UNIT D

Question 1

A staff nurse completes orientation to a psychiatric unit. This nurse may expect an advanced practice nurse to perform which additional intervention?

a. Conduct mental health assessments.
b. Prescribe psychotropic medication.
c. Establish therapeutic relationships.
d. Individualize nursing care plans.

Answer 1

ANS: B
In most states, prescriptive privileges are granted to master’s-prepared nurse practitioners and clinical nurse specialists who have taken special courses on prescribing medication. The nurse prepared at the basic level is permitted to perform mental health assessments, establish relationships, and provide individualized care planning.

Question 2

A nursing student expresses concerns that mental health nurses “lose all their clinical nursing
skills.” Select the best response by the mental health nurse.
a. “Psychiatric nurses practice in safer environments than other specialties.
Nurse-to-patient ratios must be better because of the nature of the patients’
problems.”
b. “Psychiatric nurses use complex communication skills as well as critical thinking
to solve multidimensional problems. I am challenged by those situations.”
c. “That’s a misconception. Psychiatric nurses frequently use high technology
monitoring equipment and manage complex intravenous therapies.”
d. “Psychiatric nurses do not have to deal with as much pain and suffering as
medical–surgical nurses do. That appeals to me.”

Answer 2

ANS: B
The practice of psychiatric nursing requires a different set of skills than medical–surgical nursing, though there is substantial overlap. Psychiatric nurses must be able to help patients with medical as well as mental health problems, reflecting the holistic perspective these nurses must have. Nurse–patient ratios and workloads in psychiatric settings have increased, just like other specialties. Psychiatric nursing involves clinical practice, not just documentation. Psychosocial pain and suffering are as real as physical pain and suffering.

Question 3

When a new bill introduced in Congress reduces funding for care of persons diagnosed with mental illness, a group of nurses write letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled?

a. Recovery
b. Attending
c. Advocacy
d. Evidence-based practice

Answer 3

ANS: C
An advocate defends or asserts another’s cause, particularly when the other person lacks the ability to do that for self. Examples of individual advocacy include helping patients understand their rights or make decisions. On a community scale, advocacy includes political activity, public speaking, and publication in the interest of improving the human condition. Since funding is necessary to deliver quality programming for persons with mental illness, the letter-writing campaign advocates for that cause on behalf of patients who are unable to articulate their own needs.

Question 4

A family has a long history of conflicted relationships among the members. Which family member’s comment best reflects a mentally healthy perspective?

a. “I’ve made mistakes but everyone else in this family has also.”
b. “I remember joy and mutual respect from our early years together.”
c. “I will make some changes in my behavior for the good of the family.”
d. “It’s best for me to move away from my family. Things will never change.”

Answer 4

ANS: C
The correct response demonstrates the best evidence of a healthy recognition of the
importance of relationships. Mental health includes rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem. Recalling joy from earlier in life may be healthy, but the correct response shows a higher level of mental health. The other incorrect responses show blaming and avoidance.

Question 5

Which assessment finding most clearly indicates that a patient may be experiencing a mental illness? The patient

a. reports occasional sleeplessness and anxiety.
b. reports a consistently sad, discouraged, and hopeless mood.
c. is able to describe the difference between “as if” and “for real.”
d. perceives difficulty making a decision about whether to change jobs.

Answer 5

ANS: B
The correct response describes a mood alteration, which reflects mental illness. The distracters describe behaviors that are mentally healthy or within the usual scope of human experience.

Question 6

Which finding best indicates that the goal “Demonstrate mentally healthy behavior” was achieved for an adult patient? The patient

a. sees self as capable of achieving ideals and meeting demands.
b. behaves without considering the consequences of personal actions.
c. aggressively meets own needs without considering the rights of others.
d. seeks help from others when assuming responsibility for major areas of own life.

Answer 6

ANS: A

The correct response describes an adaptive, healthy behavior. The distracters describe maladaptive behaviors.

Question 7

A nurse encounters an unfamiliar psychiatric disorder on a new patient’s admission form. Which resource should the nurse consult to determine criteria used to establish this diagnosis?
a. International Statistical Classification of Diseases and Related Health Problems
(ICD-10)
b. The ANA’s Psychiatric-Mental Health Nursing Scope and Standards of Practice
c. Diagnostic and Statistical Manual of Mental Disorders (DSM-V)
d. A behavioral health reference manual

Answer 7

ANS: C
The DSM-V gives the criteria used to diagnose each mental disorder. It is the official guideline for diagnosing psychiatric disorders. The distracters may not contain diagnostic criteria for a psychiatric illness.

Question 8

A nurse wants to find a description of diagnostic criteria for anxiety disorders. Which resource would have the most complete information?

a. Nursing Outcomes Classification (NOC)
b. DSM-V
c. The ANA’s Psychiatric-Mental Health Nursing Scope and Standards of Practice
d. ICD-10

Answer 8

ANS: B
The DSM-V details the diagnostic criteria for psychiatric clinical conditions. It is the official guideline for diagnosing psychiatric disorders. The other references are good resources but do not define the diagnostic criteria.

Question 9

Which individual is demonstrating the highest level of resilience? One who

a. is able to repress stressors.
b. becomes depressed after the death of a spouse.
c. lives in a shelter for 2 years after the home is destroyed by fire.
d. takes a temporary job to maintain financial stability after loss of a permanent job.

Answer 9

ANS: D
Resilience is closely associated with the process of adapting and helps people facing tragedies, loss, trauma, and severe stress. It is the ability and capacity for people to secure the resources they need to support their well-being. Repression and depression are unhealthy. Living in a shelter for 2 years shows a failure to move forward after a tragedy. See related audience response question.

Question 10

Complete this analogy. NANDA: clinical judgment: NIC: _________________

a. patient outcomes.
b. nursing actions.
c. diagnosis.
d. symptoms.

Answer 10

ANS: B
Analogies show parallel relationships. NANDA, the North American Nursing Diagnosis Association, identifies diagnostic statements regarding human responses to actual or potential health problems. These statements represent clinical judgments. NIC (Nursing Interventions Classification) identifies actions provided by nurses that enhance patient outcomes. Nursing care activities may be direct or indirect.

Question 11

An adult says, “Most of the time I’m happy and feel good about myself. I have learned that what I get out of something is proportional to the effort I put into it.” Which number on this mental health continuum should the nurse select?

a. 1
b. 2
c. 3
d. 4
e. 5

Answer 11

ANS: E
The adult is generally happy and has an adequate self-concept. The statement indicates the adult is reality-oriented, works effectively, and has control over own behavior. Mental health does not mean that a person is always happy.

Question 12

Which disorder is an example of a culture-bound syndrome?

a. Epilepsy
b. Schizophrenia
c. Running amok
d. Major depressive disorder

Answer 12

ANS: C
Culture-bound syndromes occur in specific sociocultural contexts and are easily recognized by people in those cultures. A syndrome recognized in parts of Southeast Asia is running amok, in which a person (usually a male) runs around engaging in furious, almost indiscriminate violent behavior.

Question 13

The DSM-V classifies:

a. deviant behaviors.
b. present disability or distress.
c. people with mental disorders.
d. mental disorders people have.

Answer 13

ANS: D
The DSM-V classifies disorders people have rather than people themselves. The terminology
of the tool reflects this distinction by referring to individuals with a disorder rather than as a
“schizophrenic” or “alcoholic,” for example. Deviant behavior is not generally considered a
mental disorder. Present disability or distress is only one aspect of the diagnosis.

Question 14

A citizen at a community health fair asks the nurse, “What is the most prevalent mental disorder in the United States?” Select the nurse’s correct response.

a. Schizophrenia
b. Bipolar disorder
c. Dissociative fugue
d. Alzheimer’s disease

Answer 14

ANS: D
The 12-month prevalence for Alzheimer’s disease is 10% for persons older than 65% and 50% for persons older than 85. The prevalence of schizophrenia is 1.1% per year. The prevalence of bipolar disorder is 2.6%. Dissociative fugue is a rare disorder.

Question 15

In the majority culture of the United States, which individual has the greatest risk to be labeled mentally ill? One who

a. describes hearing God’s voice speaking.
b. is usually pessimistic but strives to meet personal goals.
c. is wealthy and gives away $20 bills to needy individuals.
d. always has an optimistic viewpoint about life and having own needs met.

