Chapter 06: Psychiatric Mental Health Nursing in Community Settings

Question 1

Select the response that is an example of tertiary prevention.

a. Helping a person diagnosed with a serious mental illness learn to manage money
b. Restraining an agitated patient who has become aggressive and assaultive
c. Teaching school-age children about the dangers of drugs and alcohol
d. Genetic counselling with a young couple expecting their first child

Answer 1

ANS: A
Tertiary prevention involves services that address residual impairments, with a goal of improved independent functioning. Restraint is a secondary prevention. Genetic counselling and teaching school-age children about substance abuse and dependence are examples of primary prevention

Question 2

A suspicious, socially isolated patient lives alone, eats one meal a day at a local shelter, and spends the remaining daily food allowance on cigarettes. Select a community psychiatric nurse’s best initial action.

a. Explore ways to help the patient stop smoking.
b. Report the situation to the manager of the shelter.
c. Assess the patient’s weight; determine foods and amounts eaten.
d. Arrange hospitalization for the patient in order to formulate a new treatment plan.

Answer 2

ANS: C
Assessment of biopsychosocial needs and general ability to live in the community is called for before any other action is taken. Both nutritional status and income adequacy are critical assessment parameters. A patient may be able to maintain adequate nutrition while eating only one meal a day. The rule is to assess before taking action. Hospitalization may not be necessary. Smoking cessation strategies can be pursued later.

Question 3

A nurse receives the following three phone calls regarding a community patient.
• The psychiatrist wants to complete a follow-up assessment.
• An internist wants to schedule a physical examination.
• The patient’s attorney wants an appointment with the patient.
The nurse schedules the activities for the patient. Which role has the nurse fulfilled?
a. Advocate
b. Case manager
c. Milieu manager
d. Provider of care

Answer 3

ANS: B
Case managers design individually tailored treatment services for patients and track outcomes of care. The new case management includes assessing patient needs, developing a plan for service, linking the patient with necessary services, monitoring the effectiveness of services, and advocating for the patient as needed. Nurses routinely coordinate patient services, serving as case managers as described in this scenario. The role of advocate would require the nurse to speak out on the patient’s behalf. The role of milieu manager refers to maintaining a therapeutic environment. Provider of care refers to giving direct care to the patient.

Question 4

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

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

Answer 4

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

Question 5

A patient with which of the following diagnoses would be most appropriate to refer for assertive community treatment (ACT)?

a. A phobic fear of crowded places.
b. A single episode of major depression.
c. A catastrophic reaction to a tornado in the community.
d. Schizophrenia and four hospitalizations in the past year.

Answer 5

ANS: D
Assertive community treatment (ACT) provides intensive case management for persons with serious persistent mental illness who live in the community. Repeated hospitalization is a frequent reason for this intervention. The distracters identify mental health problems of a more episodic nature.

Question 6

Select the response that is an example of primary prevention.

a. Assisting a person diagnosed with a serious mental illness to fill a pill-minder
b. Helping school-age children identify and describe normal emotions
c. Leading a psychoeducational group in a community care home
d. Medicating an acutely ill patient who assaulted a staff person

Answer 6

ANS: B
Primary preventions are directed at healthy populations with a goal of preventing health problems from occurring. Helping school-age children describe normal emotions people experience promotes coping, a skill that is needed throughout life. Assisting a person with serious and persistent mental illness to fill a pill-minder is an example of tertiary prevention. Medicating an acutely ill patient who assaulted a staff person is secondary prevention. Leading a psychoeducational group in a community care home is an example of tertiary prevention.

Question 7

Which level of prevention activities would a nurse in an emergency department employ most often?

a. Primary
b. Secondary
c. Tertiary

Answer 7

ANS: B
An emergency department nurse would generally see patients in crisis or with acute illness, so secondary prevention is used. Primary prevention involves preventing a health problem from developing, and tertiary prevention applies to rehabilitative activities.

Question 8

The nurse assigned to assertive community treatment (ACT) should explain the program’s treatment goal as which of the following?

a. Assisting patients to maintain abstinence from alcohol and other substances of abuse
b. Providing structure and a therapeutic milieu for mentally ill patients whose symptoms require stabilization
c. Maintaining medications and stable psychiatric status for incarcerated inmates who have a history of mental illness
d. Providing services for mentally ill individuals who require intensive treatment to continue to live in the community

Answer 8

ANS: D
An assertive community treatment (ACT) program provides intensive community services to persons with serious, persistent mental illness who live in the community but require aggressive services to prevent repeated hospitalizations.

