UNIT L Flashcards
How does managed care affect the economics of health care delivery?
a.
Provides incentives for smaller private or individual hospitals
b.
Increases the tax base for the community
c.
Uses corporate economics to achieve a profit
d.
Care is paid for at a prearranged rate
ANS: D
Under a managed care system, care is paid for at a prearranged rate, rather that at the billed rate. This was the start of efforts to reduce health care costs. Managed care does not increase the community tax base because the costs are paid by the patients and their insurance. Managed care is more of an incentive for larger hospitals and corporations. The focus is to reduce duplication of services and not to use corporate economics to achieve a profit.
Which statement regarding characteristics of clinical pathways shows the nurse’s lack of understanding?
a.
“Clinical pathways focus on patient outcomes.”
b.
“Clinical pathways use a timeline with sequenced interventions.”
c.
“Clinical pathways collaborate efforts by health care professionals.”
d.
“Clinical pathways involve nurse-centered orientation.”
ANS: D
Clinical pathways help reduce expensive variations in care. Clinical pathways are interdisciplinary plans of care that outline the optimal sequencing and timing of interventions for patients with a particular diagnosis, procedure, or symptom. Clinical pathways are not a nurse-centered orientation.
Which statement shows the nurse’s understanding of patient-focused care?
a.
“Patient-focused care is a nursing care delivery system.”
b.
“Patient-focused care is a model for a health care organization.”
c.
“Patient-focused care is a clinical pathway within an institution.”
d.
“Patient-focused care is an institutional value and philosophy.”
ANS: A
Patient-focused care is another type of delivery system. The level of productivity is increased through centralization of functions (e.g., phlebotomy, diet instruction, respiratory therapy) on the unit under the direction of the nurse and cross training ancillary workers to do more than one function. The patient comes into contact with fewer people under this organizational framework.
Which statement by the nurse manager is inaccurate regarding the forces of magnetism? “Forces of magnetism include a. professional models of care.” b. consultation and resources.” c. cost reduction and sound budgets.” d. nurses as teachers.”
ANS: C
The forces of magnetism include professional models of care, consultation and resources, and nurses as teachers among several others. Budgets are not included.
A nurse manager is training a new hire. Which statement shows an understanding of functional nursing? a. “Functional nursing is organized around tasks.” b. “Functional nursing is patient led.” c. “Functional nursing is physician led.” d. “Functional nursing is unorganized.”
ANS: A
Functional nursing is where nursing care is broke into a series of tasks performed by many people, which results in a fragmented, impersonal kind of care. Fragmentation of care caused patient problems to be overlooked because they did not fit into a defined assignment. Aides, vocational nurses, and licensed practical nurses are allowed to perform functions such as administration of medication and treatments. None of the other statements is correct.
Which of the following statements shows the nurse’s understanding of primary nursing?
a.
“One nurse plans and directs patient care over 24 hours.”
b.
“Involves care for 48 hours or more”
c.
“Includes only one nurse planning care for the patient”
d.
“Is the only method of care used today”
ANS: C
In primary nursing, the fragmentation between shifts and nurses is eliminated because one nurse is accountable for planning the care of the patient around the clock. In primary nursing, an associate nurse takes over when then primary is not working. There are many models of nursing care delivery systems in use today.
Which statement is true about case management?
a.
It helps clients achieve goals effectively and efficiently.
b.
It is used to reduce resource utilization only.
c.
To be effective, it requires case managers to provide direct patient care.
d.
It eliminates the need for other caregivers (LPNs, LVNs, nursing assistants).
ANS: A
Case management is one of the strategies to reduce costs while ensuring coordination of care. Its main purpose is to help clients achieve goals, but also it is a cost control strategy. The case manager does not always provide direct care. Many other members of the health care team are involved in case management.
A nurse is interested in case management. Which statement indicates an understanding of the primary work environment of case managers?
a.
“They work most often in acute care institutions.”
b.
“Their work is focused on community activities and is based within the community.”
c.
“They typically work for insurance companies, providing coordination of care.”
d.
“All types of health care organizations, as well as organizations with health-related functions, hire case managers.”
ANS: D
Nurses who are case managers work in all types of health care institutions. They may also work for insurance or utilization review companies or in health-related areas of various types of large businesses. Registered nurses, social workers, and therapists may all be case managers, but how they perform their role depends on the scope of practice of their discipline. All case managers must be skilled at communication, critical thinking, negotiation, and collaboration. They must be knowledgeable about resources available to patients. The case manager not only deals with individual patients but also with family and other support systems of the patient; however, a case manager’s work is not focused on just the community.
Which statement is true about patient classification systems?
a.
They measure all the needs of patients.
b.
They provide an absolute formula for unit staffing.
c.
They should not be used to make patient-care assignments because acuity systems are more accurate.
d.
They have been used to determine the number of nurses needed on a unit at any one time.
ANS: D
A patient classification or acuity system is used in many acute care hospitals to estimate the intensity of nursing care required to meet patient needs. This system does not measure the needs of all patients, is not used an as absolute formula for unit staffing, and is not used to make patient assignments. Patient acuity is the measure of categorizing patients based on their nursing care requirements.
Which of the following best describes the concept of evidence-based practice?
a.
It is a method of improving nursing care and effectively maintaining cost containment.
b.
Insurance companies review the evidence of the health care practice for reimbursement.
c.
It achieves large-scale economics while providing cost-effective care.
d.
It provides for the use of recent research in current nursing practice.
ANS: D
The IOM reported that it took 17 years for research to be reflected into daily practice. Evidence-based practice is the use of the current best evidence to provide care and make decisions regarding patient care. Evidence-based practice is not a method of improving nursing care and maintaining cost containment. Insurance companies do not review the evidence of health care practice for reimbursement. Evidence-based practice does not achieve large-scale economics while providing cost-effective care.
A female patient is admitted to the labor and delivery unit, where she is assigned a registered nurse who will manage her care for the duration of her hospitalization. What type of nursing care delivery model is represented in this nursing unit? a. Functional care b. Primary care c. Patient-focused care d. Case management
ANS: B
This is an example of primary care nursing, in which the nurse is the principal or primary person to manage and coordinate the patient’s care around the clock. Patient-focused care is an interdisciplinary approach to patient care. Functional care is the provision of care by nursing and nursing ancillary staff rather than by an all-nursing staff as seen in primary care nursing. Case management is a model of care delivery in which a nurse case manager coordinates and collaborates with other health services when a patient has complicated health care needs, but the case manager may not be involved in the daily care activities of the patient.
The nurse is reviewing upcoming discharges. Which patient would a case manager be assigned to?
a.
A 55-year-old woman post hysterectomy, who has adequate support from family
b.
A 42-year-old man post appendectomy, who is able to change his own dressing
c.
A 60-year-old man post sepsis, in need of nursing home placement
d.
A 38-year-old woman, post shoulder repair, who needs to follow up with the orthopedic surgeon
ANS: C
Case managers become involved when patients with complicated health care needs are receiving care that is expensive or are receiving care from multiple providers. The patient who is post sepsis is likely to be seeing a team of doctors and will need that care transferred over to the nursing home setting. The case manager can bridge that care so that the transition is smooth for the patient. The other patients need minimal support and therefore would not qualify for case management.
A chief nursing officer wants to create a healthy work environment. What action by the CNO would be best to accomplish this goal?
a.
Use a nursing theory to support the environment and nursing care.
b.
Send unit managers to frequent leadership development workshops.
c.
Be a nursing advocate and make most nursing decisions him/herself.
d.
Offer bonuses for high-performing nurses and ancillary staff.
ANS: A
Development of and “living” a patient-centered culture in which values are known, subscribed to, and transmitted to newcomers is one way to create a healthy work environment. Using a single nursing theorist, the hospital would have values that are known to all who work there. Sending unit managers to workshops on leadership will help create good managers. Bonuses can help with retention, but the broadest option is to use a nursing theorist to undergird the nursing division. Managers and nursing staff need the autonomy and trust to make most decisions that affect their daily work
Which of the following statements about evidence-based practice shows that the nurse has an adequate understanding?
a.
“Evidence-based practice is the hospital’s protocol for providing care.”
b.
“Evidence-based practice is based on community need.”
c.
“Evidence-based practice is a set of guidelines determined by each hospital unit.”
d.
“Evidence-based practice is the use of current best evidence in making decisions about patient care.”
ANS: D
The statement “Evidence-based practice is the use of current best evidence in making decision about patient care” shows that the nurse has an adequate understanding. The other statements about evidence-based practice are false.
A new nurse is determining which hospital to apply for. The nurse has heard a lot about magnet hospitals from friends who are nurses and knows that working for a magnet hospital would mean
a.
the nurse would likely experience high job satisfaction.
b.
the nurse would likely experience poor job satisfaction.
c.
the nurse would have to have a BSN before being able to apply.
d.
the nurse would be hired after having a year of nursing experience.
ANS: A
Magnet hospitals are known for attracting and retaining nurses because of their high satisfaction rates among nurses. These hospitals have low job turnover and low nurse vacancy even when the hospital is in an area experiencing a nursing shortage.
A nurse is covering for a coworker who is on a lunch break. While administering medications, the nurse notices a bag of antibiotic hanging with another patient’s name on it. The nurse immediately stops the infusion. What should the next step be?
a.
Say nothing about the error because the patient is fine.
b.
Speak with the coworker about the error and document the error.
c.
Tell the other coworkers about the error.
d.
Tell the patient about the error.
ANS: B
The next step that the nurse should take is to speak to the coworker about the error and then fill out paperwork for documentation. The nurse needs to have a “crucial conversation” with this coworker to alert him/her about the error. This allows for a decrease in the number of errors and a safer health care environment.
The nurse assesses the quality of patient care to be higher in the Total Patient Care model because:
a.
patients are able to perform the majority of their own care.
b.
nurses are required to perform less care.
c.
nurses are able to focus all of their care on one patient.
d.
nurses are hired to care for two patients.
ANS: C
The quality of care is higher in the Total Patient Care model because nurses are able to focus all of their care on one patient instead of juggling the care of two or more.
A nurse has been assigned as team leader for the day and is working with two LPNs and two unlicensed personnel. What should the nurse do to ensure success in caring for patients?
a.
