Flashcards in Chapter 4 Deck (42):
1. Inpatient hospitalization for persons with mental illness is generally reserved for patients who:
a. present a clear danger to self or others.
b. are noncompliant with medication at home.
c. have limited support systems in the community.
d. develop new symptoms during the course of an illness.
Hospitalization is justified when the patient is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. The distracters do not necessarily describe patients who require inpatient treatment.
2. A patient was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the case manager learned that the patient received a notice of eviction immediately prior to admission. Select the case manager’s most appropriate action.
a. Postpone the patient’s discharge from the hospital.
b. Contact the landlord who evicted the patient to further discuss the situation.
c. Arrange a temporary place for the patient to stay until new housing can be arranged.
d. Determine whether the adverse medication reaction was genuine because the patient had nowhere to live.
The case manager should intervene by arranging temporary shelter for the patient until an apartment can be found. This activity is part of the coordination and delivery of services that falls under the case manager role. None of the other options is a viable alternative.
3. Select the example of tertiary prevention.
a. Helping a person diagnosed with a serious mental illness learn to manage money
b. Restraining an agitated patient who has become aggressive and assaultive
c. Teaching school-age children about the dangers of drugs and alcohol
d. Genetic counseling with a young couple expecting their first child
Tertiary prevention involves services that address residual impairments, with a goal of improved independent functioning. Restraint is a secondary prevention. Genetic counseling and teaching school-age children about substance abuse and dependence are examples of primary prevention.
4. A patient diagnosed with schizophrenia had an exacerbation related to medication noncompliance and was hospitalized for 5 days. The patient’s thoughts are now more organized, and discharge is planned. The patient’s family says, “It’s too soon for discharge. We will just go through all this again.” The nurse should:
a. ask the case manager to arrange a transfer to a long-term care facility.
b. notify hospital security to handle the disturbance and escort the family off the unit.
c. explain that the patient will continue to improve if the medication is taken regularly.
d. contact the health care provider to meet with the family and explain the discharge rationale.
Patients do not stay in a hospital until every symptom disappears. The nurse must assume responsibility to advocate for the patient’s right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. The health care provider will use the same rationale. Shifting blame will not change the discharge. Security is unnecessary. The nurse can handle this matter.
5. A nurse inspects an inpatient psychiatric unit and finds that exits are free of obstructions, no one is smoking, and the janitor’s closet is locked. These observations relate to:
a. coordinating care of patients.
b. management of milieu safety.
c. management of the interpersonal climate.
d. use of therapeutic intervention strategies.
Nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse’s concerns, are unrelated to the observations cited.
6. The patients below were evaluated in the emergency department. The psychiatric unit has one bed available. Which patient should be admitted? The patient:
a. feeling anxiety and a sad mood after separation from a spouse of 10 years.
b. who self-inflicted a superficial cut on the forearm after a family argument.
c. experiencing dry mouth and tremor related to taking haloperidol (Haldol).
d. who is a new parent and hears voices saying, “Smother your baby.”
Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.
7. A suspicious, socially isolated patient lives alone, eats one meal a day at a local shelter, and spends the remaining daily food allowance on cigarettes. Select a community psychiatric nurse’s best initial action.
a. Explore ways to help the patient stop smoking.
b. Report the situation to the manager of the shelter.
c. Assess the patient’s weight; determine foods and amounts eaten.
d. Arrange hospitalization for the patient in order to formulate a new treatment plan.
Assessment of biopsychosocial needs and general ability to live in the community is called for before any other action is taken. Both nutritional status and income adequacy are critical assessment parameters. A patient may be able to maintain adequate nutrition while eating only one meal a day. The rule is to assess before taking action. Hospitalization may not be necessary. Smoking cessation strategies can be pursued later.
8. A nurse surveys medical records. Which finding signals a violation of patients’ rights?
a. A patient was not allowed to have visitors.
b. A patient’s belongings were searched at admission.
c. A patient with suicidal ideation was placed on continuous observation.
d. Physical restraint was used after a patient was assaultive toward a staff member.
The patient has the right to have visitors. Inspecting patients’ belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self.
9. Which principle has the highest priority when addressing a behavioral crisis in an inpatient setting?
a. Resolve the crisis with the least restrictive intervention possible.
b. Swift intervention is justified to maintain the integrity of a therapeutic milieu.
c. Rights of an individual patient are superseded by the rights of the majority of patients.
d. Patients should have opportunities to regain control without intervention if the safety of others is not compromised.
The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the patient’s legal right. Planned interventions are nearly always preferable. Intervention may be necessary when the patient threatens harm to self.
