization. c. anosognosia. b. identification. d. projection.

c. anosognosia. The patient scenario describes anosognosia, the inability to recognize ones deficits due to ones illness. The patient is not projecting an undesirable thought or emotion from himself onto others. He is not justifying his behavior via rationalization and is not identifying with another. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 588 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

9. A family discusses the impact of a seriously mental ill member. Insurance partially covered treatment expenses, but the family spent much of their savings for care. The patients sibling says, My parents have no time for me. The parents are concerned that when they are older, there will be no one to care for the patient. Which response by the nurse would be most helpful? a. Acknowledge their concerns and consult with the treatment team about ways to bring the patients symptoms under better control. b. Give them names of financial advisors that could help them save or borrow sufficient funds to leave a trust fund to care for their loved one. c. Refer them to crisis intervention services to learn ways to manage caregiver stress and provide titles of some helpful books for families. d. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the patient become more independent.

d. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the patient become more independent. 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 patients future. The National Alliance on Mental Illness (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 patients 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. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 585-586 | Page 591 TOP: Nursing Process: Planning/Implementation MSC: Client Needs: Psychosocial Integrity

17. A patient diagnosed with schizophrenia tells the community mental health nurse, I threw away my pills because they interfere with Gods voice. The nurse identifies the etiology of the patients ineffective management of the medication regime as: a. inadequate discharge planning. b. poor therapeutic alliance with clinicians. c. dislike of antipsychotic medication side effects. d. impaired reasoning secondary to the schizophrenia.

d. impaired reasoning secondary to the schizophrenia. The patients ineffective management of the medication regime is most closely related to impaired reasoning. The patient believes in being an exalted personage who hears Gods 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 587 | Page 593 (Table 31-1) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

4. An outpatient diagnosed with schizophrenia tells the nurse, I am here to save the world. I threw away the pills because they make God go away. The nurse identifies the patients reason for medication nonadherence as: a. poor alliance with clinicians. b. inadequate discharge planning. c. dislike of medication side effects. d. lack of insight associated with the illness.

d. lack of insight associated with the illness. The patients nonadherence is most closely related to lack of insight into his illness. The patient believes he is an exalted personage who hears Gods 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 patients nonadherence, the correct response is most likely. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 588 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

10. A patient diagnosed with a serious mental illness lives independently and attends a psychosocial rehabilitation program. The patient presents at the emergency department seeking hospitalization. The patient has no acute symptoms but says, I have no money to pay my rent or refill my prescription. Select the nurses best action. a. Involve the patients case manager to provide crisis intervention. b. Send the patient to a homeless shelter until housing can be arranged. c. Arrange for a short in-patient admission and begin discharge planning. d. Explain that one must have active psychiatric symptoms to be admitted.

a. Involve the patients case manager to provide crisis intervention. Impaired stress tolerance and problem-solving abilities can cause persons with SMI to experience relatively minor stressors as crises. This patient has run out of money, and this has overwhelmed her ability to cope, resulting in a crisis for which crisis intervention would be an appropriate response. Inpatient care is not clinically indicated nor is the patient homeless (although she may fear she is). Telling the patient that she is not symptomatic enough to be admitted may prompt malingering. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 589-590 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

2. The nurse manager of a mental health center wants to improve medication adherence among the seriously mentally ill persons treated there. Which interventions are likely to help achieve this goal? Select all that apply. a. Maintain stable and consistent staff. b. Increase the length of medication education groups. c. Stress that without treatment, illnesses will worsen. d. Prescribe drugs in smaller but more frequent dosages. e. Make it easier to access prescribers and pay for drugs. f. Require adherence in order to participate in programming.

a. Maintain stable and consistent staff. e. Make it easier to access prescribers and pay for drugs. Trust in ones providers is a key factor in treatment adherence, and mentally ill persons can sometimes take a very long time to develop such trust, therefore, interventions which stabilize staffing allow patients to have more time with staff to develop these bonds. Ready access to prescribers allows medicine-related concerns to be addressed quickly, reducing obstacles to adherence such as side effects or ineffective dosages. Medication costs can be obstacles to adherence as well. Many SMI patients have anosognosia and do not adhere to treatment because they believe they are not ill, so telling them nonadherence will worsen an illness they do not believe they have is unlikely to be helpful. Increasing medication education is helpful only when the cause of nonadherence is a knowledge deficit. Other issues that reduce adherence, particularly anosognosia and side effects, are seldom helped by longer medication education. Requiring medication adherence to participate in other programs is coercive and unethical. Smaller, more frequent doses do not reduce side effects and make the regimen more difficult for the patient to remember. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 588 (Box 31 1) | Page 592-594 TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