Give the assignments for the day out to the team, and plan to meet right before the end of shift.
b.
Continuously communicate with the members of the team throughout the entire day.
c.
Report changes in a patient’s condition to the health care provider only.
d.
Revise each patient’s plan of care once a shift.
ANS: B
To ensure success for the day, the nurse should continuously communicate with the members of the team throughout the entire day. The nurse should be sure to update all members of the team on any change in patient status. The LPN can also report changes in a patient’s condition to a health care provider because it doesn’t have to be the team leader. Revisions of each patient’s plan of care should be done continuously as changes arise and not just once a shift.
The nurse has an adequate understanding of patient-focused care when stating which of the following?
a.
“Patient-focused care includes the physician, who supervises care.”
b.
“Patient-focused care decreases productivity.”
c.
“In patient-focused care, the nurse supervises delivery of care.”
d.
“The patient is not an active participant in patient-focused care.”
ANS: C
In patient-focused care, the nurse (not a physician) supervises delivery of care. This system increases productivity and encourages the patient to be an active member of the health care team. Patients are encouraged to be active participants in the planning of their care.
Which type of nursing delivery models would be appropriate in a rural area that would require fewer numbers of registered nurses? (Select all that apply.) a. Functional nursing b. Team nursing c. Primary care nursing d. Patient-focused care e. Transitional care
ANS: A, B, D
When you have a limited number of nurses, then functional nursing, team nursing, and patient-focused care are useful because you can deliver quality care by using more ancillary staff. Primary care is usually 24-hour nurse coverage, and transitional care is when advanced practice nurses (APRNs) conduct assessments and—with physicians—design and coordinate patient care and discharge plans.
The nurse understands cost containment when stating which of the following? Major elements of the law that support cost containment include (Select all that apply.)
a.
“increased governmental regulation of insurers.”
b.
“less use of technology.”
c.
“increasing incentives for coordination of care.”
d.
“emphasis on physician-centered care.”
e.
“decreasing consumer out-of-pocket costs.”
ANS: A, C
Major elements of the law that supports cost containment include increased governmental regulation of insurers, increased use of technology, increasing incentives for coordination of care, emphasis on patient-centered care, and increased consumer out-of-pocket costs. These measures are in an effort to reduce the overall cost of health care.
Which actions can the hospital administrator take to reduce health care costs? (Select all that apply.)
a.
Hire case managers to see all patients who have extensive medical needs.
b.
Reduce the number of patients the hospital can accommodate.
c.
Ensure that appropriate staff is available.
d.
Encourage the use of evidence-based practice.
e.
Accept only patients with health insurance.
ANS: A, C, D
To reduce health care costs, the hospital administrator can take different actions. The hospital administrator can hire case managers to see all patients with extensive medical needs, ensure that appropriate staff is available, and encourage the use of evidence-based practice. It is not realistic for the hospital administrator to reduce the number of patients that the hospital can accommodate. It is illegal to turn away patients without health insurance.
Which statements by the nurse indicate understanding of the case manager’s role? The case manager (Select all that apply.)
a.
“guides patients through the health care delivery process.”
b.
“ensures quicker discharge for patients without insurance.”
c.
“coordinates care for the patient.”
d.
“assists patients in achieving goals effectively and efficiently.”
e.
“collaborates with the health care team.”
ANS: A, C, D, E
The role of the nurse case manager includes guiding patients through the health care delivery process, coordinating care for the patient, assisting patients in achieving goals effectively and efficiently, and collaborating with the health care team. Patients without insurance do not necessarily have a quicker discharge process.
The nurse judges that the disease management program has been successful when the patient (Select all that apply.)
a.
assumes responsibility for his/her own health.
b.
learns how to maintain good health.
c.
can state how to manage his/her chronic condition.
d.
relies on the health care team for maintenance of health.
e.
can state how to avoid worsening of health
ANS: A, B, C, E
The disease management program has been successful when the patient assumes responsibility for his/her own health, learns how to maintain good health, can state how to manage his/her chronic condition, and can state how to avoid worsening of health.
The nursing shortage is projected to reach 1.2 million by 2020. Which actions can hospitals take to retain nurses? (Select all that apply.)
a.
Create a health care system that supports nursing advancement.
b.
Encourage a work environment that fosters work group cohesion.
c.
Allow nurses to have autonomy.
d.
Reduce the number of managers within the health care system.
e.
Allow nurses a variety of specialties to choose from.
ANS: A, B, C, E
To retain nurses, hospitals must take actions that will attract nurses to their institutions. These actions can include creating a health care system that supports nursing advancement, encouraging a work environment that fosters work group cohesion, allowing nurses to have autonomy, and allowing nurses a variety of specialties to choose from.
The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, “If I avoid strangers or situations where I am alone outside at night, I’ll be safe from sexual attacks.” Choose the nurse’s best response.
a. “Your plan is not adequate. You could still be raped or sexually assaulted.”
b. “I am glad you have this excellent safety plan. Would others like to comment?”
c. “It’s better to walk with someone or call security when you enter or leave a
building.”
d. “Sexual assaults are more often perpetrated by acquaintances. Let’s discuss ways
to prevent that.”
ANS: D
Almost half of female victims have been raped by an acquaintance. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion.
A woman was found confused and disoriented after being abducted and raped at gunpoint by
an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman’s level of anxiety?
a. Weak
b. Mild
c. Moderate
d. Severe
ANS: D
Acute anxiety results from the personal threat to the victim’s safety and security. In this case, the patient’s symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level.
After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome?
a. Decreased motor activity
b. Confusion and disbelief
c. Flashbacks and dreams
d. Fears and phobias
ANS: B
Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase.
A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, “I shouldn’t have been there alone. I knew it was a dangerous area.” What is the patient’s present coping strategy?
a. Projection
b. Self-blame
c. Suppression
d. Rationalization
ANS: B
The patient’s statements reflect self-blame, an unhealthy coping mechanism. The patient’s statements do not reflect rationalization, suppression, or projection.
An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important?
a. The patient’s vital signs
b. Consent signed by the patient
c. Supervision and credentials of the examiner
d. Storage location of the patient’s personal effects
ANS: B
Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps.
A nurse in the emergency department assesses an unresponsive victim of rape. The victim’s friend reports, “That guy gave her salty water before he raped her.” Which question is most important for the nurse to ask of the victim’s friend?
a. “Does the victim have any kidney disease?”
b. “Has the victim consumed any alcohol?”
c. “What time was she given salty water?”
d. “Did you witness the rape?”
ANS: B
Salty water is a slang/street name for GHB (-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1 to 12 hours, but the duration is less important than the potential for respiratory depression. Seeking evidence is less important than the victim’s physiologic stability.
A rape victim says to the nurse, “I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?” Which communication by the nurse is most therapeutic?
a. Support the victim to separate issues of vulnerability from blame.
b. Emphasize the importance of using a buddy system in public places.
c. Reassure the victim that the outcome of the situation will be positive.
d. Pose questions about the rape and help the patient explore why it happened.
ANS: A
Although the victim may have made choices that made her vulnerable, she is not to blame for the rape. Correcting this distortion in thinking allows the victim to begin to restore a sense of control. This is a positive response to victimization. The distracters do not permit the victim to begin to restore a sense of control or offer use of nontherapeutic communication techniques. In this interaction, the victim needs to talk about feelings rather than prevention.
A rape victim tells the nurse, “I should not have been out on the street alone.” Select the nurse’s most therapeutic response.
a. “Rape can happen anywhere.”
b. “Blaming yourself increases your anxiety and discomfort.”
c. “You are right. You should not have been alone on the street at night.”
d. “You feel as though this would not have happened if you had not been alone.”
ANS: D
A reflective communication technique is most helpful. Looking at one’s role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victim’s perceived role and interfere with further discussion.
The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient.
a. The memory of the rape will be less vivid and less frightening.
b. The patient is able to describe feelings of safety and relaxation.
c. Symptoms of pain, discomfort, and anxiety are no longer present.
d. The patient agrees to a follow-up appointment with a rape victim advocate.
ANS: D
Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department.
A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful and the victim is now in recovery?
a. “I have a rash on my buttocks. It itches all the time.”
b. “Now I know what I did that triggered the attack on me.”
c. “I’m sleeping better although I still have an occasional nightmare.”
d. “I have lost 8 pounds since the attack, but I needed to lose some weight.”
ANS: C
Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victim’s sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing.
A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim?
a. “Male victims of sexual assault are usually better equipped than women to deal
with the emotional pain that occurs.”
b. “Male victims of sexual assault often experience physical injuries and are assaulted
by more than one person.”
c. “Do you have any male friends who have also been victims of sexual assault?”
d. “Why do you think you became a victim of sexual assault?”
ANS: B
Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. “Why” questions represent probing, which is a nontherapeutic communication technique. The victim may or may not have friends who have had this experience, but it is important to talk about his feelings rather than theirs.
A nurse works at rape telephone hotline. Communication with potential victims should focus on
a. explaining immediate steps victims should take.
b. providing callers with a sympathetic listener.
c. obtaining information for law enforcement.
d. arranging counseling.
ANS: A
The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Counseling is not the focus until immediate problems are resolved. The victim remains anonymous. The other distracters are inappropriate or incorrect because counselors are trained to be empathetic rather than sympathetic.
A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for
a. coma.
b. seizures.
c. hypotonia.
d. respiratory depression.
ANS: D
Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma.
Before a victim of sexual assault is discharged from the emergency department, the nurse should
a. notify the victim’s family to provide emotional support.
b. offer to stay with the patient until stability is regained.
c. advise the patient to try not to think about the assault.
d. provide referral information verbally and in writing.
ANS: D
Immediately after the assault, rape victims are often disorganized and unable to think well or remember instructions. Written information acknowledges this fact and provides a solution. The distracters violate the patient’s right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.
A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, “I can’t believe I’ve been raped.” This behavior is characteristic of which stage of rape-trauma syndrome?
a. The acute phase reaction
b. The long-term phase
c. A delayed reaction
d. The angry stage
ANS: A
The victim’s response is typical of the acute phase and shows cognitive, affective, and behavioral disruptions. This response is immediate and does not include a display of behaviors suggestive of the long-term (reorganization) phase, anger, or a delayed reaction.