10. Clinical pathways are used in managed care settings to:
a. stabilize aggressive patients.
b. identify obstacles to effective care.
c. relieve nurses of planning responsibilities.
d. streamline the care process and reduce costs.
Clinical pathways provide guidelines for assessments, interventions, treatments, and outcomes as well as a designated timeline for accomplishment. Deviations from the timeline must be reported and investigated. Clinical pathways streamline the care process and save money. Care pathways do not identify obstacles or stabilize aggressive patients. Staff are responsible for the necessary interventions. Care pathways do not relieve nurses of the responsibility of planning; pathways may, however, make the task easier.
11. A nurse receives these three phone calls regarding a newly admitted patient.
• The psychiatrist wants to complete an initial assessment.
• An internist wants to perform a physical examination.
• The patient’s attorney wants an appointment with the patient.
The nurse schedules the activities for the patient. Which role has the nurse fulfilled?
a. Advocate c. Milieu manager
b. Case manager d. Provider of care
Nurses on psychiatric units routinely coordinate patient services, serving as case managers as described in this scenario. The role of advocate would require the nurse to speak out on the patient’s behalf. The role of milieu manager refers to maintaining a therapeutic environment. Provider of care refers to giving direct care to the patient.
12. Which aspect of direct care is an experienced, inpatient psychiatric nurse most likely to provide for a patient?
a. Hygiene assistance
b. Diversional activities
c. Assistance with job hunting
d. Building assertiveness skills
Assertiveness training relies on the counseling and psychoeducational skills of the nurse. Assistance with personal hygiene would usually be accomplished by a psychiatric technician or nursing assistant. Diversional activities are usually the province of recreational therapists. The patient would probably be assisted in job hunting by a social worker or vocational therapist.
13. Which characteristic would be more applicable to a community mental health nurse than to a nurse working in an operating room?
a. Kindness c. Compassion
b. Autonomy d. Professionalism
A community mental health nurse often works autonomously. Kindness, compassion, and professionalism apply to both nurses.
14. Which patient would be most appropriate to refer for assertive community treatment (ACT)? A patient diagnosed with:
a. a phobic fear of crowded places.
b. a single episode of major depression.
c. a catastrophic reaction to a tornado in the community.
d. schizophrenia and four hospitalizations in the past year.
Assertive community treatment (ACT) provides intensive case management for persons with serious persistent mental illness who live in the community. Repeated hospitalization is a frequent reason for this intervention. The distracters identify mental health problems of a more episodic nature.
15. The unit secretary receives a phone call from the health insurer for a hospitalized patient. The caller seeks information about the patient’s projected length of stay. How should the nurse instruct the unit secretary to handle the request?
a. Obtain the information from the patient’s medical record and relay it to the caller.
b. Inform the caller that all information about patients is confidential.
c. Refer the request for information to the patient’s case manager.
d. Refer the request to the health care provider.
The case manager usually confers with insurers and provides the treatment team with information about available resources. The unit secretary should be mindful of patient confidentiality and should neither confirm that the patient is an inpatient nor disclose other information.
16. Select the example of primary prevention.
a. Assisting a person diagnosed with a serious mental illness to fill a pill-minder
b. Helping school-age children identify and describe normal emotions
c. Leading a psychoeducational group in a community care home
d. Medicating an acutely ill patient who assaulted a staff person
Primary preventions are directed at healthy populations with a goal of preventing health problems from occurring. Helping school-age children describe normal emotions people experience promotes coping, a skill that is needed throughout life. Assisting a person with serious and persistent mental illness to fill a pill-minder is an example of tertiary prevention. Medicating an acutely ill patient who assaulted a staff person is a secondary prevention. Leading a psychoeducational group in a community care home is an example of tertiary prevention.
17. Which level of prevention activities would a nurse in an emergency department employ most often?
a. Primary c. Tertiary
An emergency department nurse would generally see patients in crisis or with acute illness, so secondary prevention is used. Primary prevention involves preventing a health problem from developing, and tertiary prevention applies to rehabilitative activities.
18. The nurse assigned to assertive community treatment (ACT) should explain the program’s treatment goal as:
a. assisting patients to maintain abstinence from alcohol and other substances of abuse.
b. providing structure and a therapeutic milieu for mentally ill patients whose symptoms require stabilization.
c. maintaining medications and stable psychiatric status for incarcerated inmates who have a history of mental illness.
d. providing services for mentally ill individuals who require intensive treatment to continue to live in the community.
An assertive community treatment (ACT) program provides intensive community services to persons with serious, persistent mental illness who live in the community but require aggressive services to prevent repeated hospitalizations.