Question 9

The case manager plans to discuss the treatment plan with a patient’s family. Select the case manager’s first action.

a. Determine an appropriate location for the conference.
b. Support the discussion with examples of the patient’s behaviour.
c. Obtain the patient’s permission for the exchange of information.
d. Determine which family members should participate in the conference.

Answer 9

ANS: C
The case manager must respect the patient’s right to privacy, which extends to discussions with family. Talking to family members is part of the case manager’s role, with the patients consent. Actions identified in the distracters occur after the patient has given permission.

Question 10

A patient diagnosed with schizophrenia has been stable for 2 months. Today the patient’s spouse calls the nurse to report the patient has not taken prescribed medication and is having disorganized thinking. The patient forgot to refill the prescription. The nurse arranges a refill. Select the best outcome to add to the plan of care.

a. The patient’s spouse will mark dates for prescription refills on the family calendar.
b. The nurse will obtain prescription refills every 90 days and deliver to the patient.
c. The patient will call the nurse weekly to discuss medication-related issues.
d. The patient will report to the clinic for medication follow-up every week.

Answer 10

ANS: A
The nurse should use the patient’s support system to meet patient needs whenever possible. Delivery of medication by the nurse should be unnecessary for the nurse to do if patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as medication is taken as prescribed.

Question 11

A community mental health nurse has worked for months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and could no longer afford prescribed medications. The patient says, “Only a traitor would make me go to the hospital.” Select the nurse’s best initial intervention.

a. Collaborate with the patient to contact resources to provide medications without charge temporarily.
b. Arrange a bed in a local homeless shelter with nightly on-site supervision.
c. Hospitalize the patient until the symptoms have stabilized.
d. Ask the patient, “Do you feel like I am a traitor?”

Answer 11

ANS: A
Hospitalization may damage the nurse–patient relationship, even if it provides an opportunity for rapid stabilization. The treatment outcome is to stabilize and improve the patients’ level of functioning in the community. If medication is restarted, the patient may possibly be stabilized in the home setting, even if it takes a little longer. Programs are available to help patients who are unable to afford their medications. A homeless shelter is inappropriate and unnecessary. Hospitalization may be necessary later, but a less restrictive solution should be tried first, since the patient is not dangerous. A yes/no question is non-therapeutic communication.

Question 12

Which activity is appropriate for a nurse engaged exclusively in community-based primary prevention?

a. Medication follow-up
b. Teaching parenting skills
c. Substance abuse counselling
d. Making a referral for family therapy

Answer 12

ANS: B
Primary prevention activities are directed to healthy populations to provide information for developing skills that promote mental health. The distracters represent secondary or tertiary prevention activities.

Question 13

A psychiatrist prescribed depot injections every 3 weeks at the clinic for a patient with a history of medication noncompliance. For this plan to be successful, which factor will be of critical importance?

a. The attitude of significant others toward the patient
b. Nutrition services in the patient’s neighbourhood
c. The level of trust between the patient and nurse
d. The availability of transportation to the clinic

Answer 13

ANS: D
The ability of the patient to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the patient of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, nonadherence will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem.

Question 14

Which assessment finding for a patient in the community deserves priority intervention by the psychiatric nurse?

a. The patient receives provincial disability income plus a small cheque from a trust fund every month.
b. The patient was absent from three of six planned Alcoholics Anonymous meetings in the past 2 weeks.
c. The patient lives in an apartment with two patients who attend partial hospitalization programs.
d. The patient has a sibling who was recently diagnosed with a mental illness.

Answer 14

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

Question 15

The nurse should refer which of the following patients to a partial hospitalization program?

a. A patient who has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up.
b. A patient who needs psychoeducation for relaxation therapy related to agoraphobia and panic episodes.
c. A patient who spent yesterday in a supervised crisis care centre and continues to have active suicidal ideation.
d. A patient who states, “I’m not sure I can avoid using alcohol when my spouse goes to work every morning.”

Answer 15

ANS: D
This patient could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends, the spouse could assume responsibility for supervision. A suicidal patient needs inpatient hospitalization. The other patients can be served in the community or with individual visits.

Question 16

A Category V tornado hits a community, destroying many homes and businesses. Which nursing intervention would best demonstrate compassion and caring?

a. Encouraging people to describe their memories and feelings about the event
b. Arranging transportation to the local community mental health centre
c. Referring a local resident to a community food bank
d. Coordinating psychiatric home care services

Answer 16

ANS: A
Disaster victims benefit from telling their story. Nurses show compassion by listening and offering hope. The distracters identify other aspects of psychological first aid and services on the mental health continuum.

Question 17

A nurse makes an initial visit to a homebound patient diagnosed with a serious mental illness. A family member offers the nurse a cup of coffee. Select the nurse’s best response.

a. “Thank you. I would enjoy having a cup of coffee with you.”
b. “Thank you, but I would prefer to proceed with the assessment.”
c. “No, but thank you. I never accept drinks from patients or families.”
d. “Our agency policy prohibits me from eating or drinking in patients’ homes.”

Answer 17

ANS: A
Accepting refreshments or chatting informally with the patient and family represent therapeutic use of self and help to establish rapport. The distracters fail to help establish rapport

Question 18

A nurse can best address factors of critical importance to successful community treatment by including making assessments relative to which of the following: Select all that apply.

a. Source of income
b. Family and support systems
c. Housing adequacy and stability
d. Early psychosocial development
e. Substance abuse history and current use

Answer 18

ANS: A, B, C, E
Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a patient is homeless or fears homelessness, focusing on other treatment issues is impossible. Sufficient income for basic needs and medication is necessary. Adequate support is a requisite to community placement. Substance abuse undermines medication effectiveness and interferes with community adjustment.

Question 19

Which statements by patients diagnosed with a serious mental illness best demonstrate that the case manager has established an effective long-term relationship? Select all that apply.

a. “My case manager talks in language I can understand.”
b. “My case manager helps me keep track of my medication.”
c. “My case manager gives me little gifts from time to time.”
d. “My case manager looks at me as a whole person with many needs.”
e. “My case manager lets me do whatever I choose without interfering.”

Answer 19

ANS: A, B, D
Each correct answer is an example of appropriate nursing foci: communicating at a level understandable to the patient, providing medication supervision, and using holistic principles to guide care. The distracters violate relationship boundaries or suggest a laissez faire attitude on the part of the nurse.

Question 20

Which statements most clearly reflect the stigma of mental illness? Select all that apply.

a. “Many mental illnesses are hereditary.”
b. “Mental illness can be evidence of a brain disorder.”
c. “People claim mental illness so they can get disability cheques.”
d. “Mental illness results from the breakdown of nuclear families.”
e. “If people with mental illness went to church, their symptoms would vanish.”

Answer 20

ANS: C, D, E
Stigma is represented by judgemental remarks that discount the reality and validity of mental illness. Many mental illnesses are genetically transmitted. Neuroimaging can show changes associated with some mental illnesses.

Question 21

A person in the community asks, “People with mental illnesses went to isolated hospitals in earlier times. Why has that changed?” Select the nurse’s accurate responses. Select all that apply.

a. “Science has made significant improvements in drugs for mental illness, so now many people may live in their communities.”
b. “There’s now a better selection of less restrictive treatment options available in communities to care for people with mental illness.”
c. “National rates of mental illness have declined significantly. There actually is not a need for state institutions anymore.”
d. “Most psychiatric institutions were closed because of serious violations of patients’ rights and unsafe conditions.”
e. “Federal legislation and payment for treatment of mental illness has shifted the focus to community rather than institutional settings.”

Answer 21

ANS: A, B, E
The community is a less restrictive alternative than hospitals for treatment of people with mental illness. Funding for treatment of mental illness remains largely inadequate but now focuses on community rather than institutional care. Antipsychotic medications improve more symptoms of mental illness; hence, management of psychiatric disorders has improved. Rates of mental illness have increased, not decreased. Hospitals were closed because funding shifted to the community. Conditions in institutions have improved.

Question 22

A patient diagnosed with schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns the following:
• The patient wants to attend an activity group at the mental health outreach centre
• The patient is worried about being able to pay for the therapy
• The patient does not know how to get from home to the outreach centre
• The patient has an appointment to have blood work at the same time an activity group meets
• The patient wants to attend services at a church that is about a kilometre from the patient’s home
Which tasks are part of the role of a community mental health nurse? Select all that apply.
a. Rearranging conflicting care appointments
b. Negotiating the cost of therapy for the patient
c. Arranging transportation to the outreach centre
d. Accompanying the patient to church services weekly
e. Monitoring to ensure the patient’s basic needs are met

Answer 22

ANS: A, C, E
The correct answers reflect the coordinating role of the community psychiatric nurse case manager. Negotiating the cost of therapy and accompanying the patient to church services are interventions the nurse would not be expected to undertake. The patient can walk to the church services; the nurse can provide encouragement.