Answer 15

ANS: A
The question asks about risk. Hearing voices is generally associated with mental illness, but in charismatic religious groups, hearing the voice of God or a prophet is a desirable event. Cultural norms vary, which makes it more difficult to make an accurate diagnosis. The individuals described in the other options are less likely to be labeled mentally ill.

Question 16

A patient’s relationships are intense and unstable. The patient initially idealizes the significant other and then devalues him or her, resulting in frequent feelings of emptiness. This patient will benefit from interventions to develop which aspect of mental health?

a. Effectiveness in work
b. Communication skills
c. Productive activities
d. Fulfilling relationships

Answer 16

ANS: D
The information given centers on relationships with others that are described as intense and unstable. The relationships of mentally healthy individuals are stable, satisfying, and socially integrated. Data are not present to describe work effectiveness, communication skills, or activities.

Question 17

Which belief will best support a nurse’s efforts to provide patient advocacy during a multidisciplinary patient care planning session?

a. All mental illnesses are culturally determined.
b. Schizophrenia and bipolar disorder are cross-cultural disorders.
c. Symptoms of mental disorders are unchanged from culture to culture.
d. Assessment findings in mental illness reflect a person’s cultural patterns.

Answer 17

ANS: D
Symptoms must be understood in terms of a person’s cultural background. A nurse who understands that a patient’s symptoms are influenced by culture will be able to advocate for the patient to a greater degree than a nurse who believes that culture is of little relevance. The distracters are untrue statements.

Question 18

A nurse is part of a multidisciplinary team working with groups of depressed patients. One group of patients receives supportive interventions and antidepressant medication. The other group receives only medication. The team measures outcomes for each group. Which type of study is evident?

a. Incidence
b. Prevalence
c. Comorbidity
d. Clinical epidemiology

Answer 18

ANS: D
Clinical epidemiology is a broad field that addresses studies of the natural history (or what happens if there is no treatment and the problem is left to run its course) of an illness, studies of diagnostic screening tests, and observational and experimental studies of interventions used to treat people with the illness or symptoms. Prevalence refers to numbers of new cases. Comorbidity refers to having more than one mental disorder at a time. Incidence refers to the number of new cases of mental disorders in a healthy population within a given period. See related audience response question.

Question 19

The spouse of a patient diagnosed with schizophrenia says, “I don’t understand how events from childhood have anything to do with this disabling illness.” Which response by the nurse will best help the spouse understand the cause of this disorder?

a. “Psychological stress is the basis of most mental disorders.”
b. “This illness results from developmental factors rather than stress.”
c. “Research shows that this condition more likely has a biological basis.”
d. “It must be frustrating for you that your spouse is sick so much of the time.”

Answer 19

ANS: C
Many of the most prevalent and disabling mental disorders have strong biological influences. Genetics are only one part of biological factors. Empathy does not address increasing the spouse’s level of knowledge about the cause of the disorder. The other distracters are not established facts.

Question 20

A category 5 tornado occurred in a community of 400 people. Many homes and businesses were destroyed. In the 2 years following the disaster, 140 individuals were diagnosed with posttraumatic stress disorder (PTSD). Which term best applies to these newly diagnosed cases?

a. Prevalence
b. Comorbidity
c. Incidence
d. Parity

Answer 20

ANS: C
Incidence refers to the number of new cases of mental disorders in a healthy population within a given period of time. Prevalence describes the total number of cases, new and existing, in a given population during a specific period of time, regardless of when they became ill. Parity refers to equivalence, and legislation required insurers that provide mental health coverage to offer annual and lifetime benefits at the same level provided for medical–surgical coverage. Comorbidity refers to having more than one mental disorder at a time.

Question 21

Which component of treatment of mental illness is specifically recognized by Quality and Safety Education for Nurses (QSEN)?

a. All genomes are unique.
b. Care is centered on the patient.
c. Healthy development is vital to mental health.
d. Recovery occurs on a continuum from illness to health.