A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person’s rights, the nurse should
a. say, “You may not leave until you receive prophylactic treatment for sexually
transmitted diseases.”
b. provide written information about physical and emotional reactions the person may
experience.
c. explain the need and importance of infectious disease and pregnancy tests.
d. give verbal information about legal resources in the community
ANS: B
All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to later. Patients may not be kept against their will or coerced into treatment. This constitutes false imprisonment.
An unconscious teenager is treated in the emergency department. The teenager’s friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on
a. preserving rape evidence.
b. maintaining physiological stability.
c. determining what drugs were ingested.
d. obtaining a description of the rape from a friend.
ANS: B
Because the patient is unconscious, the risk for airway obstruction is present. The nurse’s priority will focus on maintaining physiological stability. The distracters are of lower priority than preserving physiological functioning.
A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, “I will never be the same again. I can’t face my friends. There is no reason to go on.” Select the nurse’s most appropriate response.
a. “Are you thinking of harming yourself?”
b. “It will take time, but you will feel the same as before the attack.”
c. “Your friends will understand when you explain it was not your fault.”
d. “You will be able to find meaning from this experience as time goes on.”
ANS: A
The patient’s words suggest hopelessness. Whenever hopelessness is present, so is suicide risk. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment.
When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase, which symptoms should be included? (Select all that apply.)
a. Development of fears and phobias
b. Decreased motor activity
c. Feelings of numbness
d. Flashbacks, dreams
e. Syncopal episodes
ANS: A, C, D
These reactions are common to the long-term phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes would not be expected.
A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? (Select all that apply.)
a. Allow the patient to talk at a comfortable pace.
b. Place the patient in a private room with a caregiver.
c. Pose questions in nonjudgmental, empathetic ways.
d. Invite the patient’s family members to the examination room.
e. Put an arm around the patient to demonstrate support and compassion.
ANS: A, B, C
Neutral, nonjudgmental care and emotional support are critical to crisis management for the rape victim. The rape victim should have privacy but not be left alone. The rape victim’s anxiety may escalate when touched by a stranger, even when the stranger is a nurse. Some rape victims prefer not to have family involved. The patient’s privacy may be compromised by family presence.
An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? (Select all that apply.)
a. Camera
b. Body map
c. DNA swabs
d. Pulse oximeter
e. Sphygmomanometer
ANS: A, B, C
Body maps, DNA swabs, and photographs are used to collect and preserve body fluids and other forensic evidence.
Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.)
a. Coping mechanisms, the patient is using
b. The patient’s previous sexual experiences
c. The patient’s history of sexually transmitted diseases
d. Signs and symptoms of emotional and physical trauma
e. Adequacy and availability of the patient’s support system
ANS: A, D, E
The nurse assesses the victim’s level of anxiety, coping mechanisms, available support systems, signs and symptoms of emotional trauma, and signs and symptoms of physical trauma. The history of STDs or previous sexual experiences has little relevance.
A rape victim tells the emergency nurse, “I feel so dirty. Help me take a shower before I get examined.” The nurse should (Select all that apply.)
a. arrange for the victim to shower.
b. explain that bathing destroys evidence.
c. give the victim a basin of water and towels.
d. offer the victim a shower after evidence is collected.
e. explain that bathing facilities are not available in the emergency department.
ANS: B, D
As uncomfortable as the victim may be, she should not bathe until the examination is completed. Collection of evidence is critical for prosecution of the attacker. Showering after the examination will provide comfort to the victim. The distracters will result in destruction of evidence or are untrue.
Which scenarios describe completed rape? (Select all that apply.)
a. A husband forces vaginal sex when he comes home intoxicated from a party. The
wife objects.
b. A woman’s lover pleads with her to have oral sex. She gives in but later regrets the
decision.
c. A person is beaten, robbed, and forcibly subjected to anal penetration by an
assailant.
d. A dentist gives anesthesia for a procedure and then has intercourse with the
unconscious patient.
e. A perpetrator grabs a potential victim, tears off most of her clothing, and fondles
her breasts before she escapes.
ANS: A, C, D
The correct responses depict scenarios of completed rape. The incorrect responses represent consensual sexual contact and sexual assault. Consensual sex is not considered rape if the participants are of legal age.
A student nurse visiting a senior center says, “It’s depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion.” The student is expressing
a. reality.
b. ageism.
c. empathy.
d. vulnerability.
ANS: B
Ageism is a bias against older people because of their age. None of the other options applies to the ideas expressed by the student.
A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include?
a. Pain assessment techniques for older adults
b. Psychosocial stimulation for those who live alone
c. Preparation of psychiatric advance directives in the elderly
d. Ways to manage disinhibition in elderly persons with dementia
ANS: A
The topic of greatest immediacy is the assessment of pain in older adults. Unmanaged pain can precipitate other problems, such as substance abuse and depression. Elderly patients are less likely to be accurately diagnosed and adequately treated for pain. The distracters are unrelated or of lesser importance.
Select the best comment for a nurse to begin an interview with an elderly patient.
a. “I am a nurse. Are you familiar with what nurses do?”
b. “Hello. I am going to ask you some questions to get to know you better.”
c. “You look comfortable and ready to participate in an admission interview. Shall
we get started?”
d. “Hello. My name is _______ and I am a nurse. How you would like to be
addressed by staff?”
ANS: D
The correct opening identifies the nurse’s role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should address patients by name and not assume patients want to be called by a first name. The nurse should always introduce self.
Which information is most important to obtain during assessment of an older adult diagnosed with health problems?
a. Functional ability and emotional status
b. Chronological age and sexual function
c. Economic status and sources of income
d. Developmental history, interests, and activities
ANS: A
Information related to functional ability and emotional status provides an overview of a patient’s problems and abilities. It guides selection of interventions and services to meet identified needs. The distracters reflect information of relevance, but are not of highest priority.
A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important?
a. Complete a neurological assessment.
b. Determine whether the patient can hear as the nurse speaks.
c. Suggest that the patient lie down in a darkened room for a few minutes.
d. Administer medication to relieve the patient’s pain before continuing the
assessment.
ANS: B
Before proceeding with any further assessment, the nurse should assess the patient’s ability to hear questions. Impaired hearing could lead to inaccurate answers.
Which statement about aging provides the best rationale for focused assessment of elderly patients?
a. The elderly are usually socially isolated and lonely.
b. Vision, hearing, touch, taste, and smell decline with age.
c. The majority of elderly patients have some form of early dementia.
d. As people age, thinking becomes more rigid and learning is impaired.
ANS: B
Only the key is a true statement. It cues the nurse to assess sensory function in the elderly patient. Correcting vision and hearing are critical to providing safe care. The distracters are myths about aging.
A nurse assesses an elderly patient. The nurse should complete the Geriatric Depression Scale if the patient answers which question affirmatively.
a. “Would you say your mood is often sad?”
b. “Are you having any trouble with your memory?”
c. “Have you noticed an increase in your alcohol use?”
d. “Do you often experience moderate to severe pain?”
ANS: A
Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need for further assessment for other symptoms of depression. The other options do not focus on mood.
A health care provider writes these new prescriptions for a resident in a skilled nursing
facility: 2 g sodium diet, restraint as needed, limit fluids to 1800 mL daily, continue
antihypertensive medication, milk of magnesia 30 mL PO once if no bowel movement for 3
days. The nurse should
a. question the fluid restriction.
b. question the order for restraint.
c. transcribe the prescriptions as written.
d. assess the resident’s bowel elimination.
ANS: B
Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate.
An elderly patient must be physically restrained. Who is responsible for the patient’s safety?
a. The nurse assigned to care for the patient
b. Unlicensed assistive personnel who apply the restraint
c. Family member who agrees to application of the restraint
d. Health care provider who prescribed application of restraint
ANS: A
Although restraint is prescribed by a health care provider, the restraint is a measure carried out by nursing staff. The nurse caring for the patient is responsible for safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the application of restraining devices and the care of the patient in restraint, but the nurse remains responsible for outcomes. Even when family agree to restraint, nurses are responsible for providing safe outcomes.
A new nurse asks, “My elderly patient’s CT scan of the head shows many Lewy bodies are present. What should I do about assessing for pain?” Select the best response from the nurse manager.
a. “Ask the patient’s family if they think the patient is experiencing pain.”
b. “Use a visual analog scale to help the patient determine the presence and severity of pain.”
c. “There are special scales for assessing patients with dementia. Let’s review how to use them.”
d. “The perception of pain is diminished by this type of dementia. Focus your assessment on the patient’s mental status.”
ANS: C
Lewy bodies associated with dementia [Faculty note: Lewy bodies are defined and addressed
in Chapter 23]. There are special scales to assess the presence and severity of pain in patients
with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing,
negative vocalizations, body language, and consolability. A patient with dementia would be
unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths.
An advance directive gives legally binding direction for health care interventions when a patient
a. has a new diagnosis of cancer.
b. is diagnosed with Parkinson’s disease.
c. is unable to make decisions for self because of illness.
d. diagnosed with amyotrophic lateral sclerosis is unable to speak.
ANS: C
Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinson’s disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking.
A patient asks, “What advantage does a durable power of attorney for health care have over a living will?” The nurse should reply, “A durable power of attorney for health care
a. gives your agent authority to make decisions during any illness if you are
incapacitated.”
b. can be given only to a relative, usually the next of kin, who has your best interests
at heart.”
c. can be used only if you have a terminal illness and become incapacitated.”
d. cannot be implemented until 30 days after the documents are signed.”
ANS: A
A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individual’s agent in the event that he or she is unable to make medical decisions. No waiting period is required for it to become effective, and the individual does not have to be terminally ill or incompetent for the person appointed to act on the individual’s behalf.
A physically frail elderly patient with mild cognitive impairments needs services of a facility that can provide supervision and safety as well as recreation and social interaction. The family cares for this patient during the evening and night. Which type of facility should the nurse suggest to meet this patient’s needs?
a. Adult day care program
b. Skilled nursing facility
c. Partial hospitalization
d. Group home
ANS: A
A day care program provides recreation and social interaction as well as supervision in a safe environment. Nursing, medical, and rehabilitative care are usually not provided. Skilled nursing facilities go beyond meeting recreational and social needs by providing medical interventions and nursing and rehabilitation services on a 24-hour basis. Partial hospitalization provides acute psychiatric hospital programs. A group home is inappropriate and would not meet the patient’s needs.