19. Which scenario best depicts a behavioral crisis? A patient is:
a. waving fists, cursing, and shouting threats at a nurse.
b. curled up in a corner of the bathroom, wrapped in a towel.
c. crying hysterically after receiving a phone call from a family member.
d. performing push-ups in the middle of the hall, forcing others to walk around.
This behavior constitutes a behavioral crisis because the patient is threatening harm to another individual. Intervention is called for to defuse the situation. The other options speak of behaviors that may require intervention of a less urgent nature because the patients in question are not threatening harm to self or others.
20. The case manager plans to discuss the treatment plan with a patient’s family. Select the case manager’s first action.
a. Determine an appropriate location for the conference.
b. Support the discussion with examples of the patient’s behavior.
c. Obtain the patient’s permission for the exchange of information.
d. Determine which family members should participate in the conference.
The case manager must respect the patient’s right to privacy, which extends to discussions with family. Talking to family members is part of the case manager’s role. Actions identified in the distracters occur after the patient has given permission.
21. A patient usually watches television all day, seldom going out in the community or socializing with others. The patient says, “I don’t know what to do with my free time.” Which member of the treatment team would be most helpful to this patient?
a. Psychologist c. Recreational therapist
b. Social worker d. Occupational therapist
Recreational therapists help patients use leisure time to benefit their mental health. Occupational therapists assist with a broad range of skills, including those for employment. Psychologists conduct testing and provide other patient services. Social workers focus on the patient’s support system.
22. A patient diagnosed with schizophrenia has been stable for 2 months. Today the patient’s spouse calls the nurse to report the patient has not taken prescribed medication and is having disorganized thinking. The patient forgot to refill the prescription. The nurse arranges a refill. Select the best outcome to add to the plan of care.
a. The patient’s spouse will mark dates for prescription refills on the family calendar.
b. The nurse will obtain prescription refills every 90 days and deliver to the patient.
c. The patient will call the nurse weekly to discuss medication-related issues.
d. The patient will report to the clinic for medication follow-up every week.
The nurse should use the patient’s support system to meet patient needs whenever possible. Delivery of medication by the nurse should be unnecessary for the nurse to do if patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as medication is taken as prescribed.
23. A community mental health nurse has worked for months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and could no longer afford prescribed medications. The patient says, “Only a traitor would make me go to the hospital.” Select the nurse’s best initial intervention.
a. With the patient’s consent, contact resources to provide medications without charge temporarily.
b. Arrange a bed in a local homeless shelter with nightly on-site supervision.
c. Hospitalize the patient until the symptoms have stabilized.
d. Ask the patient, “Do you feel like I am a traitor?”
Hospitalization may damage the nurse-patient relationship, even if it provides an opportunity for rapid stabilization. If medication is restarted, the patient may possibly be stabilized in the home setting, even if it takes a little longer. Programs are available to help patients who are unable to afford their medications. A homeless shelter is inappropriate and unnecessary. Hospitalization may be necessary later, but a less restrictive solution should be tried first, since the patient is not dangerous. A yes/no question is non-therapeutic communication.
24. Which activity is appropriate for a nurse engaged exclusively in community-based primary prevention?
a. Medication follow-up
b. Teaching parenting skills
c. Substance abuse counseling
d. Making a referral for family therapy
Primary prevention activities are directed to healthy populations to provide information for developing skills that promote mental health. The distracters represent secondary or tertiary prevention activities.
25. A health care provider prescribed depot injections every 3 weeks at the clinic for a patient with a history of medication noncompliance. For this plan to be successful, which factor will be of critical importance?
a. The attitude of significant others toward the patient
b. Nutrition services in the patient’s neighborhood
c. The level of trust between the patient and nurse
d. The availability of transportation to the clinic
The ability of the patient to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the patient of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, non-adherence will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem.
26. Which assessment finding for a patient in the community deserves priority intervention by the psychiatric nurse? The patient:
a. receives Social Security disability income plus a small check from a trust fund every month.
b. was absent from two of six planned Alcoholics Anonymous meetings in the past 2 weeks.
c. lives in an apartment with two patients who attend partial hospitalization programs.
d. has a sibling who was recently diagnosed with a mental illness.
Patients who use alcohol or illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of substances on cellular brain function, promotes relapse. The distracters do not suggest problems.
27. The nurse should refer which of the following patients to a partial hospitalization program? A patient who:
a. has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up.
b. needs psychoeducation for relaxation therapy related to agoraphobia and panic episodes.
c. spent yesterday in a supervised crisis care center and continues to have active suicidal ideation.
d. states, “I’m not sure I can avoid using alcohol when my spouse goes to work every morning.”
This patient could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends, the spouse could assume responsibility for supervision. A suicidal patient needs inpatient hospitalization. The other patients can be served in the community or with individual visits.
28. A Category V tornado hits a community, destroying many homes and businesses. Which nursing intervention would best demonstrate compassion and caring?
a. Encouraging persons to describe their memories and feelings about the event
b. Arranging transportation to the local community mental health center
c. Referring a local resident to a community food bank
d. Coordinating psychiatric home care services
Disaster victims benefit from telling their story. Nurses show compassion by listening and offering hope. The distracters identify other aspects of psychological first aid and services on the mental health continuum
29. A nurse makes an initial visit to a homebound patient diagnosed with a serious mental illness. A family member offers the nurse a cup of coffee. Select the nurse’s best response.
a. “Thank you. I would enjoy having a cup of coffee with you.”
b. “Thank you, but I would prefer to proceed with the assessment.”
c. “No, but thank you. I never accept drinks from patients or families.”
d. “Our agency policy prohibits me from eating or drinking in patients’ homes.”
Accepting refreshments or chatting informally with the patient and family represent therapeutic use of self and help to establish rapport. The distracters fail to help establish rapport.
30. A nurse performed these actions while caring for patients in an inpatient psychiatric setting. Which action violated patients’ rights?
a. Prohibited a patient from using the telephone
b. In patient’s presence, opened a package mailed to patient
c. Remained within arm’s length of patient with homicidal ideation
d. Permitted a patient with psychosis to refuse oral psychotropic medication
The patient has a right to use the telephone. The patient should be protected against possible harm to self or others. Patients have rights to send and receive mail and be present during package inspection. Patients have rights to refuse treatment.
1. A nurse can best address factors of critical importance to successful community treatment by including making assessments relative to: (Select all that apply.)
a. housing adequacy.
b. family and support systems.
c. income adequacy and stability.
d. early psychosocial development.
e. substance abuse history and current use.
ANS: A, B, C, E
Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a patient is homeless or fears homelessness, focusing on other treatment issues is impossible. Sufficient income for basic needs and medication is necessary. Adequate support is a requisite to community placement. Substance abuse undermines medication effectiveness and interferes with community adjustment.
2. The health care team at an inpatient psychiatric facility drafts these criteria for admission. Which criteria should be included in the final version of the admission policy? Select all that apply.
a. Clear risk of danger to self or others
b. Adjustment needed for doses of psychotropic medication
c. Detoxification from long-term heavy alcohol consumption needed
d. Respite for caregivers of persons with serious and persistent mental illness
e. Failure of community-based treatment, demonstrating need for intensive treatment
ANS: A, C, E
Medication doses can be adjusted on an outpatient basis. The goal of caregiver respite can be accomplished without hospitalizing the patient. The other options are acceptable, evidence-based criteria for admission of a patient to an inpatient service.
3. A psychiatric nurse discusses rules of the therapeutic milieu and patients’ rights with a newly admitted patient. Which rights should be included? (Select all that apply.)
The right to:
a. have visitors
c. a private room
d. complain about inadequate care
e. select the nurse assigned to their care
ANS: A, B, D
Patients’ rights should be discussed shortly after admission. Patients have rights related to receiving/refusing visitors, privacy, filing complaints about inadequate care, and accepting/refusing treatments (including medications). Patients do not have a right to a private room or selecting which nurse will provide care.
4. Which statements by patients diagnosed with a serious mental illness best demonstrate that the case manager has established an effective long-term relationship? “My case manager:
(select all that apply)
a. talks in language I can understand.”
b. helps me keep track of my medication.”
c. gives me little gifts from time to time.”
d. looks at me as a whole person with many needs.”
e. lets me do whatever I choose without interfering.”
ANS: A, B, D
Each correct answer is an example of appropriate nursing foci: communicating at a level understandable to the patient, providing medication supervision, and using holistic principles to guide care. The distracters violate relationship boundaries or suggest a laissez faire attitude on the part of the nurse.
5. Which statements most clearly reflect the stigma of mental illness? Select all that apply.
a. “Many mental illnesses are hereditary.”
b. “Mental illness can be evidence of a brain disorder.”
c. “People claim mental illness so they can get disability checks.”
d. “Mental illness results from the breakdown of American families.”
e. “If people with mental illness went to church, their symptoms would vanish.”
ANS: C, D, E
Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. Many mental illnesses are genetically transmitted. Neuroimaging can show changes associated with some mental illnesses.
6. A person in the community asks, “People with mental illnesses went to state hospitals in earlier times. Why has that changed?” Select the nurse’s accurate responses. Select all that apply.
a. “Science has made significant improvements in drugs for mental illness, so now many persons may live in their communities.”
b. “There’s now a better selection of less restrictive treatment options available in communities to care for people with mental illness.”
c. “National rates of mental illness have declined significantly. There actually is not a need for state institutions anymore.”
d. “Most psychiatric institutions were closed because of serious violations of patients’ rights and unsafe conditions.”
e. “Federal legislation and payment for treatment of mental illness has shifted the focus to community rather than institutional settings.”
ANS: A, B, E
The community is a less restrictive alternative than hospitals for treatment of persons with mental illness. Funding for treatment of mental illness remains largely inadequate but now focuses on community rather than institutional care. Antipsychotic medications improve more symptoms of mental illness; hence, management of psychiatric disorders has improved. Rates of mental illness have increased, not decreased. Hospitals were closed because funding shifted to the community. Conditions in institutions have improved.
7. A patient diagnosed with schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns that the patient:
• wants to attend an activity group at the mental health outreach center.
• is worried about being able to pay for the therapy.
• does not know how to get from home to the outreach center.
• has an appointment to have blood work at the same time an activity group meets.
• wants to attend services at a church that is a half-mile from the patient’s home.
Which tasks are part of the role of a community mental health nurse? Select all that apply.
a. Rearranging conflicting care appointments
b. Negotiating the cost of therapy for the patient
c. Arranging transportation to the outreach center
d. Accompanying the patient to church services weekly
e. Monitoring to ensure the patient’s basic needs are met
ANS: A, C, E
The correct answers reflect the coordinating role of the community psychiatric nurse case manager. Negotiating the cost of therapy and accompanying the patient to church services are interventions the nurse would not be expected to undertake. The patient can walk to the church services; the nurse can provide encouragement.
There is one bed on a locked psychiatric unit. Which of the following patients is appropriate for involuntary admission?
a. Jill, aged 23 years, a college student who has developed symptoms of anxiety and is missing classes and work
b. Michael, aged 30 years, an accountant who has developed symptoms of depression
c. Mia, aged 26 years, a kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road
d. Rose, aged 76 years, a retired librarian who is experiencing memory loss and some confusion at times
Inpatient involuntary admission is reserved for patients who are at risk for self-harm or who cannot adequately protect themselves from harm because of their illness (e.g., a psychotic patient). The other options can all be managed at this point in the community setting and don’t meet criteria (risk of harm to self and/or others) for admission.
Which of the following structural safety precautions is most important to prevent the most common type of inpatient suicides?
a. Break-away closet bars to prevent hanging
b. Bedroom and dining areas with locked windows to prevent jumping
c. Double-locked doors to prevent escaping from the unit
d. Platform beds to prevent crush injuries
Hangings are the most common method of inpatient suicide. The other options are important safety measures but don’t directly address the suicide method of hanging.
Which of the following patients would be appropriate to refer to a partial hospitalization program (PHP)?
a. Ramon, who is suicidal with a plan
b. Marty, a substance abuser who is being discharged from an inpatient alcohol rehabilitation unit
c. Ellen, who stopped taking her antipsychotic medication and is decompensated and not caring for herself
d. Jeff, who has mild depression symptoms and is starting outpatient therapy
PHP is for patients who may need a “step-down” environment from inpatient status or for those who are being diverted from hospitalization with intensive, short-term care from which they return home each day. This patient would be a good candidate after completing alcohol rehab; PHP could possibly help prevent relapse in the early stages after rehab. This patient can be managed with regular outpatient therapy and does not need intensive short-term therapy such as PHP. Someone who is suicidal would require inpatient hospitalization for safety as would someone who is decompensated and not caring for herself. A patient exhibiting mild depression would be managed with outpatient therapy and would not need intensive short-term therapy such as PHP.
George W. Bush’s New Freedom Commission on Mental Health’s report emphasized that mental illness is not a hopeless life sentence but a condition from which people can recover. Recovery, which is still the number 1 goal, could be described as:
a. the ability to work, live, and participate in the community.
b. never having to visit a mental health provider again.
c. a short-term journey that leaves people better able to cope with symptoms.
d. a long-term journey over the individual’s life span.
Recovery is described as the ability of the individual to work, live, and participate in the community. Never having to visit a mental health provider is unrealistic. Recovery is usually not a short-term journey but rather a long-term journey. While recovery may be a long-term journey over months or even years, it would not cover an entire life span.