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A patient diagnosed with a serious mental illness 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 nurses best action.
- A. Involve the patients 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
Correct Answer: A
Rationale: 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.
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An 11-year-old child stays home from school to care for his siblings while his mother works, is demeaned by his father, and has negative self-perceptions. Which intervention(s) would be appropriate? Select all that apply.
- A. Crisis intervention
- B. Create a safety plan.
- C. Refer to family therapy.
- D. Refer for case management.
Correct Answer: A
Rationale: The correct answer is A: Crisis intervention. This is appropriate because the child is experiencing multiple stressors that require immediate support. Crisis intervention focuses on providing immediate assistance to individuals in distress and can help address the child's current emotional and psychological needs.
Summary of other choices:
B: Creating a safety plan may be relevant if there are safety concerns, but it does not address the child's emotional well-being.
C: Referring to family therapy may be beneficial in addressing family dynamics, but it may not be the most urgent intervention in this case.
D: Referring for case management is important for coordinating services, but it may not provide the immediate emotional support needed in this situation.
Which nursing progress note would most suggest that the treatment plan of a severely depressed and withdrawn patient has been effective?
- A. Slept 6 hours straight, sang with activity group, eager to see grandchild.
- B. Slept 8 hours, attended craft group, ate half of lunch, denies suicidal ideation.
- C. Slept 10 hours, personal hygiene adequate with assistance, lost one pound.
- D. Slept 7 hours on and off, reports "food has no taste", no self-harm noted.
Correct Answer: A
Rationale: The correct answer is A because it indicates positive changes in mood, engagement, and social interaction, which are key indicators of effective treatment for severe depression. Sleeping 6 hours straight shows improved sleep patterns, singing with the activity group reflects increased participation and enjoyment, and being eager to see the grandchild demonstrates a renewed sense of joy and connection.
Choice B is incorrect because although the patient denies suicidal ideation, the level of activity and engagement is not as high as in choice A. Choice C is incorrect as the focus is on physical aspects rather than emotional well-being and social interaction. Choice D is incorrect because the patient still shows signs of depression such as lack of appetite and loss of interest in activities.
Which of the following signs indicates that a patient with an eating disorder may need immediate hospitalization?
- A. Serum potassium level of 3.2 mEq/L
- B. Body mass index (BMI) of 18.5
- C. Noncompliance with meal plans
- D. Low energy and fatigue
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level of 3.2 mEq/L. This indicates severe hypokalemia, which can lead to life-threatening cardiac arrhythmias in patients with eating disorders. Hospitalization is necessary for immediate monitoring and intervention to prevent serious complications. Choices B, C, and D do not indicate imminent life-threatening risks requiring immediate hospitalization.
Marty is a 15-year-old boy whose parents have brought him to a mental health clinic for evaluation. They are concerned because his grades have fallen and he has become angry and sometimes even violent. He spends long periods of time alone and does not want to see his friends. The parents report that he has never been a bad boy nor had problems in school. They are worried about the changes in his behavior. Which of the following is the most likely cause?
- A. Depression
- B. Running around with a tough crowd
- C. Normal adolescent phase
- D. Attention deficit hyperactivity disorder
Correct Answer: A
Rationale: In addition to classic symptoms of depression, adolescents often display irritability and problems in school performance. This is not normal teen behavior. Because Marty has been functioning well in school up until now, it is unlikely that ADHD would be exhibited at this point.
A client with borderline personality disorder is having difficulty with memories of sexual abuse. She has a history of suicidal gestures, self-mutilation, sexual addiction, and substance addiction. She complains of vague pains, menstrual problems, and headaches. She entered the partial hospital program to prevent another suicide gesture or self-mutilation. The nurse recognizes that collaborative therapy may be helpful for this client and knows that the most useful collaboration in this case would be the client, the nurse, and the:
- A. Occupational therapist exploring ways to reduce stress
- B. Physical therapist exploring ways to reduce back pain
- C. Acupuncturist exploring ways to reduce pain
- D. Sexologist exploring healthy sexuality and safe sex
Correct Answer: A
Rationale: The correct answer is A: Occupational therapist exploring ways to reduce stress. In the case of a client with borderline personality disorder experiencing trauma-related symptoms, such as memories of sexual abuse, the focus is on addressing underlying emotional issues and coping strategies. Collaborative therapy involving the client, nurse, and occupational therapist can be beneficial. The occupational therapist can help the client develop coping skills, manage stress, and improve daily functioning. This approach targets the root of the client's difficulties and provides holistic support.
Summary:
- Choice B (Physical therapist exploring ways to reduce back pain): This option does not directly address the client's primary concerns related to trauma and emotional distress.
- Choice C (Acupuncturist exploring ways to reduce pain): While pain management is important, it does not address the client's complex psychological needs and trauma history.
- Choice D (Sexologist exploring healthy sexuality and safe sex): While important in some cases, focusing solely on sexuality does not address the broader range of issues the client