A 79-year-old white male tells a nurse, “I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.” The nurse should analyze this comment as
a. normal pessimism of the elderly.
b. evidence of risks for suicide.
c. a call for sympathy.
d. normal grieving.
ANS: B
The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.
In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse’s priority is to determine whether which nursing diagnosis applies to this patient?
a. Risk for suicide related to recent deaths of significant others
b. Anxiety related to sudden and abrupt lifestyle changes
c. Social isolation related to loss of existing family
d. Spiritual distress related to anger with God
ANS: A
The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patient’s social isolation is important, but the risk for suicide has higher priority.
When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
a. Evidence of spasticity or flaccidity
b. The patient’s level of motor activity
c. Medications the patient has recently taken
d. Level of preoccupation with somatic symptoms
ANS: C
Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.
An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, “It’s awful to be old. Every day is a struggle. No one cares about old people.” Select the nurse’s best response.
a. “Everyone here cares about old people. That’s why we work here.”
b. “It sounds like you’re having a difficult time. Tell me about it.”
c. “Let’s not focus on the negative. Tell me something good.”
d. “You are still able to get around, and your mind is alert.”
ANS: B
The nurse uses empathetic understanding to permit the patient to express frustration and clarify her “struggle” for the nurse. The distracters block communication.
A 76-year-old is indifferent and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization?
a. Orientation
b. Activity group
c. Psychotherapy
d. Reminiscence
ANS: D
Reminiscence therapy in a group setting can help to resocialize regressed and apathetic patients. The nurse can encourage discussion about past pleasant events or memories: first car, favorite memory from school, favorite band or song, seasonal activities growing up, etc. Assisting to evoke pleasant feelings or memories is an effective method to improve mood particularly in those with memory impairment. Group psychotherapy would not be effective for this patient. An activity group does not address the patient’s problem. Orientation groups can exacerbate a patient’s distress.
A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who
a. consumes 1 glass of wine nightly with dinner.
b. began drinking alcohol daily after retirement and says, “A few drinks keep my
mind off my arthritis.”
c. drank socially throughout adult life and continues this pattern, saying “I’ve earned
the right to do as I please.”
d. abused alcohol between the ages of 25 and 40 but now abstains and occasionally
attends Alcoholics Anonymous (AA).
ANS: B
Alcohol abuse and dependence can develop at any age, and the geriatric population is particularly at risk. Losses, such as retirement, widowhood, and loneliness, are often related. The distracters describe patients with a lower risk for alcohol abuse.
A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin this assessment.
a. “Are there any things going on in your life that would cause you to consider
suicide?”
b. “What are your beliefs about a person’s right to take his or her own life?”
c. “Do you think you are vulnerable to developing a depressed mood?”
d. “If you felt suicidal, would you tell someone about your feelings?”
ANS: B
This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion.
A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, “I get lonely and drink a little to help me forget.” Select the nurse’s most therapeutic intervention.
a. Assess whether this patient is drinking and driving.
b. Advise the person not to drink alone because the risks for injury increase.
c. Teach the person about risks for alcoholism and suggest other coping strategies.
d. Arrange for the person to attend an AA meeting for older adults.
ANS: D
This person needs help with alcohol abuse as well as social involvement. An AA meeting for
older adults will provide an opportunity for peer bonding as well as strategies for coping with
stress without abusing alcohol. The distracters will not be therapeutic in this instance.
Discharge planning begins for an elderly patient hospitalized for 2 weeks diagnosed with major depressive disorder. The patient needs ongoing assessment and socialization opportunities as well as education about medication and relapse prevention. The patient lives with a daughter, who works during the week. Select the best referral for this patient.
a. Behavioral health home care
b. A skilled nursing facility
c. Partial hospitalization
d. A halfway house
ANS: C
Partial hospitalization will provide services the patient needs as well as give supervision and meals to the patient while the daughter is at work. Home care would not provide socialization. The patient does not need the intensity of a skilled nursing facility. A halfway house provides 24-hour care and usually expects involvement in off-campus programs.
A patient living in community housing for the elderly says, “I don’t go to the senior citizen’s club. They play cards and talk about the past because that’s all they can do.” The nurse analyzes these remarks to represent
a. failure to achieve developmental tasks.
b. thinking associated with ageism.
c. hypercritical behavior.
d. paranoid thinking.
ANS: B
Ageism is negative stereotyping and devaluation of people based on their age. Older adults might be as guilty of ageism as younger individuals. The other options are not substantiated by the information given in the scenario.
A nurse plans a staff education program for employees of a senior living community. Which topic has priority?
a. Late-onset schizophrenia
b. Depression and suicide
c. Dementia
d. Delirium
ANS: B
Older Americans frequently experience undiagnosed depression and are disproportionately
more likely to commit suicide. Educating staff about signs and symptoms of high-risk patients
and early intervention strategies will decrease morbidity and mortality. The other conditions have a lower prevalence.
An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful?
a. Ask questions that can be answered with “yes” or “no.”
b. Ask clear, simple questions using concrete language.
c. Use silence often and let the patient take the lead.
d. Use open-ended, indirect questions.
ANS: B
Communication with individuals with a long history of schizophrenia might be difficult because of the individual’s various thought disorders. The nurse can be most effective by using simple language, keeping to concrete concepts, and clarifying and validating as needed. The nurse needs more information than “yes” or “no” questions will provide.
An elderly patient brings a bag of medications to the clinic. The nurse finds bottles of medications as well as assorted pills in no containers in the bag. What is the nurse’s priority action?
a. Dispose of all medications that are not in properly labeled bottles.
b. Confer with a family member about the patient’s management of medication.
c. Engage the patient in education about safe storage and labeling of medication.
d. Ask the patient to name the purpose and date of expiration of each medication not
in a bottle.
ANS: C
The patient needs medication education and help with proper, safe, and consistent labeling of medications. There is no evidence that the patient cannot self-administer medication. The nurse does not have the authority to dispose of the patient’s property. The nurse would first need to obtain the patient’s consent to confer with family. While the patient may be able to name the purpose of each unbottled medication, naming the expiration date is unlikely and may frustrate the patient.
The highest priority for assessment by nurses caring for older adults who self-administer medications is
a. use of multiple drugs with anticholinergic effects.
b. overuse of medications for erectile dysfunction.
c. missed doses of medications for arthritis.
d. trading medications with acquaintances.
ANS: A
Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries. The distracters may be relevant but are not the highest priority.
A nurse and social worker co-lead a reminiscence group for eight old-old and centenarian adults. Which activity is appropriate to include in the group?
a. Mild aerobic exercise
b. Singing a song from World War II
c. Discussing national leadership during the Vietnam War
d. Identifying the most troubling story in today’s newspaper
ANS: B
Old-old adults and centenarians are persons 85 to 104 years of age. They were young people during World War II. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group or reminiscence.
A nurse and social worker co-lead a reminiscence group for eight young-old adults. Which activity is most appropriate to include in the group?
a. Mild aerobic exercise
b. Singing a song from World War II
c. Discussing national leadership during the Vietnam War
d. Identifying the most troubling story in today’s newspaper
ANS: C
Young-old adults are persons 65 to 75 years of age. These adults were attuned to conflicts in national leadership associated with the Vietnam War. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group or reminiscence.
A nurse leads a staff development session about ageism among health care workers. What information should the nurse include about the consequences of ageism? (Select all that apply.)
a. Failure of the elderly to receive necessary medical information
b. Development of public policy that discriminates against the elderly
c. Staff shortages because caregivers prefer working with younger adults
d. The perception that elderly consume a smaller share of medical resources
e. More ancillary than professionNaUl RpSeIrNsoGnTnBe.lCdOiMscriminate with regard to age
ANS: A, B, C
Because of society’s negative stereotyping of the elderly as having little to offer, some staff persons avoid working with older patients. Staff shortages in long-term care are common. Elderly patients are often provided less information about their conditions and fewer treatment options than younger patients are because some health care staff members perceive them as less able to understand. This problem exists among both professional and ancillary personnel. Public policy discriminates against programs for the elderly. Anger exists because the elderly are perceived to consume a disproportionately large share of medical resources.
A nurse assessing an elderly patient for depression and suicide potential should include questions about mood as well as (Select all that apply.)
a. personal hygiene.
b. increased appetite.
c. sleep pattern changes.
d. evidence of grandiosity.
e. increased concerns with bodily functions.
ANS: A, C, E
The correct responses relate to symptoms often noted in elderly patients with depression. Somatic symptoms are often present but missed by nurses as related to depression. Anorexia, rather than hyperphagia, occurs in major depression. Grandiosity is associated with bipolar disorder.
Which assessment findings would alert the nurse that an older patient may have an increased risk for development of geriatric alcohol abuse? (Select all that apply.)
a. Mild recent memory impairment
b. Eighth grade education
c. Death of spouse
d. Retirement
e. Loneliness
ANS: B, C, D, E
The geriatric problem drinker begins drinking in later life, often in response to stressors such as retirement, loss of spouse, and loneliness. Once the demands of job, career, and care of a family and household are gone, the structure of daily life is disrupted. Mild cognitive impairment is not a predisposing factor in the development of geriatric problem drinking. Other risk factors include less than a high school education, smoking, low income, and male gender.
Which remarks by a 72-year-old patient should prompt the nurse to assess for depression? (Select all that apply.)
a. “Lately I have had a lot of aches and pains and just haven’t felt very well.”
b. “People are in and out of my room all day and all night taking my things.”
c. “Don’t ask me to eat. I can’t because my stomach is upset all the time.”
d. “I’m eating more than usual, and I am sleeping about 6 hours a night.”
e. “Life seems more organized now that I don’t live in my own home.”
ANS: A, B, C
Any of the remarks listed as correct should be enough to trigger use of an assessment tool for depression. Somatic symptoms, delusions of persecution, and nihilistic delusions are more common in late-onset depression than in early-onset depression. The distracters do not suggest symptoms of depression.
Which beliefs by a nurse facilitate provision of safe, effective care for older adult patients? (Select all that apply.)
a. Sexual interest declines with aging.
b. Older adults are able to learn new tasks.
c. Aging results in a decline in restorative sleep.
d. Older adults are prone to become crime victims.
e. Older adults are usually lonely and socially isolated.
ANS: B, C, D
Myths about aging are common and can negatively impact the quality of care older patients receive. Older individuals are more prone to become crime victims. A decline in restorative sleep occurs as one ages. Learning continues long into life. These factors affect care delivery.
After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This patient now requires continual direction to accomplish activities of daily living and expects others to provide meals and do laundry. The nurse assesses this behavior as the probable result of
a. side effects of antipsychotic medications.
b. dependency caused by institutionalization.
c. cognitive deterioration from schizophrenia.
d. stress associated with acclimation to the community.
ANS: B
Institutions tend to impede independent functioning; for example, daily activities are planned and directed by staff; others provide meals and only at set times. Over time, patients become dependent on the institution to meet their needs and adapt to being cared for rather than caring for themselves. When these patients return to the community, many continue to demonstrate passive behaviors despite efforts to promote. Cognitive dysfunction and antipsychotic side effects can make planning and carrying out activities more difficult, but the question is more suggestive of adjustment to institutional care and difficulty readjusting to independence instead.
An adult diagnosed with a serious mental illness (SMI) says, “I do not need help with money management. I have excellent ideas about investments.” This patient usually does not have money to buy groceries by the middle of the month. The nurse assesses the patient as demonstrating
a. rationalization.
b. identification.
c. anosognosia.
d. projection.
ANS: C
The patient scenario describes anosognosia, the inability to recognize one’s deficits due to one’s illness. The patient is not projecting an undesirable thought or emotion from himself onto others. He is not justifying his behavior via rationalization and is not identifying with another.
Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with SMI?
a. Clubhouse model
b. Cognitive-behavioral therapy (CBT)
c. Assertive community treatment (ACT)
d. Cognitive enhancement therapy (CET)
ANS: C
ACT involves consumers working with a multidisciplinary team that provides a comprehensive array of services. At least one member of the team is available 24 hours a day for crisis needs, and the emphasis is on treating the patient within his own environment.
An outpatient diagnosed with schizophrenia tells the nurse, “I am here to save the world. I threw away the pills because they make God go away.” The nurse identifies the patient’s reason for medication nonadherence as
a. poor alliance with clinicians.
b. inadequate discharge planning.
c. dislike of medication side effects.
d. thought disturbances associated with the illness.
ANS: D
The patient’s nonadherence is most closely related to thought disturbances associated with the
illness. The patient believes he is an exalted personage who hears God’s voice rather than an
individual with a serious mental disorder who needs medication to control his symptoms.
While the distracters may play a part in the patient’s nonadherence, the correct response is most likely.
An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, “I threw away the pills because they keep me from hearing God.” Which response by the nurse would most likely to benefit this patient?
a. “You need your medicine. Your schizophrenia will get worse without it.”
b. “Do you want to be hospitalized again? You must take your medication.”
c. “I would like you to come to the medication education group every Thursday.”
d. “I noticed that when you take the medicine, you are able to keep the job you
wanted. ”
ANS: D
The patient appears not to understand that he has an illness. He has stopped his medication because it interferes with a symptom that he finds desirable (auditory hallucinations—the voice of God). Connecting medication adherence to one of the patient’s goals (the job) can serve to motivate the patient to take the medication and override concerns about losing the hallucinations. Exhorting a patient to take medication because it is needed to control his illness is unlikely to be successful; he does not believe he has an illness. Medication psychoeducation would be appropriate if the cause of nonadherence was a knowledge deficit.
A homeless individual diagnosed with SMI and a history of persistent treatment nonadherence plans to begin attending the day program at a community mental health center. Which intervention should be the team’s initial focus?
a. Teach appropriate health maintenance and prevention practices.
b. Educate the patient about the importance of treatment adherence.
c. Help the patient obtain employment in a local sheltered workshop.
d. Interact regularly and supportively without trying to change the patient.
ANS: D
Given the history of treatment nonadherence and the difficulty achieving other goals until psychiatrically stable and adherent, getting the patient to accept and adhere to treatment is the fundamental goal to address. The intervention most likely to help meet that goal at this stage is developing a trusting relationship with the patient. Interacting regularly, supportively, and without demands is likely to build the necessary trust and relationships that will be the foundation for all other interventions later on. No data here suggest the patient is in crisis, so it is possible to proceed slowly and build this foundation of trust.
A hospitalized patient diagnosed with schizophrenia has a history of multiple relapses. The
patient usually responds quickly to antipsychotic medication but soon discontinues the
medication. Discharge plans include follow-up at the mental health center, group home
placement, and a psychosocial day program. Which strategy should apply first as the patient transitions from hospital to community?
a. Administer a second-generation antipsychotic to help negative symptoms.
b. Use a quick-dissolving medication formulation to reduce “cheeking.”
c. Prescribe a long-acting intramuscular antipsychotic medication.
d. Involve the patient in decisions about which medication is best.
ANS: D
Persons with schizophrenia are at high risk for treatment nonadherence, so the strategy needs primarily to address that risk. Of the options here, involving the patient in the decision is best because it will build trust and help establish a therapeutic alliance with care providers, an essential foundation to adherence. Intramuscular depot medications can be helpful for promoting adherence if other alternatives have been unsuccessful, but IM medications are painful and may jeopardize the patient’s acceptance. All of the other strategies also apply but are secondary to trust and bonding with providers.
The sibling of a patient who was diagnosed with a SMI asks why a case manager has been assigned. The nurse’s reply should cite the major advantage of the use of case management as: a. “The case manager can modify traditional psychotherapy for homeless patients so
that it is more flexible.”
b. “Case managers coordinate services and help with accessing them, making sure the patient’s needs are met.”
c. “The case manager can focus on social skills training and esteem building in the real world where the patient lives.”
d. “Having a case manager has been shown to reduce hospitalizations, which prevents disruption and saves money.”
ANS: B
The case manager helps the patient gain entrance into the system of care, can coordinate multiple referrals that so often confuse the seriously mentally ill person and his family, and can help overcome obstacles to access and treatment participation. Case managers do not usually possess the credentials needed to provide psychotherapy or function as therapists. Case management promotes efficient use of services in general, but only ACT programming has been shown to reduce hospitalization (which the sibling might see as a disadvantage). Case managers operate in the community, but this is not the primary advantage of their services.
A family discusses the impact of a seriously mental ill member. Insurance partially covers treatment expenses, but the family spends much of their savings for care. The patient’s sibling says, “My parents have no time for me.” The parents are concerned that when they are older, there will be no one to care for the patient. Which response by the nurse would be most helpful?
a. Acknowledge their concerns and consult with the treatment team about ways to
bring the patient’s symptoms under better control.
b. Give them names of financial advisors that could help them save or borrow
sufficient funds to leave a trust fund to care for their loved one.
c. Refer them to crisis intervention services to learn ways to manage caregiver stress
and provide titles of some helpful books for families.
d. Discuss benefits of participating in National Alliance on Mental Illness (NAMI)
programs and ways to help the patient become more independent.
ANS: D
The family has raised a number of concerns, but the major issues appear to be the effects caregiving has had on the family and their concerns about the patient’s future. NAMI offers support, education, resources, and access to other families who have experience with the issues now facing this family. NAMI can help address caregiver burden and planning for the future needs of SMI persons. Improving the patient’s symptom control and general functioning can help reduce caregiver burden but would likely be a slow process, whereas NAMI involvement could benefit them on a number of fronts, possibly in a shorter time period. The family will need more than financial planning; their issues go beyond financial. The family is distressed but not in crisis. Crisis intervention is not an appropriate resource for the longer-term issues and needs affecting this family.
A patient diagnosed with a SMI lives independently and attends a psychosocial rehabilitation program. The patient presents at the emergency department seeking hospitalization. The patient has no acute symptoms but says, “I have no money to pay my rent or refill my prescription.” Select the nurse’s best action.
a. Involve the patient’s case manager to provide crisis intervention.
b. Send the patient to a homeless shelter until housing can be arranged.
c. Arrange for a short in-patient admission and begin discharge planning.
d. Explain that one must have active psychiatric symptoms to be admitted.
ANS: A
Impaired stress tolerance and problem-solving abilities can cause persons with SMI to experience relatively minor stressors as crises. This patient has run out of money, and this has overwhelmed her ability to cope, resulting in a crisis for which crisis intervention would be an appropriate response. Inpatient care is not clinically indicated nor is the patient homeless (although she may fear she is). Telling the patient that she is not symptomatic enough to be admitted may prompt malingering.
The nurse wants to enroll a patient with poor social skills in a training program for patients diagnosed with schizophrenia. Which description accurately describes social skills training?
a. Patients learn to improve their attention and concentration.
b. Group leaders provide support without challenging patients to change.
c. Complex interpersonal skills are taught by breaking them into simpler behaviors.
d. Patients learn social skills by practicing them in a supported employment setting.
ANS: C
In social skills training, complex interpersonal skills are taught by breaking them down into component behaviors that are covered in a stepwise fashion. Social skills training is not based in employment settings, although such skills can be addressed as part of supported employment services. The other distracters are less relevant to social skills training.
A patient diagnosed with a SMI died suddenly at age 52. The patient lived in the community for 5 years without relapse and held supported employment the past 6 months. The distressed family asks, “How could this happen?” Which response by the nurse accurately reflects research and addresses the family’s question?
a. “A certain number of people die young from undetected diseases, and it’s just one of those sad things that sometimes happen.”
b. “Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, smoke more, or are overweight.”
c. “We will have to wait for the autopsy to know what happened. There were some medical problems, but we were not expecting death.”
d. “We are all surprised. The patient had been doing so well and saw the nurse every other week.”
ANS: B
The family is in distress. Because they do not understand his death, they are less able to accept it and seek specific information to help them understand what happened. Persons with SMI die an average of 25 years prematurely. Contributing factors include failing to provide for their own health needs (e.g., forgetting to take medicine), inability to access or pay for care, higher rates of smoking, poor diet, criminal victimization, and stigma. The most accurate answer indicates that seriously mentally ill people are at much higher risk of premature death for a variety of reasons. Staff would not have been surprised that the patient died prematurely, and they would not attribute his death to random, undetected medical problems. Although the cause of death will not be reliably established until the autopsy, this response fails to address the family’s need for information.
Many persons brought before a criminal court have mental illness, have committed minor offenses, and are off medications. The judge consults the nurse at the local community mental health center for guidance about how to respond when handling such cases. Which advice from the nurse would be most appropriate?
a. “Sometimes a little time in jail makes a person rethink what they’ve been doing and puts them back on the right track.”
b. “Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses.”
c. “Arresting these people helps them in the long run. Sometimes we cannot hospitalize them, but in jail they will get their medication.”
d. “Research suggests that speciaNlUmReSnINtaGl ThBea.CltOhMcourts do not make much difference so far, but outpatient commitment does seem to help.”
ANS: B
Research supports the use of special mental health courts that can sentence mentally ill persons to treatment instead of jail. Jail exposes vulnerable mentally ill persons to criminals, victimization, and high levels of stimulation and stress. Incarceration can also interrupt eligibility for benefits or lead to the loss of housing and often provides lower-quality mental health treatment in other settings. Recidivism rates for both mentally ill and non-mentally ill offenders are relatively high, so it does not appear that incarceration necessarily leads people to behave more appropriately. In addition, a criminal record can leave them more desperate and with fewer options after release. Research indicates that outpatient commitment is less effective at improving the mental health of mentally ill persons than was expected.
A nurse’s neighbor says, “My sister has been diagnosed with bipolar disorder but will not take her medication. I have tried to help her for over 20 years, but it seems like everything I do fails. Do you have any suggestions?” Select the nurse’s best response.
a. “NAMI offers a family education series that you might find helpful.”
b. “Since your sister is noncompliant, perhaps it’s time for her to be changed to injectable medication.”
c. “You have done all you can. Now it’s time to put yourself first and move on with your life.”
d. “You cannot help her. Would it be better for you to discontinue your relationship?”
ANS: A
NAMI offers a family education series that assists with the stress caregivers and other family members often experience. The nurse should not give advice about injectable medication or encourage the family member to give up on the patient.
SMI is characterized as
a. any mental illness of more than 2 weeks’ duration.
b. a major long-term mental illness marked by significant functional impairments.
c. a mental illness accompanied by physical impairment and severe social problems.
d. a major mental illness that cannot be treated to prevent deterioration of cognitive
and social abilities.
ANS: B
“Serious mental illness” has replaced the term “chronic mental illness.” Global impairments in function are evident, particularly social. Physical impairments may be present. SMI can be treated, but remissions and exacerbations are part of the course of the illness.
Which nursing diagnosis is likely to apply to an individual diagnosed with a SMI who is homeless?
a. Insomnia
b. Substance abuse
c. Chronic low self-esteem
d. Impaired environmental interpretation syndrome
ANS: C
Many individuals with SMI do not live with their families and become homeless. Life on the street or in a shelter has a negative influence on the individual’s self-esteem, making this nursing diagnosis one that should be considered. Substance abuse is not an approved North American Nursing Diagnosis Association (NANDA)-International diagnosis. Insomnia may be noted in some patients but is not a universal problem. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not seen in a majority of the homeless.
A patient diagnosed with schizophrenia tells the community mental health nurse, “I threw away my pills because they interfere with God’s voice.” The nurse identifies the etiology of the patient’s ineffective management of the medication regime as
a. inadequate discharge planning.
b. poor therapeutic alliance with clinicians.
c. dislike of antipsychotic medication side effects.
d. impaired reasoning secondary to the schizophrenia.
ANS: D
The patient’s ineffective management of the medication regime is most closely related to impaired reasoning associated with the thought disturbances of schizophrenia. The patient believes in being an exalted personage who hears God’s voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest any of the other factors often related to medication nonadherence.
A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, “You cause too much trouble.” What problem is the patient experiencing?
a. Grief
b. Stigma
c. Homelessness d. Nonadherence
ANS: B
The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as daNmUaRgSeItNoGrTeBp.uCtOatMion, shame, and ridicule society places on mental illness. Data are not present to identify grief as a patient problem. Data do not suggest that the patient is actually homeless. See relationship to audience response question.
A person diagnosed with a SMI enters a shelter for the homeless. Which intervention should be the nurse’s initial priority?
a. Find supported employment.
b. Develop a trusting relationship.
c. Administer prescribed medication.
d. Teach appropriate health care practices.
ANS: B
Basic psychosocial needs do not change because a person is homeless. The first step in caring for health care needs is establishing rapport. Once a trusting relationship is established, the nurse pursues other interventions.
A homeless patient diagnosed with a SMI became suspicious and delusional. Depot antipsychotic medication began and housing was obtained in a local shelter. One month later, which statement by the patient indicates significant improvement?
a. “They will not let me drink. They have many rules in the shelter.”
b. “I feel comfortable here. Nobody bothers me.”
c. “Those shots make my arm very sore.”
d. “Those people watch me a lot.”
ANS: B
Evaluation of a patient’s progress is made based on patient satisfaction with the new health status and the health care team’s estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being “bothered” by others denotes improvement in the patient’s condition. The other options suggest that the patient is in danger of relapse.
For patients diagnosed with SMI, what is the major advantage of case management?
a. The case manager can modify traditional psychotherapy.
b. With one coordinator of services, resources can be more efficiently used.
c. The case manager can focus on social skills training and esteem building.
d. Case managers bring groups of patients together to discuss common problems.
ANS: B
The case manager coordinates the care and multiple referrals that so often confuse the
seriously mentally ill patient and the patient’s family. Case management promotes efficient
use of services. The other options are lesser advantages or are irrelevant.
The parent of a seriously mentally ill adult asks the nurse, “Why are you making a referral to a vocational rehabilitation program? My child won’t ever be able to hold a job.” Which is the nurse’s best reply?
a. “We make this referral to continue eligibility for federal funding.”
b. “Are you concerned that we’re trying to make your child too independent?”
c. “If you think the program would be detrimental, we can postpone it for a time.”
d. “Most patients are capable of employment at some level, competitive or
supported. ”
ANS: D
Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression.
A consumer at a rehabilitative psychosocial program says to the nurse, “People are not cleaning up behind themselves in the bathrooms. The building is dirty and cluttered.” How should the nurse respond?
a. Encourage the consumer to discuss it at a meeting with everyone.
b. Hire a professional cleaning service to clean the restrooms.
c. Address the complaint at the next staff meeting.
d. Tell the consumer, “That’s not my problem.”
ANS: A
Consumer-run programs range from informal “clubhouses,” which offer socialization and recreation, to competitive businesses, such as snack bars or janitorial services, which provide needed services and consumer employment while encouraging independence and building vocational skills. Consumers engage in problem solving under the leadership of staff. See related audience response question.
A person diagnosed with a SMI living in the community was punched, pushed to the ground, and robbed of $7 during the day on a public street. Which statements about violence and SMI in general are accurate? (Select all that apply.)
a. Persons with SMI are more likely to be violent.
b. SMI persons are more likely to commit crimes than to be the victims of crime.
c. Impaired judgment and socialNskUiRllSsINcaGnTpBr.CoOvoMke hostile or assaultive behavior.
d. Lower incomes force SMI persons to live in high-crime areas, increasing risk.
e. SMI persons experience higher rates of sexual assault and victimization than
others.
f. Criminals may believe SMI persons are less likely to resist or testify against them.
ANS: C, D, E, F
Mentally ill persons are more likely to be victims of crime than perpetrators of criminal acts. They are often victims of criminal behavior, including sexual crimes, at a higher rate than others. When a mentally ill person commits a crime, it is usually nonviolent. Mental illnesses interfere with employment and are associated with poverty, limiting SMI persons to living in inexpensive areas that also tend to be higher-crime areas. SMI persons may inadvertently provoke others because of poor judgment or socially inappropriate behavior, or they may be victimized because they are perceived as passive, less likely to resist, and less likely to be believed as witnesses. See related audience response question.
The nurse manager of a mental health center wants to improve medication adherence among the seriously mentally ill persons treated there. Which interventions are likely to help achieve this goal? (Select all that apply.)
a. Maintain stable and consistent staff.
b. Increase the length of medication education groups.
c. Stress that without treatment, illnesses will worsen.
d. Prescribe drugs in smaller but more frequent dosages.
e. Make it easier to access prescribers and pay for drugs.
f. Require adherence in order to participate in programming.
ANS: A, E
Trust in one’s providers is a key factor in treatment adherence, and mentally ill persons can sometimes take a very long time to develop such trust; therefore, interventions which stabilize staffing allow patients to have more time with staff to develop these bonds. Ready access to prescribers allows medicine-related concerns to be addressed quickly, reducing obstacles to adherence such as side effects or ineffective dosages. Medication costs can be obstacles to adherence as well. Many SMI patients have anosognosia and do not adhere to treatment because they believe they are not ill, so telling them nonadherence will worsen an illness they do not believe they have is unlikely to be helpful. Increasing medication education is helpful only when the cause of nonadherence is a knowledge deficit. Other issues that reduce adherence, particularly anosognosia and side effects, are seldom helped by longer medication education. Requiring medication adherence to participate in other programs is coercive and unethical. Smaller, more frequent doses do not reduce side effects and make the regimen more difficult for the patient to remember.
A person diagnosed with SMI has frequent relapses, usually precipitated by situational stressors such as running out of money or the absence of key staff at the mental health center. Which interventions would the nurse suggest to reduce the risk of stressors to cause relapse? (Select all that apply.)
a. Discourage potentially stressful activities such as groups or volunteer work.
b. Develop written plans that will help the patient remember what to do in a crisis.
c. Help the patient identify and anticipate events that are likely to be overwhelming.
d. Encourage health-promoting activities such as exercise and getting adequate rest.
e. Accompany the patient to a NAMI support group.
ANS: B, C, D, E
Basic interventions for coping with crises involve anticipating crises where possible and then developing a plan with specific actions to take when faced with an overwhelming stressor. Written plans are helpful; it can be difficult for anyone, especially a person with cognitive or memory impairments, to develop or remember steps to take when under overwhelming stress. Health-promoting activities enhance a person’s ability to cope with stress. As the name suggests, support groups help a person develop a support system, and they provide practical guidance from peers who learned from experience how to deal with issues the patient may be facing. Groups and volunteer work may involve a measure of stress but also provide benefits that help persons cope and should not be discouraged unless they are being done to excess.
A patient diagnosed with SMI was living successfully in a group home but wanted an apartment. The prospective landlord said, “People like you have trouble getting along and paying their rent.” The patient and nurse meet for a problem-solving session. Which options should the nurse endorse? (Select all that apply.)
a. Coach the patient in ways to control symptoms effectively.
b. Seek out landlords less affected by the stigma associated with mental illness.
c. Threaten the landlord with legal action because of the discriminatory actions.
d. Encourage the patient to remain in the group home until the illness is less obvious.
e. Suggest that the patient list a false current address in the rental application.
f. Have the case manager meet with the landlord to provide education about mental
illness.
ANS: A, B, F
Managing symptoms so that they are less obvious or socially disruptive can reduce negative reactions and reduce rejection due to stigma. Seeking a more receptive landlord might be the most expeditious route to housing for this patient. Educating the landlord to reduce stigma might make him more receptive and give the case manager an opportunity to address some of his concerns (e.g., the case manager could arrange a payee to assure that the rent is paid each month). However, threatening a lawsuit would increase the landlord’s defensiveness and would likely be a long and expensive undertaking. Delaying the patient’s efforts to become more independent is not clinically necessary according to the data noted here; the problem is the landlord’s bias and response, not the patient’s illness. It would be unethical to encourage falsification and poor role modeling to do so; further, if falsification is discovered, it could permit the landlord to refuse or cancel her lease. See related audience response question.
An adult patient tells the case manager, “I don’t have bipolar disorder anymore, so I don’t need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I’m bored and don’t have any friends.” Where should the nurse refer the patient? (Select all that apply.)
a. Psychoeducational classes
b. Vocational rehabilitation
c. Social skills training
d. A homeless shelter
e. Crisis intervention
ANS: A, B, C
The patient does not understand the illness and need for adherence to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with SMI have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking the skill down into smaller verbal and nonverbal components. Work gives meaning and purpose to life, so vocational rehabilitation can assist with this aspect of care. The nurse case manager will function in the role of crisis stabilizer, so no related referral is needed. The patient presently has a home and does not require a homeless shelter.
Which statements most clearly indicate the speaker views mental illness with stigma? (Select all that apply.)
a. “We are all a little bit crazy.”
b. “If people with mental illness would go to church, their problems would be
solved.”
c. “Many mental illnesses are genetically transmitted. It’s no one’s fault that the
illness occurs.”
d. “Anyone can have a mental illness. War or natural disasters can be too stressful for
healthy people.”
e. “People with mental illness are lazy. They get government disability checks
instead of working.”
ANS: A, B, E
Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame. See related audience response question.
A person diagnosed with bipolar disorder ran out of money, did not refill a lithium prescription, and then relapsed. After assaulting several people in the community, this person was convicted and sentenced. Prior to parole, which outcome has priority for the correctional nurse to achieve? The person
a. agrees in writing to continue lithium therapy.
b. is reestablished on an appropriate dose of lithium.
c. lists community resources for prescription assistance.
d. agrees to a follow-up appointment in an outpatient clinic.
ANS: C
To increase medication adherence, reduce the risk of relapse, and prevent further criminal activity due to mental illness, the person’s awareness of community resources for medication refills and medication-related services is the most important outcome. Agreeing to take lithium, being reestablished on medication in the jail, and agreeing to follow-up mental health care are important, but none of these will address the primary reason for the criminal behavior: the relapse caused by inability to access medication in the community.
An inmate was diagnosed with posttraumatic stress disorder (PTSD) caused by severe sexual abuse. One day this inmate sees a person with characteristics similar to the perpetrator, has a flashback, and then attacks the person. Correctional officers place the inmate in restraint. The correctional nurse should anticipate that the inmate would react to restraint by
a. committing to counseling to reduce the incidence of flashbacks.
b. becoming less likely to assault others during future flashbacks.
c. gradually calming and returning from the flashback to reality.
d. becoming more frightened, agitated, and combative.
ANS: D
The correctional nurse recognizes that events occurring in the present reality are likely to be incorporated into a flashback, leading the inmate to become more frightened and desperate to escape. Even if no longer experiencing a flashback, persons will likely re-experience their original trauma if restrained, including the emotions experienced during that trauma, leading to increased fearfulness and resistance to the jail restraints. Restraints are not likely to calm the individual or reduce aggressiveness but instead increase the sense of helplessness and desperation.
An inmate was diagnosed with PTSD caused by severe sexual abuse. One day this inmate sees a person with similar characteristics to the perpetrator, has a flashback, and then attacks the person. Correctional officers place the inmate in restraint. Which action by the correctional nurse is most appropriate?
a. Plan to meet with the inmate for debriefing after release from the required period of restraint.
b. Support use of restraints as needed to control violent outbursts and assure the safety of all inmates.
c. Contact a supervisor authorized to make an exception to the restraint policy and explain why an alternate response is needed.
d. Confront the correctional officers who initiated the restraint, explain the inappropriateness of this action, and request the inmate’s release.
ANS: C
Nurses have advocacy responsibilities, regardless of the setting. The optimum outcome in this situation would be to minimize the duration of the restraint episode. The inmate and others are at risk of injury until the inmate is calm. The restraints will likely worsen and extend the inmate’s distress and agitation. Supporting the use of restraints ignores the need of select inmates for alternate responses that do not paradoxically worsen the situation instead of help it. Meeting with the patient to calm her after her release would be the second most helpful response, but it does not shorten the duration of the patient’s restraint. Confronting the officers is unlikely to be successful, since they are following proper procedures; accusing them of improper actions will likely increase defensiveness rather than expedite the inmate’s release from restraint.
As a nurse in the prison clinic changes the dressing on an inmate’s wound, the inmate says, “You know I never did anything, right? I am totally innocent any crime.” Select the nurse’s best response.
a. “I hear that same comment from most of the inmates here.”
b. “Whether you are innocent or guilty is of no concern to me.”
c. “Your innocence or guilt is the Court’s decision, not my decision.”
d. “I trust you to tell me the truth. I will document your comments in your medical
record. ”
ANS: C
It is not the role of the forensic nurse to make a decision as to guilt or innocence or whether a victim is being candid in reporting what happened not. The correct response asserts this information, along with where the responsibility lies. In this interaction, it is irrelevant what other inmates say. The nurse should be compassionate rather than dismissive. It is important to remember that in forensic nursing, the nurse–patient relationship occurs based on the possibility that a crime has been committed.
A large group of inmates are in line up at the prison clinic window for medication administration. One inmate near the end of the line calls out to the nurse using slang terms about the nurse’s sexuality. What is the nurse’s best action?
a. Call for a guard to place the offending inmate in seclusion.
b. Ignore the comment and continue medication administration.
c. Ask the other inmates, “What do you think about those comments?”
d. Postpone the current medication administration until later in the day.
ANS: B
It is important for the nurse to be mindful of characteristics of the incarcerated population and not react personally to the comments. The nurse is safe; therefore, it is unnecessary to respond to the comments. The nurse has an obligation to provide care, which includes medication administration. Exploring the thoughts of other inmates may precipitate further problems. Seclusion is a last resort. The offending inmate’s comments do not justify use of seclusion.
A psychiatric clinical nurse specialist works with a defendant as a competency evaluator. A staff member asks, “Why are you spending so much time with that defendant? You spend one-to-one time and write volumes. Usually, we give defendants some medication and return them to court.” Select the clinical nurse specialist’s most appropriate response.
a. “My role is to be an advocate for the defendant, so I have to know him well and build a trusting relationship.”
b. “My focus is providing intensive psychotherapy to ensure the defendant becomes competent before returning to court.”
c. “The specialized assessments I make on behalf of the Court require very lengthy and detailed interviews, so it takes a lot of time.”
d. “I spend the time observing, assessing, and documenting competency, writing a report, and preparing expert testimony for the Court.”
ANS: D
The competency evaluator has to determine the patient’s current competence to act on his own behalf during his trial; without competency, the inmate cannot stand trial. Determining competency goes well beyond the mental status, functional, and risk assessments most psychiatric nurses are accustomed to and are very complex and time-consuming. A complete formal report is prepared for the Court and all pertinent details addressed in anticipation of questioning by officers of the Court. The evaluator represents the Court, not the patient. Interviews of the inmate are only a portion of the evaluator’s work. Evaluators help the Court determine competency but do not intervene to increase the patient’s competency.
During arraignment, a defendant behaves bizarrely, fails to respond to the judge’s questions, and shouts obscenities. The judge orders an evaluation by a forensic nurse examiner. Which information provided by the examiner will be most important to the Court at this time?
a. The defendant’s mental state at the time of the crime
b. The defendant’s competence to proceed with trial
c. The cause of the defendant’s courtroom behavior d. The defendant’s history and cognitive abilities
ANS: B
Competence to proceed refers to one’s capacity to assist the attorney and understand legal proceedings. In the United States, no one is tried unless deemed competent. An incompetent individual is remanded to a locked facility for treatment to regain competency. The Court will desire a full assessment of the patient’s present mental state related to his ability to assist in his own defense, but at this time, the Court is not interested in his state of mind at the time of the original crime nor his history.
A psychiatric forensic nurse examiner was asked by a defendant’s attorney to determine the defendant’s legal sanity. What is the priority task of the nurse examiner?
a. Determine if the defendant understands the charges and can assist the attorney with
the defense.
b. Complete a risk assessment to determine if the defendant is a danger to self or
others.
c. Reconstruct the defendant’s mental state and motives at the time of the crime.
d. Collect and compile evidence to determine whether a crime occurred.
ANS: C
Legal sanity is determined for the specific time of the alleged crime, so reconstructing the
defendant’s mental state, motivation, thinking, and other elements of functioning at the time
of the alleged crime is essential to making the determination. The defendant’s ability to understand the charges and assist in his defense is pertinent to an evaluation of competency. Unless the Court has specifically asked for a risk assessment (which would be unusual), the risk assessment is the responsibility of clinical staff caring for the patient, not the forensic nurse examiner. Police collect evidence about the crime, and the prosecutor compiles it. A forensic nurse examiner does not participate in evidence collection other than that related to the assessment of the patient’s state of mind at the time of the alleged crime.
Select the best question for a psychiatric forensic nurse examiner to ask when assessing the legal sanity of an individual charged with a crime.
a. “Tell me about what you were thinking at the time of the alleged crime.”
b. “What would you do if you heard a fire alarm going off where you live?”
c. “At this time, are you having any experiences that others might think strange?”
d. “Do you feel as though you would like to harm yourself or anyone else at the
present time?”
ANS: A
Legal sanity refers to the individual’s ability to know right from wrong with reference to the act charged, the capacity to know the nature and quality of the act charged, and the capacity to form the intent to commit the crime. It is determined for the specific time of the act. The distracters apply to other parts of a mental status assessment and do not assess the patient’s state at the time of the alleged crime.
In which circumstance would a psychiatric forensic nurse examiner determine it appropriate for a defendant and attorney to consider the insanity defense? At the time of the crime, the defendant
a. shot a drug dealer who tried to overcharge for cocaine.
b. acted on auditory hallucinations of the voice of God commanding, “Kill the children.”
c. tampered with the brakes on his wife’s car after discovering she had an extramarital affair.
d. was frightened because of a home robbery the preceding night, assumed a family member was another burglar, and shot him.
ANS: B
The defendant, demonstrating symptoms of psychosis and acting on the direction of command
hallucinations, could use the defense of legal insanity because he was unable to recognize his
action as wrong due to a psychiatric illness. The other options suggest the defendant knew
right from wrong, had the capacity to know the nature and quality of the act, and had the
capacity to form intent to commit the crime.
A nurse testifies about care provided to a patient in the 8 hours before a successful suicide. The nurse responds to questions about observations regarding the patient’s behavior as well as interventions performed and documented during the shift. In what capacity was this nurse testifying?
a. Forensic nurse examiner
b. Expert witness
c. Fact witness
d. Consultant
ANS: C
A fact witness testifies regarding first-hand experience only; that is, the facts the witness possesses because of personal experience with the situation under review. Forensic nurse examiners conduct court-ordered examinations and provide written reports and court testimony regarding the findings of the examinations, but they do not give direct patient care. Consultants are neutral experts who educate or advise the Court or its officers on technical matters such as standards of nursing care. An expert witness shares professional expertise about the defendant or elements of the crime and testifies on behalf of the prosecution or defendant.
The highest degree of credibility is required by a nurse who provides testimony before the Court as a(n)
a. fact witness.
b. expert witness.
c. correctional nurse.
d. critical care nurse.
ANS: B
An expert witness is recognized by the Court as having a higher level of skill or expertise in a specific area. In addition to testifying about involvement with the individual and documentation of the interactions, an expert witness is permitted by the Court to give a professional opinion. A fact witness may testify only regarding what was seen, heard, performed, or documented regarding first-hand nursing care. Correctional and critical care nurses may testify as fact witnesses.
The psychiatric forensic nurse provides this description of work responsibilities: “I use
knowledge of psychopathology as I investigate and reconstruct crimes and then try to
understand a criminal’s reasoning process. This allows me to compile information on what
type of individual would have most likely committed the crime.” The work the nurse
describes is that of a
a. competency therapist.
b. hostage negotiator.
c. forensic examiner.
d. criminal profiler.
ANS: D
Criminal profilers attempt to provide law enforcement with specific information and the type of individual who would have committed a certain crime. Profilers use behavioral and psychological indicators left at violent crime scenes and apply their understanding of psychopathology, attempt to reconstruct the crime, formulate hypotheses, and develop a profile, which is then tested against known data. The distracters refer to roles the psychiatric forensic nurse may fill, but none of these roles fits the description given in the scenario.
A correctional nurse plans a health education series for prison inmates. Which topic is most important for the nurse to include in this series?
a. Sleep hygiene
b. Personal grooming
c. Social skills training
d. Assertive communication
ANS: A
The most common mental health symptoms experienced by inmates are insomnia and hypersomnia; therefore, sleep hygiene would address these needs. Sleep is a basic physiological need that must be met before higher needs are addressed.
Health problems most commonly encountered by correctional nurses are
a. routine infections and minor trauma.
b. chronic medical and psychiatric disorders.
c. similar to the non-incarcerated population.
d. injuries acquired during arrest or incarceration.
ANS: B
Correctional nurses provide care for inmates who have disproportionately high rates of mental illness, substance abuse, tuberculosis, AIDS, hepatitis, diabetes, and other chronic disorders and infections. The health problems of inmates are more complex and chronic, not similar to their non-incarcerated peers. Trauma is an important issue that affects inmate health, but it is not the primary health issue for this population as a whole.
A guard tells an inmate diagnosed with schizophrenia to ask the desk officer for a mop and bucket, then get some water from the shower area and mop the kitchen and hall. The inmate
does not comply. The guard becomes angry and cancels the inmate’s recreation time. Which action by the correctional nurse is most appropriate?
a. Document the inmate’s response as indicative of resistance and psychopathology.
b. Do not intervene. Intervention is not part of a correctional nurse’s scope of
practice.
c. Confer with the prison psychiatrist regarding reevaluation of this inmate’s
antipsychotic medication regime.
d. Explain to the guard that this inmate has difficulty following multiple instructions.
Suggest stating one idea at a time.
ANS: D
Correctional nurses, like most direct-care nurses outside of corrections, have a professional responsibility to advocate for inmates regarding needed care. A psychiatric nurse would have an understanding of schizophrenia and recognize that the inmate’s ability to process multistep instructions was impaired. Advocacy for the inmate is evident by educating the guard so he would not misperceive the reason the inmate did not respond. Documentation is needed for all nursing activities. Involving the psychiatrist might be of some value but is at best a passive form of advocacy, and again, as worded here, suggests that the nurse does not understand how schizophrenia contributed to the inmate’s not responding to complex instructions.
A new nursing graduate obtained licensure as a registered nurse. This nurse searched unsuccessfully for employment in desired settings and, after a year, accepted a position in a forensic facility. One year later, which statement by the nurse best demonstrates successful adaptation to the role?
a. “I am surprised by how challenging the position is and how many skills I have developed.”
b. “I have told a few of my former classmates about my job but not my former nursing faculty.”
c. “I plan to work here another year and then try again to get a position in a major medical center.”
d. “I think it’s better not to post my position or name of my employer on my social network page.”
ANS: A
The correct response demonstrates pride in skills obtained and the challenges of the role, both of which indicate successful adaptation to the role. The incorrect responses suggest the nurse is ashamed of the role or employment site.
Which statement about the practice of correctional nursing is accurate?
a. Because the majority of inmates are younger than 40 years of age, most have lower
rates of chronic illnesses than the general population.
b. Correctional nurses work primarily with medically ill persons rather than persons
with psychiatric or substance abuse disorders.
c. More persons diagnosed with mental illness receive treatment services in prisons than in inpatient psychiatric facilities.
d. Correctional nurses commonly provide holistic and comprehensive care for the incarcerated population.
ANS: C
When compared to the rates in the general population (11% of whom have a mental health problem, with approximately 55,000 individuals hospitalized at an inpatient psychiatric hospital on any given day), correctional facilities carry a disproportionate share of the burden for the provision of mental health services. Rates of chronic illness are higher among inmates than in the general population due to factors such as higher rates of poverty, lower educational status, higher rates of trauma, institutional living when incarcerated, reduced access to health care, poor health habits, and higher rates of high-risk behaviors such as IV drug abuse. Correctional settings provide adequate care of inmates, but it is rarely holistic or comprehensive.
Which credential would be expected of an expert witness in the area of forensic psychiatric nursing?
a. 3 years of experience in an inpatient psychiatric facility
b. 10 years of experience in community health nursing
c. Educational preparation of an associate degree in nursing
d. Publication of three articles in peer-reviewed psychiatric nursing journals
ANS: D
To establish credibility as an expert witness and have one’s opinion given equal weight to that of other professionals in court, the forensic nurse specialist must have current clinical expertise, trustworthiness, and a professional presentation style. The expert witness is an authority in a specialty area. If the expert has conducted research and published in the area, it is an added strength. Expert testimony is based on evidence-based practice. Forensic nurses with advanced degrees are more likely to be called upon as expert witnesses.
A psychiatric forensic nurse assigned to a hostage negotiation tactical team is deployed when an individual takes several hostages. Which tasks apply to the nurse’s role on the team? (Select all that apply.)
a. Assess released hostages.
b. Negotiate with the perpetrator.
c. Direct strategies for police deployment.
d. Assess the mental status of the perpetrator.
e. Suggest communication techniques to a negotiator.
ANS: A, D, E
The forensic nurse assigned to a hostage tactical team serves to assist the team and provide them with clinical information and assessments consistent with the nurse’s training and experience. This nurse does not negotiate with the perpetrator or direct actions of police officers. Assistance can include assessing the perpetrator, assisting the freed hostages, educating police officers on mental health-related topics, assessing the stress level of the negotiator, suggesting techniques that might be appropriate (particularly when the perpetrator is mentally ill), and serving as a go-between with local mental health agencies.
Which characteristics best qualify a nurse for employment as a forensic psychiatric nurse? (Select all that apply.)
a. Incorporation of “street smarts” into clinical practice
b. Comfortable in a variety of practice settings
c. Desire to punish perpetrators of crime
d. Able to think clearly under stress
e. Autonomous and self-sufficient
f. Critical care skills
ANS: A, B, D, E
Forensic nursing requires the ability to address the issues and provide care in a truly neutral manner. All forensic nurses, whatever their specific title or responsibilities, must therefore be objective and not be motivated by any personal beliefs about what should or should not happen to patients involved in the criminal justice system. Street smarts can be a desirable trait in working with perpetrators, especially in hostage negotiation situations. Forensic nurses practice in a wide variety of nontraditional settings. While forensic nurses are often members of teams, autonomy and self-sufficiency are important traits. Forensic nurses do not need critical care skills.