5. An adult patient tells the case manager, I dont have bipolar disorder anymore, so I dont need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now Im bored and dont have any friends. Where should the nurse refer the patient? Select all that apply. a. Psychoeducational classes b. Vocational rehabilitation c. Social skills training d. A homeless shelter e. Crisis intervention

a. Psychoeducational classes b. Vocational rehabilitation c. Social skills training The patient does not understand the illness and need for adherence to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with serious mental illness have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking the skill down into smaller verbal and nonverbal components. Work gives meaning and purpose to life, so vocational rehabilitation can assist with this aspect of care. The nurse case manager will function in the role of crisis stabilizer, so no related referral is needed. The patient presently has a home and does not require a homeless shelter. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 589-590 | Page 591-593 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

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

a. The National Alliance on Mental Illness offers a family education series that you might find helpful. The National Alliance on Mental Illness (NAMI) offers a family education series that assists with the stress caregivers and other family members often experience. The nurse should not give advice about injectable medication or encourage the family member to give up on the patient. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 585-586 | Page 591 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

6. Which statements most clearly indicate the speaker views mental illness with stigma? Select all that apply. a. We are all a little bit crazy. b. If people with mental illness would go to church, their problems would be solved. c. Many mental illnesses are genetically transmitted. Its no ones fault that the illness occurs. d. Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people. e. People with mental illness are lazy. They get government disability checks instead of working.

a. We are all a little bit crazy. b. If people with mental illness would go to church, their problems would be solved. e. People with mental illness are lazy. They get government disability checks instead of working. Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame. See related audience response question. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 586-587 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

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

b. Case managers coordinate services and help with accessing them, making sure the patients needs are met. The case manager helps the patient gain entrance into the system of care, can coordinate multiple referrals that so often confuse the seriously mentally ill person and his family, and can help overcome obstacles to access and treatment participation. Case managers do not usually possess the credentials needed to provide psychotherapy or function as therapists. Case management promotes efficient use of services in general, but only Assertive Community Treatment (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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 589 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment '

3. A person diagnosed with serious mental illness has frequent relapses, usually precipitated by situational stressors such as running out of money or the absence of key staff at the mental health center. Which interventions would the nurse suggest to reduce the risk of stressors to cause relapse? Select all that apply. a. Discourage potentially stressful activities such as groups or volunteer work. b. Develop written plans that will help the patient remember what to do in a crisis. c. Help the patient identify and anticipate events that are likely to be overwhelming. d. Encourage health-promoting activities such as exercise and getting adequate rest. e. Accompany the patient to a National Alliance on Mental Illness support group.

b. Develop written plans that will help the patient remember what to do in a crisis. c. Help the patient identify and anticipate events that are likely to be overwhelming. d. Encourage health-promoting activities such as exercise and getting adequate rest. e. Accompany the patient to a National Alliance on Mental Illness support group. Basic interventions for coping with crises involve anticipating crises where possible and then developing a plan with specific actions to take when faced with an overwhelming stressor. Written plans are helpful, it can be difficult for anyone, especially a person with cognitive or memory impairments, to develop or remember steps to take when under overwhelming stress. Health-promoting activities enhance a persons ability to cope with stress. As the name suggests, support groups help a person develop a support system, and they provide practical guidance from peers who learned from experience how to deal with issues the patient may be facing. Groups and volunteer work may involve a measure of stress but also provide benefits that help persons cope and should not be discouraged unless they are being done to excess. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 588 (Box 31 1) | Page 592-594 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

20. A homeless patient diagnosed with a serious mental illness became suspicious and delusional. Depot antipsychotic medication began, and housing was obtained in a local shelter. One month later, which statement by the patient indicates significant improvement? a. They will not let me drink. They have many rules in the shelter. b. I feel comfortable here. Nobody bothers me. c. Those shots make my arm very sore. d. Those people watch me a lot.

b. I feel comfortable here. Nobody bothers me. Evaluation of a patients progress is made based on patient satisfaction with the new health status and the health care teams estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being bothered by others denotes improvement in the patients condition. The other options suggest that the patient is in danger of relapse. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 584-585 | Page 587 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

12. A patient diagnosed with a serious mental illness died suddenly at age 52. The patient lived in the community for 5 years without relapse and held supported employment the past 6 months. The distressed family asks, How could this happen? Which response by the nurse accurately reflects research and addresses the familys question? a. A certain number of people die young from undetected diseases, and its just one of those sad things that sometimes happen. b. Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, smoke more, or are overweight. c. We will have to wait for the autopsy to know what happened. There were some medical problems, but we were not expecting death. d. We are all surprised. The patient had been doing so well and saw the nurse every other week.

b. Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, smoke more, or are overweight. 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 serious mental illness die an average of 25 years prematurely. Contributing factors include failing to provide for their own health needs (e.g. forgetting to take medicine), inability to access or pay for care, higher rates of smoking, poor diet, criminal victimization, and stigma. The most accurate answer indicates that seriously mentally ill people are at much higher risk of premature death for a variety of reasons. Staff would not have been surprised that the patient died prematurely, and they would not attribute his death to random, undetected medical problems. Although the cause of death will not be reliably established until the autopsy, this response fails to address the familys need for information. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 586-587 | Page 593 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

13. Many persons brought before a criminal court have mental illness, have committed minor offenses, and are off medications. The judge consults the nurse at the local community mental health center for guidance about how to respond when handling such cases. Which advice from the nurse would be most appropriate? a. Sometimes a little time in jail makes a person rethink what theyve been doing and puts them back on the right track. b. Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses. c. Arresting these people helps them in the long run. Sometimes we cannot hospitalize them, but in jail they will get their medication. d. Research suggests that special mental health courts do not make much difference so far, but outpatient commitment does seem to help.

b. Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses. 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 593-595 TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

18. A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, You cause too much trouble. What problem is the patient experiencing? a. Grief c. Homelessness b. Stigma d. Nonadherence

b. Stigma 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 patient problem. Data do not suggest that the patient is actually homeless. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 585-587 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

21. For patients diagnosed with serious mental illness, what is the major advantage of case management? a. The case manager can modify traditional psychotherapy. b. With one coordinator of services, resources can be more efficiently used. c. The case manager can focus on social skills training and esteem building. d. Case managers bring groups of patients together to discuss common problems.

b. With one coordinator of services, resources can be more efficiently used. The case manager coordinates the care and multiple referrals that so often confuse the seriously mentally ill patient and the patients family. Case management promotes efficient use of services. The other options are lesser advantages or are irrelevant. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 589-590 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

15. Serious mental illness is characterized as: a. any mental illness of more than 2 weeks duration. b. a major long-term mental illness marked by significant functional impairments. c. a mental illness accompanied by physical impairment and severe social problems. d. a major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities.

b. a major long-term mental illness marked by significant functional impairments. Serious mental illness has replaced the term chronic mental illness. Global impairments in function are evident, particularly social. Physical impairments may be present. Serious mental illness can be treated, but remissions and exacerbations are part of the course of the illness. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 584-585 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

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

b. dependency caused by institutionalization. Institutions tend to impede independent functioning, for example, daily activities are planned and directed by staff, others provide meals and only at set times. Over time, patients become dependent on the institution to meet their needs and adapt to being cared for rather than caring for themselves. When these patients return to the community, many continue to demonstrate passive behaviors despite efforts to promote. Cognitive dysfunction and antipsychotic side effects can make planning and carrying out activities more difficult, but the question is more suggestive of adjustment to institutional care and difficulty readjusting to independence instead. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 585 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

16. Which nursing diagnosis is likely to apply to an individual diagnosed with a serious mental illness who is homeless? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome

c. Chronic low self-esteem Many individuals with serious mental illness do not live with their families and become homeless. Life on the street or in a shelter has a negative influence on the individuals self-esteem, making this nursing diagnosis one that should be considered. Substance abuse is not an approved NANDA-International diagnosis. Insomnia may be noted in some patients but is not a universal problem. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not seen in a majority of the homeless. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 587 | Page 593 (Table 31-1) TOP: Nursing Process: Nursing Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