Answer 21

ANS: B
The key areas of care promoted by QSEN are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

Question 22

Select the best response for the nurse to a question from another health professional regarding
the difference between a diagnosis in DSM-V and a nursing diagnosis.
a. “There is no functional difference between the two. Both identify human
disorders.”
b. “The DSM-V diagnosis disregards culture, whereas the nursing diagnosis takes
culture into account.”
c. “The DSM-V diagnosis describes causes of disorders whereas a nursing diagnosis
does not explore etiology.”
d. “The DSM-V diagnosis guides medical treatment, whereas the nursing diagnosis
offers a framework for identifying interventions for issues a patient is experiencing.”

Answer 22

ANS: D
The medical diagnosis is concerned with the patient’s disease state, causes, and cures, whereas the nursing diagnosis focuses on the patient’s response to stress and possible caring interventions. Both tools consider culture. The DSM-V is multiaxial. Nursing diagnoses also consider potential problems.

Question 23

Which nursing intervention below is part of the scope of an advanced practice psychiatric/mental health nurse rather than a basic level registered nurse?

a. Coordination of care
b. Health teaching
c. Milieu therapy
d. Psychotherapy

Answer 23

ANS: D
Psychotherapy is part of the scope of practice of an advanced practice nurse. The distracters are within a basic level registered nurse’s scope of practice.

Question 24

An experienced nurse says to a new graduate, “When you’ve practiced as long as I have, you automatically know how to take care of patients experiencing psychosis.” Which factors should the new graduate consider when analyzing this comment? (Select all that apply.)
a. The experienced nurse may have lost sight of patients’ individuality, which may
compromise the integrity of practice.
b. New research findings should be integrated continuously into a nurse’s practice to
provide the most effective care.
c. Experience provides mental health nurses with the essential tools and skills needed
for effective professional practice.
d. Experienced psychiatric nurses have learned the best ways to care for mentally ill
patients through trial and error.
e. An intuitive sense of patients’ needs guides effective psychiatric nurses.

Answer 24

ANS: A, B
Evidence-based practice involves using research findings and standards of care to provide the most effective nursing care. Evidence is continuously emerging, so nurses cannot rely solely on experience. The effective nurse also maintains respect for each patient as an individual. Overgeneralization compromises that perspective. Intuition and trial and error are unsystematic approaches to care.

Question 25

Which findings are signs of a person who is mentally healthy? (Select all that apply.)

a. Says, “I have some weaknesses, but I feel I’m important to my family and friends.”
b. Adheres strictly to religious beliefs of parents and family of origin.
c. Spends all holidays alone watching old movies on television.
d. Considers past experiences when deciding about the future.
e. Experiences feelings of conflict related to changing jobs.

Answer 25

ANS: A, D, E
Mental health is a state of well-being in which each individual is able to realize his or her own potential, cope with the normal stresses of life, work productively, and make a contribution to the community. Mental health provides people with the capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem.

Question 26

A patient in the emergency department says, “Voices say someone is stalking me. They want to kill me because I developed a cure for cancer. I have a knife and will stab anyone who is a threat.” Which aspects of the patient’s mental health have the greatest and most immediate concern to the nurse? (Select all that apply.)

a. Happiness
b. Appraisal of reality
c. Control over behavior
d. Effectiveness in work
e. Healthy self-concept

Answer 26

ANS: B, C, E
The aspects of mental health of greatest concern are the patient’s appraisal of and control over behavior. The appraisal of reality is inaccurate. There are auditory hallucinations, delusions of persecution, and delusions of grandeur. In addition, the patient’s control over behavior is tenuous, as evidenced by the plan to stab anyone who seems threatening. A healthy self-concept is lacking, as evidenced by the delusion of grandeur. Data are not present to suggest that the other aspects of mental health (happiness and effectiveness in work) are of immediate concern.

Question 27

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.

Answer 27

ANS: A
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.

Question 28

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.

Answer 28

ANS: C
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.

Question 29

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

Answer 29

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.

Question 30

A patient diagnosed with schizophrenia had an exacerbation related to medication non-adherence 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.

Answer 30

ANS: C
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.

Question 31

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.

Answer 31

ANS: B
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.

Question 32

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 antipsychotic medication.
d. who is a new parent and hears voices saying, “Smother your baby.”

Answer 32

ANS: D
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.

Question 33

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.

Answer 33

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. Smoking cessation strategies can be pursued later.

Question 34

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.

Answer 34

ANS: A
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.

Question 35

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.

Answer 35

ANS: A
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.

Question 36

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.

Answer 36

ANS: D
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.

Question 37

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
b. Case manager
c. Milieu manager
d. Provider of care

Answer 37

ANS: B
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.

Question 38

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

Answer 38

ANS: D
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.

Question 39

Which characteristic would be more applicable to a community mental health nurse than to a nurse working in an operating room?

a. Kindness
b. Autonomy
c. Compassion
d. Professionalism

Answer 39

ANS: B
A community mental health nurse often works autonomously. Kindness, compassion, and professionalism apply to both nurses.

Question 40

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 depressive disorder.
c. a catastrophic reaction to a tornado in the community.
d. schizophrenia and four hospitalizations in the past year.

Answer 40

ANS: D
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.

Question 41

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.

Answer 41

ANS: C
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.

Question 42

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

Answer 42

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 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.

Question 43

Which level of prevention activities would a nurse in an emergency department employ most often?
a. Primary b. Secondary c. Tertiary

Answer 43

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.

Question 44

The nurse assigned to 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.

Answer 44

ANS: D
An 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.

Question 45

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.

Answer 45

ANS: A
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.

Question 46

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.

Answer 46

ANS: C
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.

Question 47

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
b. Social worker
c. Recreational therapist
d. Occupational therapist

Answer 47

ANS: C
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.

Question 48

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.

Answer 48

ANS: A
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.

Question 49

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 withoutcharge 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?”

Answer 49

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. A yes/no question is non-therapeutic communication.

Question 50

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

Answer 50

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.

Question 51

A health care provider prescribed long acting antipsychotic medication injections every 3 weeks at the clinic for a patient with a history of medication nonadherence. 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

Answer 51

ANS: D
The ability of the patient to get to the clinic is of paramount importance to the success of the plan. The long acting antipsychotic medication injections relieve 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.

Question 52

Which assessment finding for a patient diagnosed with serious and persistent mental illness and living in the community merits 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.

Answer 52

ANS: B
Patients who use alcohol or illegal substances often become medication non-adherent. Medication non-adherence, along with the disorganizing influence of substances on cellular brain function, promotes relapse. The distracters do not suggest problems.

Question 53

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.”

Answer 53

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 or with individual visits.

Question 54

After a Category 5 tornado hits a community and destroys many homes and businesses, a community mental health nurse encourages victims to describe their memories and feelings about the event. This action by the nurse best demonstrates

a. triage.
b. primary prevention.
c. psychosocial rehabilitation.
d. psychiatric case management.

Answer 54

ANS: B
Tornado victims are at risk for psychiatric problems as a consequence of stress and trauma. Primary prevention occurs before any problem is manifested and seeks to reduce the incidence, or rate of new cases. Primary prevention may prevent or delay the onset of symptoms in predisposed individuals. Coping strategies and psychosocial support for vulnerable people are effective interventions in prevention. Disaster victims benefit from telling their story. Triage refers to the process of sorting out victims based on the immediacy of their needs for treatment. Psychosocial rehabilitation programs are designed to assist persons diagnosed with serious mental illness to develop living skills. Psychiatric case management refers to services to assist patients in finding housing or obtaining entitlements.

Question 55

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.”

Answer 55

ANS: A
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.

Question 56

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

Answer 56

ANS: A
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.

Question 57

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.

Answer 57

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.

Question 58

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

Answer 58

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.

Question 59

A psychiatric nurse discusses rules of the therapeutic milieu and patients’ rights with a newly admitted patient. Which rights should be included? The right to (Select all that apply)

a. have visitors.
b. confidentiality.
c. a private room.
d. complain about inadequate care.
e. select the nurse assigned to their care.

Answer 59

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.

Question 60

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. let me do whatever I choose without interfering.”

Answer 60

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.

Question 61

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 disappear.”

Answer 61

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.

Question 62

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.”

Answer 62

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.

Question 63

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

Answer 63

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.