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Varcarolis: Mental Health Nursing, 6e

Chapter 5 Study Guide MULTIPLE CHOICE 1. a. b. c. d. Select the example of tertiary prevention. Helping a person with serious and persistent mental illness learn to manage money. Restraining a psychotic patient who has become aggressive and assaultive. Teaching school-age children about the dangers of drugs and alcohol. Genetic counseling with a young couple expecting their first child.

ANS: A 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. DIF: Cognitive Level: Application REF: Text Pages: 88-89 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. a. b. c. d. Which term would be more applicable to a community mental health nurse than a nurse working in an operating room? Kindness Autonomy Compassion Professionalism

ANS: B A community mental health nurse often works autonomously. Kindness, compassion, and professionalism would apply to both nurses. DIF: Cognitive Level: Application REF: Text Page: 89 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 3. a. b. c. d. Select the example of primary prevention. Assisting a person with serious and persistent mental illness to fill a pill-minder Helping school-age children describe normal emotions people experience Leading a psychoeducational group in a partial hospitalization program Medicating an acutely ill patient who assaulted a staff person

ANS: B 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
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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 partial hospitalization program is an example of tertiary prevention. DIF: Cognitive Level: Application REF: Text Pages: 88-89 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. a. b. c. d. Which level of prevention activities would a nurse in an emergency department employ most often? Primary Secondary Tertiary Autonomy

ANS: B 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. Autonomy is not a level of prevention. DIF: Cognitive Level: Application REF: Text Pages: 88-89 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 5. a. b. c. d. Which patient would be most appropriate to refer for assertive community treatment (ACT)? A patient diagnosed with: a phobic fear of crowded places. a single episode of major depression. a catastrophic reaction to a tornado in the community. paranoid schizophrenia and four hospitalizations in the past year.

ANS: D 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. DIF: Cognitive Level: Analysis REF: Text Page: 95 TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 6. The nurse assigned to assertive community treatment (ACT) should explain the programs 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. ANS: D 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. DIF: Cognitive Level: Comprehension REF: Text Pages: 95-96 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 7. a. b. c. d. Which competency is more important for a nurse who works in a community mental health center than a psychiatric nurse who works in an inpatient unit? Problem-solving skills A calm external manner Ability to cross service systems Knowledge of psychopharmacology

ANS: C A community mental health nurse must be able to work with schools, corrections facilities, shelters, health care providers, and employers. The mental health nurse working in an inpatient unit needs only to be able to work within the single setting. All nurses need problemsolving skills. Nurses in both settings must have knowledge of psychopharmacology. DIF: Cognitive Level: Analysis REF: Text Page: 89 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 8. A suspicious, socially isolated patient lives alone, eats one meal a day at a local soup kitchen, and spends the remaining daily food allowance on cigarettes. Select a community psychiatric nurses best initial action. Explore ways to stop smoking with the patient. Report the situation to the manager of the soup kitchen. Assess the patients weight; determine foods and amounts eaten. Arrange hospitalization for the patient while a new treatment plan is formulated.

a. b. c. d.

ANS: C 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. DIF: Cognitive Level: Application REF: Text Pages: 89-90 TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 9. A patient with schizophrenia has been stable in the community for 6 weeks. Today the patients spouse calls the nurse to report the patients thinking is disorganized. The nurse makes a home visit and learns the patient is willing to take medication but forgot to have the prescription refilled. The nurse arranges a refill. Select the best outcome to add to the plan of care. The patients spouse will mark dates for prescription refills on the family calendar. The nurse will obtain prescription refills every 90 days and deliver to the patient. The patient will call the nurse weekly to discuss medication-related issues. The patient will report to the clinic for medication follow-up every week.

a. b. c. d.