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

c. Impaired judgment and social skills can provoke hostile or assaultive behavior. d. Lower incomes force SMI persons to live in high-crime areas, increasing risk. e. SMI persons experience higher rates of sexual assault and victimization than others. f. Criminals may believe SMI persons are less likely to resist or testify against them. Mentally ill persons are more likely to be victims of crime than perpetrators of criminal acts. They are often victims of criminal behavior, including sexual crimes, at a higher rate than others. When a mentally ill person commits a crime, it is usually nonviolent. Mental illnesses interfere with employment and are associated with poverty, limiting SMI persons to living in inexpensive areas that also tend to be higher-crime areas. SMI persons may inadvertently provoke others because of poor judgment or socially inappropriate behavior, or they may be victimized because they are perceived as passive, less likely to resist, and less likely to be believed as witnesses. See related audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 587 TOP: Nursing Process: Planning/Implementation MSC: Client Needs: Safe, Effective Care Environment

5. An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, I threw away the pills because they keep me from hearing God. Which response by the nurse would most likely to benefit this patient? a. You need your medicine. Your schizophrenia will get worse without it. b. Do you want to be hospitalized again? You must take your medication. c. I would like you to come to the medication education group every Thursday. d. I noticed that when you take the medicine, you have been able to hold a job you wanted.

d. I noticed that when you take the medicine, you have been able to hold a job you wanted. The patient appears not to understand that he has an illness. He has stopped his medication because it interferes with a symptom that he finds desirable (auditory hallucinationsthe voice of God). Connecting medication adherence to one of the patients goals (the job) can serve to motivate the patient to take the medication and override concerns about losing the hallucinations. Exhorting a patient to take medication because it is needed to control his illness is unlikely to be successful, he does not believe he has an illness. Medication psychoeducation would be appropriate if the cause of nonadherence was a knowledge deficit. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 588 (Box 31 1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

6. A homeless individual diagnosed with serious mental illness, anosognosia, and a history of persistent treatment nonadherence is persuaded to come to the day program at a community mental health center. Which intervention should be the teams initial focus? a. Teach appropriate health maintenance and prevention practices. b. Educate the patient about the importance of treatment adherence. c. Help the patient obtain employment in a local sheltered workshop. d. Interact regularly and supportively without trying to change the patient.

d. Interact regularly and supportively without trying to change the patient. Given the history of treatment nonadherence and the difficulty achieving other goals until psychiatrically stable and adherent, getting the patient to accept and adhere to treatment is the fundamental goal to address. The intervention most likely to help meet that goal at this stage is developing a trusting relationship with the patient. Interacting regularly, supportively, and without demands is likely to build the necessary trust and relationships that will be the foundation for all other interventions later on. No data here suggest the patient is in crisis, so it is possible to proceed slowly and build this foundation of trust. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 588 (Box 31 1) | Page 593-594 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

7. A patient diagnosed with schizophrenia has had multiple relapses. The patient usually responds quickly to antipsychotic medication but soon discontinues the medication. Discharge plans include follow-up at the mental health center, group home placement, and a psychosocial day program. Which strategy should apply as the patient transitions from hospital to community? a. Administer a second-generation antipsychotic to help negative symptoms. b. Use a quick-dissolving medication formulation to reduce cheeking. c. Prescribe a long-acting intramuscular antipsychotic medication. d. Involve the patient in decisions about which medication is best.

d. Involve the patient in decisions about which medication is best. Persons with schizophrenia are at high risk for treatment nonadherence, so the strategy needs primarily to address that risk. Of the options here, involving the patient in the decision is best because it will build trust and help establish a therapeutic alliance with care providers, an essential foundation to adherence. Intramuscular depot medications can be helpful for promoting adherence if other alternatives have been unsuccessful, but IM medications are painful and may jeopardize the patients acceptance. All of the other strategies also apply but are secondary to trust and bonding with providers. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 588 (Box 31 1) | Page 593-594 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

22. The parent of a seriously mentally ill adult asks the nurse, Why are you making a referral to a vocational rehabilitation program? My child wont ever be able to hold a job. Which is the nurses best reply? a. We make this referral to continue eligibility for federal funding. b. Are you concerned that were trying to make your child too independent? c. If you think the program would be detrimental, we can postpone it for a time. d. Most patients are capable of employment at some level, competitive or supported.

d. Most patients are capable of employment at some level, competitive or supported. Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 591-592 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity