Psychiatric Mental Health Nursing

Front 1

Brian, a 19-year-old college sophomore with a grade point average of 3.4, is brought to the emergency department after a suicide attempt. He has been extremely depressed since the death of his girlfriend 5 months previously when the car he was driving crashed. His parents are devastated. They believe taking one’s own life prevents a person from going to heaven. Brian has epilepsy and has had more seizures since the auto accident. He says he should be punished for his carelessness and does not care what happens to him. He has not been to school or shown up for his part-time job tutoring children in reading.

A. What might be a possible DSM-IV-TR diagnosis for axis I? What information should be included on axis III? What should be included on axis IV? What score (range) might you give to Brian on the GAF Scale?

B. Before you plan your care, what are some other factors you would like to assess regarding aspects of Brian’s overall health and other influences that can affect his mental health?

C. Do you think an antidepressant might help Brian’s grieving process? Why or why not? What additional care do you think Brian needs?

D. Formulate at least two potential nursing diagnoses for Brian.

E. Would Brian’s parents’ religious beliefs factor into your plan of care? If so, how?

Back 1

A. Brian would receive a diagnosis of Reactive Major Depression for axis I, given his symptoms of melancholy and hopelessness. Axis III is related to physical illnesses, so Brian’s epilepsy would go here. Axis IV is for reporting psychosocial problems that affect the diagnosis, so the death of his girlfriend as a result of the auto accident would be important to report. Axis V would report a current GAF of 30, since Brian is hopeless and suicidal. Six months ago, he was highly functional prior to the accident, so we could assume he probably had a GAF of 90 or higher.

B. Coping skills should be assessed in any crisis: How has Brian dealt with issues of loss in the past? Brian’s epilepsy and the fact he has had increased seizure activity is important. Support systems should also be assessed: His parents’ religious beliefs related to suicide may affect his prognosis if he thinks he doesn’t have their support (and he already doesn’t care if he lives or dies). Brian’s own religious beliefs should also be assessed. Are his views similar to his parents’? What is his perception regarding suicide and going to heaven?

C. An antidepressant would help relieve the pathological depressive feelings he is experiencing. However, no medication will help him through the grieving process. Grief counseling would be most appropriate to assist him with those feelings. We must remember that it has only been 5 months since the death of his girlfriend, so we should expect him to be grieving. Brian will also need a tremendous amount of support from his family and friends to help him through this period. A support group would also be recommended.

D. Potential for self-injury related to death of girlfriend, as evidenced by suicide attempts.
Ineffective coping related to death of girlfriend, as evidenced by feeling the need to be punished and not caring what happens to him.

E. Their views are important and should be respected. However, we must carefully observe interactions between Brian and his parents to ascertain that their belief system is not detrimental to his care and prognosis, that is, making him feel guilty for being suicidal, which could potentially compound the problem.

Front 2

1. Resilience, the capacity to rebound from stresso

rs via adaptive coping, is associated with

positive mental health. Your friend has just been

laid off from his job. Which of the following

responses on your part would most likel

y contribute to enhanced resilience?

1. Using your connections to set

up an interview with your employer

2. Connecting him with a friend of th

e family who owns his own business

3. Supporting him in arranging, preparing

for, and completing multiple interviews

4. Helping him to understand that the layoff re

sulted from troubles in the economy and is

not his fault

Back 2

ANS: 3

Rationale: Resilience develops from the process

of resolving distress th

rough adaptive coping. It

is enhanced when a person experi

ences success as a result of hi

s own efforts, which gives the

person an increased sense of cont

rol or mastery over stressful even

ts. This is illustrated in the

choice involving helping your friend

to obtain and succeed in interviewing for a replacement job.

In the other choices, you are helping the person d

eal with his situation and/or find a replacement

job but not in a manner that leads him to expe

rience success via his own efforts. As a result,

these approaches do not provide you

r friend with an opportunity to

experience a sense of mastery

over stress, so they are less likely to

contribute to incr

eased resiliency.

Front 3

Which of the following situations best supports

the stress-diathesis model of mental illness

development?

1. The rate of suicide increases during

times of national disaster and despair.

2. Four of five siblings in the Jones fam

ily develop bipolar disorder by the age of 30.

3. A man with no prior mental health probl

ems experiences sadness after his divorce.

4. A man develops schizophrenia, but his identical twin remains free of mental illness.

Back 3

ANS: 4

Rationale: The stress-diathesis theory states th

at some persons are born with a biological

predisposition to mental illness, but that mental

illness does not necessarily develop unless those

susceptible persons are exposed to stressors which trigger the illness. Thus for two persons with the same genetic profile, one might develop a mental illness due to stressful life experiences,

whereas his counterpart, despite having the same genetic makeup, has a different life experience and fails to develop the illness. This scenario is best demonstrated in the case of the man who develops schizophrenia, while his identical twin, with the same genetic makeup, remains free of

Front 4

Identify all of the following statements

about mental illness which are correct:

1. In any given year, about 20% of adults experience a mental disorder.

2. Mental health is best represented as

a continuum of levels of functioning.

3. Mental disorders and diagnoses occur very consistently across cultures.

4. Most serious mental illnesses are psychological rather than biological in nature.

5. The President’s New Freedom Commission

highlighted significant gaps in care.

6. “Parity” refers to relating to mentally

ill persons the same as to the non–mentally ill.

Back 4

ANS: 1, 2, 5

Rationale: About 21% of the U.S. population experi

ences a diagnosable mental illness in any one

year. “Mental health” is not an

absolute that one either has or

does not have. As with physical

health, persons vary in how mentally fit and able

to function they are, and mental illnesses vary

in their impact at different times and in differe

nt patients. Although providers of mental health

care strive to make diagnoses in a culturally neutra

l manner, there are significant variations in the

prevalence of some mental illnesses in certain cu

ltures. For example, anor

exia nervosa is usually

diagnosed less frequently outsi

de the United States, whereas

some cultures have identified

mental disorders that are not prevalent in the Unit

ed States. Most serious mental illnesses such as

schizophrenia and mood disorders are believed to

have a biological basis. The President’s New

Freedom Commission noted that mental health care delivery was fragmented and not meeting the needs of many persons with mental illness and called for major changes in the delivery of care to persons with mental illnesses. “Parity” as it relates to mental health refers to insurance and other third-party payers reimbursing for mental health

care in a manner comparable to reimbursement

for the care of physical illnesses,

without restrictions or limitations

specific to mental disorders.

Front 5

Which of the following disorders would be included on Axis I of the

DSM IV-TR

?

1. Major depression, dementia, and alcoholism

2. Diabetes type I or II, Parkins

on’s disease, and seizure disorders

3. Narcissistic, borderline, and

paranoid personality disorders

4. Mental retardation and psychos

ocial stressors such as divorce

Back 5

ANS: 1

Rationale: Axis I disorders include disorders of

thought (cognition), fee

ling, and/or behavior

which are not developmental in nature. Examples

include most of the major mental disorders

such as mood disorders, psychotic disorders,

substance use disorders, and cognitive disorders

(such as dementia). Disorders wh

ich are developmental in nature

(i.e., occur very

early in life

and persist thereafter), such as mental retardatio

n and personality disorders, are grouped on Axis

II. Concurrent or contributing medical conditions

such as cardiovascular disease or diabetes,

when present, are listed on Axis III. Contributin

g psychosocial stressors are listed on Axis IV.

Front 6

Which of the following actions represent the

primary focus of psychi

atric nursing for a basic-

level registered nurse?

Select all that apply.

1. Determining a patient’s diagnos

is according to the DSM-IV-TR

2. Ordering diagnostic tests such

as EEGs or CT or MRI scans

3. Identifying how a patient is coping

with a symptom such as hallucinations

4. Guiding a patient to learn and use a

variety of stress-management techniques

5. Helping a patient without transportati

on find a way to his treatment appointments

6. Collecting petition signatures seeking the removal of stigmatizing images on television

Back 6

ANS: 3, 4, 5, 6

Rationale: The focus of psychiatric nursing involv

es using the nursing process to promote mental

health and/or facilitate construc

tive responses to mental health pr

oblems or psychiatric disorders.

Although advanced practice registered nurses

may prescribe diagnostic examinations or

medications or identify

DSM IV-TR

diagnoses for treatment, these functions typically require

advanced educational preparation and certification.

Front 7

The quantitative study of the distribution of mental disorders in human populations is called

* mortality.
* prevalence.
* epidemiology
* clinical epidemiology

Back 7

Epidemiology is the quantitative study of the distribution of mental disorders in human populations. Mortality refers to deaths. Prevalence refers to the proportion of a population who has a mental disorder at a given time. Clinical epidemiology deals with what happens to people with illnesses who are seen by providers of care.
Text page: 10

Front 8

What phrase best describes the DSM-IV-TR?

* Is a multiaxial psychiatric assessment system
* Is a compendium of treatment modalities
* Offers a complete list of nursing diagnoses
* Suggests common interventions for mental disorders

Back 8

A. The DSM-IV-TR is a classification of mental disorders that includes descriptions of diagnostic categories and uses an axis system to provide a broad range of assessment.

Front 9

Current information suggests that the most disabling mental disorders are the result of

* biological influences.
* psychological trauma.
* learned ways of behaving.
* faulty patterns of early nurturance.

Back 9

A. The biologically influenced illnesses include schizophrenia, bipolar disorder, major depression, obsessive-compulsive and panic disorders, posttraumatic stress disorder, and autism. Therefore many (but not all) of the most prevalent and disabling mental disorders have been found to have strong biological influences.
Text page: 7

Front 10

A nurse's identification badge includes the wording, 'Psychiatric Mental Health Nurse'. A client with a history of paranoia asks, "What does that title mean?" The nurse responds best when answering:

* "Don't be afraid, it means I'm here to help not hurt you."
* "Psychiatric Mental Health nurses care for people with mental illnesses."
* "We have the specialized skills needed to care for those with mental illnesses."
* "The nurses who work in mental health facilities have that title."

Back 10

C. A Psychiatric Mental Health Nurse possesses specialized nursing skills and implements the nursing process to manage and deliver nursing care to the mentally ill.

Front 11

Regarding individuals with mental disorders, distress refers to a painful symptom, and disability refers to

* the presence of deviant behavior.
* impairment in important areas of functioning.
* culturally appropriate responses to an event.
* a conflict between the individual and society.

Back 11

B. Disability refers to impairment in important areas of functioning or a significantly increased risk of death, pain, or an important loss of freedom.
Text page: 12

Front 12

While caring for a client who is very ill with a mental disorder, the nurse wonders if the client has always been so regressed or if he has functioned at a higher level in the recent past. The best way to obtain this information would be to

* ask the client.
* ask the family.
* refer to the progress notes.
* look at axis V of the client's DSM-IV-TR sheet.

Back 12

D. Axis V is called the Global Assessment of Functioning and gives an indication of the client's best level of psychological, social, and occupational functioning during the preceding year.

Front 13

Which statement about diagnosis of a mental disorder is true?

* The symptoms of each disorder are common among all cultures.
* Culture may cause variations in symptoms for each clinical disorder.
* All mental disorders listed in the DSM-IV-TR are seen in all other cultures.
* Global assessment of functioning is more diagnostic than symptoms noted.

Back 13

B. Every society has its own view of health and illness and the types of behavior categorized as mental illness. Culture also influences the symptoms of a particular disorder. For example, individuals of certain cultures are more likely to express depression through somatic symptoms than through affect and feeling tone.

Front 14

The prevalence rate over a 12-month period for major depressive disorder is

* lower than the prevalence rate for panic disorders.
* greater than the prevalence rate for psychotic disorders.
* equal to the prevalence rate for psychotic disorders.
* greater than the prevalence rate for generalized anxiety.

Back 14

D. Statistics show that the prevalence rate over a 12-month period for major depressive disorder is 6.7%, and the lifetime prevalence rate for generalized anxiety is 3.1%.

Front 15

N, a college student, comes to the mental health clinic with symptoms of feeling blue and having occasional difficulty sleeping. He is able to manage his course work with lowered grades but states he just doesn't get as much pleasure from life as he did several months ago. The nurse making his global assessment of functioning would probably assign the rating of

* 100.
* 70.
* 40.
* 10.

Back 15

B.

A global assessment of functioning in the 70s indicates some mild symptoms are present or some difficulty in social, occupational, or school functioning is present but the individual is functioning well enough to have some meaningful interpersonal relationships.
Text page: 15, Box 1-4

Front 16

Mental illnesses recognized across cultures include

* antisocial and borderline personality disorders.
* schizophrenia and bipolar disorder.
* bulimia and anorexia nervosa.
* amok and social phobia.

Back 16

B. Worldwide studies indicate that both schizophrenia and bipolar disorder are recognized cross-culturally.
Text page: 7

Front 17

When planning care for a specific client, of what significance to the psychiatric nurse is the fact that the DSM-IV-TR is multiaxial?

* Pertinent aspects of client functioning and problems are reported.
* Standardized treatment plans are available for each diagnosis.
* Nursing diagnoses are included for each medical diagnosis.
* No particular significance exists.

Back 17

A. The DSM-IV-TR axis system, by requiring judgments to be made on each of the five axes, forces the diagnostician to consider a broad range of information. The North American Nursing Diagnosis Association describes a nursing diagnosis as a clinical judgment about individual, family, or community responses to actual or potential health problems and life processes. Therefore the DSM-IV-TR is used to diagnose a psychiatric disorder, whereas a well-defined nursing diagnosis provides the framework for identifying appropriate nursing interventions for dealing with the phenomena a client with a mental health disorder is experiencing, such as hallucinations, low self-esteem issues, and ability to function (job/family).
Text pages: 12, 13

Front 18

A nurse conducting research is seeking data about outcomes for depressed patients who have been treated with electroconvulsive therapy. The nurse is engaged in the field of

* experimental epidemiology.
* descriptive epidemiology.
* clinical epidemiology.
* analytic epidemiology.

Back 18

C. Clinical epidemiology represents a broad field that addresses what happens to people with illnesses who are seen by providers of clinical care. Studies use traditional epidemiological methods and are conducted in groups that are usually defined by illness or symptoms or by diagnostic procedures or treatments given for the illness or symptoms.

Front 19

A client tells the mental health nurse "I am terribly frightened! I hear whispering that someone is going to kill me." Which criterion of mental health can the nurse assess as lacking?

* Control over behavior
* Appraisal of reality
* Effectiveness in work
* Healthy self-concept

Back 19

B. The appraisal of reality is lacking for this client. The client does not have a picture of what is happening around himself or herself.

Front 20

A 14-year-old who belongs to a neighborhood gang is found by her parents to lie and engage in sexually promiscuous behavior. They bring her to the mental health center. The nurse performing the assessment is told by the 14-year-old that she is happy, does well in school, and sees herself as popular and well regarded by her group. She states her parents are just old fashioned and don't understand her. The assessment the nurse will most likely make is that she

* is displaying deviant behavior.
* cannot accurately appraise reality.
* is seriously and persistently mentally ill.
* should be considered for group home placement.

Back 20

A. This client is demonstrating deviant behavior. This client demonstrates undersocialized, aggressive behavior such as a repetitive and persistent pattern of aggressive conduct in which the basic rights of others are violated.

Front 21

An important concept for nurses to remember when planning care for mentally ill clients is that each client:

* has areas of strength on which to build.
* has right that must be respected.
* comes with experiences that contribute to their problem.
* share the same fears as mentally healthy individuals.

Back 21

A. We are taught to evaluate our clients with mental health issues for their strengths and their areas of high functioning. You will find many attributes of mental health in some of your clients with mental health issues. These strengths should be built upon and encouraged.

Front 22

A nurse suspects that a client has a personality disorder in addition to displaying symptoms of a mood disorder. To determine whether these observations are correct, the nurse could look in the client's medical record on the DSM-IV-TR

* axis I.
* axis II.
* axis III.
* axis IV.

Back 22

B. Axes I and II were separated to ensure that the possible presence of long-term disturbance is considered when attention is directed to the current one. For example, a heroin addict would be diagnosed on axis I as having a substance-related disorder; this client might also have a longstanding antisocial personality disorder, which would be noted on axis II.

Front 23

A man frequently bursts out by loudly singing operatic arias. The neighbors in the next apartment find the noise disturbing. They go to his apartment to confront him and find that in he is wearing only his bathrobe and his apartment is messy. He acts outraged and tells them he must sing several hours daily and will not promise to be quieter. The conclusion that can be drawn is:

* The man is demonstrating symptoms of bipolar disorder.
* The man is socially deviant.
* The man is egocentric.
* The man may or may not be mentally ill.

Back 23

D. One myth about mental illness is that to be mentally ill is to be different and odd. Another misconception is that to be healthy, a person must be logical and rational. Everyone dreams "irrational" dreams at night, and "irrational" emotions are universal human experiences and are essential to a fulfilling life. Some people show extremely abnormal behavior and are characterized as mentally ill who are far more like the rest of us than different from us. No obvious and consistent line between mental illness and mental health exists.

Front 24

A nursing diagnosis for a client with a psychiatric disorder serves the purpose of

* justifying the use of certain psychotropic medication.
* providing data essential for insurance reimbursement.
* providing a framework for selecting appropriate interventions.
* identifying information to be placed on DSM-IV-TR axis III.

Back 24

C. Nursing diagnoses provide the framework for identifying appropriate nursing interventions for dealing with the phenomena a client with a mental health disorder is experiencing.

Front 25

A client has begun to neglect her appearance, is withdrawn and stays in her room. Her mother hears her seemingly talking to others, but no one is in the room with her. Last night she threw a chair and broke the window of her bedroom. She tells the nurse nothing is wrong. The nurse rating her current global assessment of functioning would probably assign the code

* 100.
* 70.
* 40.
* 0.

Back 25

C. According to the global assessment of functioning scale (Box 1-2), this client exhibits some impairment in reality testing or communication (speech is at times illogical, obscure, or irrelevant, as demonstrated by talking when no one was with her) or major impairment in several areas, such as work or school, family relations (neglects her appearance, stays in her room) and demonstrates impairment in mood (throwing a chair and breaking a window).

Front 26

The mental health or mental illness of a particular client can best be assessed by considering

* the degree of conformity of the individual to society's norms.
* the degree to which an individual is logical and rational.
* placement on a continuum from healthy to psychotic.
* the rate of intellectual and emotional growth.

Back 26

B. Many (but not all) of the most prevalent and disabling mental disorders have been found to have strong biological influences. Therefore these disorders can be regarded as "diseases." Visualizing these disorders along the mental health continuum is helpful.