ANS: A The nurse should use the patients 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. No patient issues except failure to obtain medication refill were identified. DIF: Cognitive Level: Application REF: Text Page: 92 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 10. 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 nurses best initial intervention. a. With the patients 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. Seek inpatient hospitalization. ANS: A 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. DIF: Cognitive Level: Analysis REF: Text Page: 92 TOP: Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment 11. Which activity is appropriate for a nurse engaged exclusively in community-based primary prevention? a. Substance abuse counseling b. Teaching parenting skills c. Medication follow-up d. Depression screening ANS: B 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. DIF: Cognitive Level: Application REF: Text Pages: 88-89 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. A community psychiatric nurse facilitates medication compliance for a patient by having the health care provider prescribe depot medications every 3 weeks at the clinic. 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 patients neighborhood c. The level of trust between the patient and nurse d. The availability of transportation to the clinic ANS: D 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, nonadherence will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem. DIF: Cognitive Level: Application REF: Text Pages: 91-93 TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 13. Which assessment finding for a patient in the community deserves priority intervention by the psychiatric nurse? The patient: a. was absent from two of six planned Alcoholics Anonymous meetings in the past 2 weeks. b. lives in an apartment with two patients who attend partial hospitalization programs. c. receives Social Security disability income plus a small check from a trust fund. d. has a sibling who is interested and active in care planning.

ANS: A 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. DIF: Cognitive Level: Analysis REF: Text Page: 91 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 14. A patient tells the nurse at the clinic, I have been leaving out my midday dose of antidepressant medication. I have lunch with friends and dont want them to know I take pills. Select the nurses most effective intervention. a. Investigate the possibility of once-daily dosing of the antidepressant. b. Explain how taking each dose of medication on time relates to health maintenance. c. Suggest the patient take the medication when none of the friends is watching. d. Establish the nursing diagnosis, Ineffective management of the therapeutic regimen. ANS: A Once-daily dosing has the highest potential for helping the patient achieve compliance. Many antidepressants can be administered by once-daily dosing. Explaining how taking each dose of medication on time relates to health maintenance is reasonable but would not achieve the goal, because it does not address the issue of stigma. Establishing a new nursing diagnosis would not correct the problem; the stem of the question asks for an intervention, not analysis. DIF: Cognitive Level: Application REF: Text Page: 92 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 15. A community psychiatric nurse assesses that a serious and persistently mentally ill patient with a mood disorder is more depressed than on the clinic visit a month ago, but the patient says, I feel the same. Which intervention supports the nurses assessment while preserving the patients autonomy? a. Arrange for a short hospitalization. b. Schedule weekly clinic appointments. c. Refer the patient to the crisis intervention clinic. d. Call the family and ask them to observe the patient closely. ANS: B Scheduling clinic appointments at shorter intervals will give an opportunity for more frequent assessment of symptoms and allow the nurse to use early intervention. If the patient does not have a crisis, referral to crisis intervention would be useless. The other distracters may or may not produce reliable information, may violate the patients privacy, and/or waste scarce resources. DIF: Cognitive Level: Analysis REF: Text Pages: 90-92 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment 16. In a rush of words, a patient tells the community mental health nurse, Everythings a disaster! I cannot concentrate. My disability check did not come. My roommate moved out and I cannot afford the rent. My therapist is moving away. I dont know what to do and feel like Im coming apart. Which nursing diagnosis applies? a. Decisional conflict related to challenges to personal values. b. Spiritual distress related to ethical implications of treatment regimen. c. Anxiety related to changes perceived as threatening to psychological equilibrium. d. Self-concept disturbance related to solving multiple problems affecting security needs. ANS: C Subjective and objective data obtained by the nurse suggest the patient is experiencing anxiety caused by multiple threats to security needs. Data are not present to suggest decisional conflict, ethical conflicts around treatment causing spiritual distress, or self-concept disturbance. DIF: Cognitive Level: Application REF: Text Pages: 90-92 TOP: Nursing Process: Nursing Diagnosis MSC: Client Needs: Psychosocial Integrity 17. The nurse would refer which patient to a partial hospitalization program? A patient who: a. spent yesterday in a supervised crisis care center and continues to be actively suicidal. b. needs psychoeducation for relaxation therapy related to agoraphobia and panic episodes. c. has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up. d. states, Im not sure I can avoid using alcohol when my spouse goes to work every morning. ANS: D 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. DIF: Cognitive Level: Analysis REF: Text Page: 93 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment 18. 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 patient to a community food bank. d. Coordinating psychiatric home care services. ANS: A 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. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation REF: Text Page: 97 MSC: Client Needs: Psychosocial Integrity

19. A nurse makes an initial visit to a homebound patient with mental illness. A family member offers the nurse a cup of coffee. Select the nurses best response. a. No, thank you. I do not use products that contain caffeine. b. Thank you. I would enjoy having a cup of coffee with you. c. Thank you, but I would prefer to proceed with the assessment. d. Our agency policy prohibits me from eating or drinking in patients homes. ANS: B Accepting refreshments or chatting informally with the patient and family represent therapeutic use of self and helps to establish rapport. These activities would not be prohibited by agency policy. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation REF: Text Page: 94 MSC: Client Needs: Psychosocial Integrity

20. A patient with serious mental illness lives alone in a neighborhood. The patient receives monthly depot medication injections but lately has missed regular clinic appointments, saying, My life is so busy I couldnt find time to come in. To prevent decompensation and hospitalization, the community mental health nurse should arrange for: a. a psychosocial rehabilitation program. b. assertive community treatment (ACT). c. an appointment with a nurse in private practice. d. insurance authorization to change to daily oral medication. ANS: B The assertive community treatment team could bring the patients medication to her in her neighborhood. Depot medication is a strategy to reduce noncompliance and is often preferable to daily oral medication. The other distracters do not directly relate to the noncompliance problem. DIF: Cognitive Level: Application REF: Text Page: 95 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE

1.

Which statement(s) by patients with serious, persistent mental illness best demonstrate that the case manager has established an effective long-term relationship? (Select all that apply.) My case manager: 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 lots of 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. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation 2. a. b. c. d. e. REF: Text Pages: 91-92 MSC: Client Needs: Psychosocial Integrity

Which statement(s) most clearly reflect the stigma of mental illness? (Select all that apply.) Many mental illnesses are hereditary. Mental illness can be evidence of a brain disorder. People claim mental illness so they can get disability checks. If people with mental illness went to church, they would be fine. Mental illness results from the breakdown of American families.

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. DIF: Cognitive Level: Analysis REF: Text Pages: 97-98 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 3. A person in the community asks the nurse, People with mental illnesses went to state hospitals in earlier times. Why has that changed? Select the nurses accurate response(s). (Select all that apply.) Science has made significant improvements in drugs for mental illness, so now many persons may live in their communities. Theres now a better selection of less restrictive treatment options available in communities to care for people with mental illness. National rates of mental illness have declined significantly. There actually is not a need for state institutions anymore. Most psychiatric institutions were closed because of serious violations of patients rights and unsafe conditions. Federal legislation and payment for treatment of mental illness has shifted the

a. b. c. d. e.

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. DIF: Cognitive Level: Analysis REF: Text Pages: 87-88 TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 4. A patient with schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns that the patient: Will begin attending an activities 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 the activities group meets. Wants to attend services at a church that is a half mile from the patients home. Which task(s) would be 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 patients 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. DIF: Cognitive Level: Application REF: Text Pages: 91-93 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment OTHER 1. Sequence the intensity of these psychiatric treatments from highest to lowest: A. Clinic visits at a community mental health center B. Psychosocial rehabilitation program C. Partial hospitalization D. Crisis stabilization ANS:

1. D 2. C 3. B 4. A The continuum of psychiatric treatment offers services along a range of intensity. Each patients needs are evaluated for the most appropriate venue of treatment. Patients may move from one level to another as their needs change. DIF: Cognitive Level: Analysis REF: Text Pages: 92-93 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment