Case Study, Mohr

CHAPTER 1, Introduction to Psychiatric–Mental Health Nursing In completing the case study, students will be addressing the following learning objectives: Explain elements that contribute to mental health.

Review trends, problems, and goals related to the delivery of mental health care and treatment of mental illness.

1. Karen is a 25-year-old white woman who lives alone in an apartment with her dog. Karen has been divorced for 2 years and is taking Prozac prescribed by her psychiatrist for depression.  Karen and her boyfriend had been discussing marriage until he told her that he wanted to end their relationship.  Karen became even more depressed and could not work for a week.  Karen returned to work, refusing to discuss her issues with family, friends, or coworkers. She did, however, make an appointment to see a psychiatric nurse practitioner.  Karen told the nurse that she was making some changes in her life.  Karen said that she and a girlfriend were joining a gym program for workouts and a social group for young men and women.  Karen stated that she realizes that her former boyfriend had not been committed to her, and she anticipates meeting and dating other young men from the adult social group.  Karen also said that she thinks that the gym exercise will be beneficial to her mentally and physically.

Learning Objectives: 1, 4)

• How will the psychiatric nurse assess if Karen has made progress toward self-realization? 
•  
• Identify strengths that Karen has for progress in personal growth.
•  

Karen has been seeking treatment for her depression. Analyze the factors that might contribute to Karen’s reluctance to discuss her depression with others.

Case Study, Mohr:  CHAPTER 2, Neuroscience: Biology and Behavior

In completing the case study, students will be addressing the following learning objectives:

Discuss neuroplasticity and how this concept relates to mental health and mental illness.

Briefly explain the importance of interaction between genes and environment, the role of endophenotypes, and the stress-diathesis model of psychiatric illness.

1. Michael is a 22-year-old college senior whose GPA has declined with this semester’s grades.  Michael plans to apply to medical school and thinks that the lower GPA may prevent his acceptance to medical school.  For the last 2 weeks, Michael has skipped most classes because he has insomnia and fatigue.  Michael is now very depressed and has been thinking of suicide.  He took a loaded gun from his father’s gun cabinet and then wrote a suicide note to his family.  At the last moment, he telephoned 911 and told them of his suicide plan.  The police came, took the gun away, and then took Michael to the city hospital to be admitted for psychiatric treatment.   In the admission interview with the psychiatric nurse, Michael said that his pastor thought that only weak-willed people experienced depression and that it was a punishment for personal sins and the sins of one’s ancestors.  Michael told the nurse that he must be weak-willed and will never be able to accomplish anything.  The psychiatric nurse explained that multiple factors are the cause of depression.  The nurse told Michael that one theory holds that an imbalance of neurotransmitters, or chemical messengers of the brain, occurs in depression.  Neurotransmitters influence the individual’s emotions, thoughts, and subsequent behavior.  Recent research implies that neurobiology, heredity, as well as Psychological and environmental factors may be involved in the development and progression of depression. 

(Learning Objectives: 5, 6)

a. Will Michael think that the psychiatric nurse’s explanation for the cause of depression is more correct than that of his pastor?

b. Michael asks the nurse why he has to have psychotherapy. He states that he only needs to take a couple of pills to get better. How should the nurse respond to Michael’s question and comment?

c. Develop an assessment question for each of the following possible causes of Michael’s    development of depression:

              Genetic, Environment and Stress.

Case Study, Mohr

CHAPTER 3, Conceptual Frameworks and Theories:

In completing the case study, students will be addressing the following learning objective:

Give examples of behavioral and cognitive-behavioral interventions.

The student nurse has been assigned a 37-year-old woman admitted to the psychiatric hospital with an anxiety disorder.  This morning, the student notices that the client has a tense facial expression and is walking constantly around the group room.   The student walked over to the client and used reflective communication by stating, “I see that you have a tense expression and are walking around almost all of the time.  Is there something that we could discuss?”  The client replied that she has talked on the telephone to her mother who was keeping her children while she was in the hospital.  The client said that her mother had told her that she was not a good mother, and then said, “I guess I am a bad mother, but I could never measure up to my mother’s expectations.”  The student has learned that negative self-talk can greatly aggravate anxiety and lead to depression.  The student decided to use a behavioral intervention with the client and asked the client who is a good artist and why the client liked the artist’s works. The student and the client then made a list of activities that the client liked. The student taught the client to engage in one of these activities when an unpleasant experience evoked negative thoughts.  The following day, the student decided that the client needed some cognitive restructuring for her relationship with her mother.  The student taught the client that during discussions with her mother, feelings of incompetence might be experienced when the mother made negative comments.  The client was instructed that if her mother made negative comments about parenting, she was to immediately tell her mother that she was a good parent to her children and terminate the conversation at the first opportunity.

(Learning Objective: 3)

a. Will the client be able to learn cognitive restructuring in her relationship with her mother?

  b.    How will engaging in activities help the client with her anxiety?

Case Study, Mohr

CHAPTER 4, Evidence-Based Practice

 In completing the case study, students will be addressing the following learning objective:

Define evidence-based care.

1. Jessica, a 17-year-old girl who came with her family from Romania to the United States 10 years ago, is brought to the mental health clinic by her mother.  At the admission psychiatric interview, the mother stated that Jessica has been saying for 6 months that aliens have been conducting experiments on her and will soon take her in a spaceship to their planet.  Jessica is often awake at night and roams the house with a hammer and sharp knife, searching for aliens. Jessica’s mother says that she fears that some night Jessica will harm a family member whom she believes to be an alien.  The mother then said that she did not bring Jessica for psychiatric care earlier because she had heard that much of mental health treatment was quackery and a waste of money. The psychiatric nurse explains to Jessica’s mother that all mental health treatment is based on scientific principles. 

(Learning Objective: 3)

a. How would the nurse best explain that the care Jessica will receive at the psychiatric   facility is based on evidence? Give two examples of psychiatric evidence-based care, and explain the scientific evidence that supports your examples.

Case Study, Mohr

CHAPTER 5, Legal and Ethical Aspects: In completing the case study, students will be addressing the following learning objectives:  Identify the basic rights of people with mental illness. Describe the different types of commitments and states of competency.

1. Gerald, a 22-year-old black man, has a diagnosis of schizoaffective disorder.  Gerald has been living at home, but this afternoon he had a physical fight with the neighbors and set a fire in their garage to burn their house.  His father took him to the local psychiatric hospital and said that he wants an involuntary commitment for Gerald since he will not agree to the hospitalization.  The father expressed concern over Gerald’s legal rights.  The psychiatric nurse practitioner recommends to the father that he commit Gerald on involuntarily for emergency care for a period of 72 hours since he is clearly a danger to others. The nurse explains that Gerald will be evaluated to determine if he needs involuntary detention for observation and treatment for a longer period of time.  The nurse explains that Gerald will be periodically evaluated, and that when it is determined that he is no longer a danger to others or himself, Gerald will be released from the hospital.

(Learning Objectives: 4, 5)

a. What basic legal rights does Gerald have at the time of this illness?

b. Why can Gerald not make the decision for himself about being an involuntary emergency commitment to the hospital?

Case Study, Mohr

CHAPTER 6, Culture

In completing the case study, students will be addressing the following learning objective:

Describe skills essential to the implementation of culturally competent care.

1. Mrs. Maria Gonzalez is a Mexican National, age 58, who was brought to a health clinic by her adult son. She is complaining that she has had aches and pains all over her body for 2 days. Mrs. Gonzalez states that her neighbor is a witch who gave her the mal do ojo (evil eye) and cast a spell on her to cause her death. The clinic nurse takes an oral temperature and it is 101º F.  The clinic nurse refers Mrs. Gonzales to the clinic physician because she believes that the client has influenza.  Mrs. Gonzales is reluctant to see the doctor and states that the doctor cannot prevent her death. 

(Learning Objective: 8)

a. How can the nurse provide culturally competent care to Mrs. Gonzalez and convince her to see the clinic doctor? 

b. Can Mrs. Gonzalez be convinced that there is no spell cast on her to cause her death? Explain your answer.

Case Study, Mohr

CHAPTER 7, Spirituality in Psychiatric Care

In completing the case study, students will be addressing the following learning objective: Explore reasons for the resurgence of interest in the spiritual aspects of healthcare.

• Marta, a 16-year-old high school teenager, has been depressed over a recent break-up with her boyfriend.  Marta, accompanied by her mother, is seen in the community mental health clinic.  A mild antidepressant is prescribed for Marta with weekly counseling sessions.  Marta and her mother ask if it would be beneficial for Marta to attend a 1-week church camp to begin in 2 months.  Marta would like to reconnect with her religion and voices a belief that the camp experience will help her. The psychiatric nurse practitioner informs them that research reveals that involvement in religious activities has been helpful in social support and in coping with depression.  Marta appears relieved and said that she will register for the church camp.

(Learning Objective: 2)

a. Why might Marta want to reconnect with her religion, and how will attendance at the church camp benefit Marta?

b. If Marta attends the church camp, will this pose a problem to counseling sessions?

Case Study, Mohr

CHAPTER 8,- Nursing Values, Attitudes, and Self-Awareness

In completing the case study, students will be addressing the following learning objective:

Discuss how situational factors can potentially influence the behavior of healthcare professionals toward clients with mental illness.

1. Joe, a 26-year-old Caucasian man, is a client in a state prison system.  Joe is admitted to the prison clinic after being involved in a fight in which he sustained a stab wound to the chest that did not penetrate the lungs or major blood vessels.  The clinic doctor on duty was an employee of several years at the prison.  The doctor showed little compassion for Joe, stating, “He is a convicted criminal, and he is just getting back some of what he deserves.”  The new graduate nurse who was being oriented to the clinic thought that the doctor did not exhibit professional behavior toward Joe.  The clinic nursing supervisor later explained that the doctor was influenced by situational factors.

(Learning Objective: 3)

• What is a situational factor, and how can this influence the behavior of healthcare workers? Provide an example where a situational factor impacted on your behavior while in a healthcare setting.

Case Study, Mohr

CHAPTER 9, the Nursing Process in Psychiatric–Mental Health Care

In completing the case study, students will be addressing the following learning objective:

Apply the nursing process to psychiatric–mental health nursing.

1. The student nurse is assigned to assist the psychiatric nurse with the admission interview of a client at the psychiatric hospital.  The nurse explains to the student that the interview is very important in obtaining a total health history of the client.  The nurse should be courteous and respectful of the client to obtain as much information from the client as possible.  Assessment information should include the subjective information from the client with the reason for needing treatment, the cause of the present problem(s), and the client’s expectation of the outcome of treatment regimen.  The nurse alerts the student to the need to be sensitive to both verbal and nonverbal behavior of the client and to focus on topics that seem important to the client.

(Learning Objective: 1)

a. How can attention to the client’s nonverbal cues be of value in an interview?

b. Why is the interview the most important aspect of the nursing process?

Case Study, Mohr

CHAPTER 10, the Interview and Assessment Process

In completing the case study, students will be addressing the following learning objective:

Describe essential elements to include in psychiatric interviews and the assessment process.

• The student nurse is accompanying the psychiatric nurse during the nursing interview and assessment of a newly admitted patient.  The psychiatric nurse told the student that preparation with subjective and objective data collection is an important part of the process.  The nurse explains that assessment has reference to the interviewer’s interpretation and prioritization of all data for the client.  The nurse must have self-awareness and self-knowledge to be objective and avoid influencing the responses of the client.  Anxiety on the part of the nurse may limit the ability for thorough data collection and interpretation.  Anxiety in the nurse may evoke anxiety on the part of the client. The psychiatric nurse stressed that a process recording, or written analysis of the interaction between the client and nurse, is essential for nurses to recognize the effects of their communication style in the assessment process.  A review of the client’s history is important, and a private setting for the interview is necessary.  The content of the nursing assessment should include the ability and reliability of the client’s response to questions of the interviewer and the skill of the nurse in identification of relevant facts.  The nurse should discuss with the client prior health history, any present illness, and the reason for seeking healthcare at this time.  Medication history with compliance and allergies of the client require investigation.   Substance use by the client, past illnesses, and family history need exploration.

(Learning Objective: 2)

a   The student nurse asked the clinical psychiatric nurse practitioner to explain what she considered the most essential part of the assessment process. How should the psychiatric nurse respond to the student’s question? Explain your answer.

Case Study, Mohr

CHAPTER 11, Therapeutic Relationships and Communication

In completing the case study, students will be addressing the following learning objectives:

List the key ingredients of therapeutic relationships. Contrast effective and ineffective communication techniques with clients.

1. Two student nurses are preparing for psychiatric–mental health clinical learning experiences.  They decided to review the assigned reading and lecture notes from their class on therapeutic communication. After discussion, the students decided that the elements of respect, genuineness, and caring in talking to clients could lead to a trusting relationship. Both students voiced concern over their ability to develop and maintain a professional and not a social relationship. 

(Learning Objectives: 1, 6)

a. How can the student nurses convey the essential elements of a therapeutic relationship in talking to clients?

b. How can the student nurses maintain a professional relationship and avoid a social one for clients in psychiatric settings?

Case Study, Mohr

CHAPTER 12, Working with the Multidisciplinary Team

In completing the case study, students will be addressing the following learning objective:

Discuss the role of multidisciplinary teams in the care of clients.

1.   A multidisciplinary team meeting is in progress for Cindy, a 21-year-old college student who has recently been diagnosed with schizophrenia.  Cindy had been an excellent student on the dean’s list until 2 weeks ago, when she stopped attending classes, stayed in her room with the blinds drawn, and refused to eat because “they have poisoned the food.” The team includes Cindy’s psychiatrist, primary nurse, unit psychologist, social worker, occupational therapist, and a registered dietician.  Cindy and her parents attend the team meeting. The team members introduced themselves and stated that they would monitor and coordinate the treatment plan for Cindy, evaluate her progress in treatment, and plan for her discharge.

(Learning Objective: 1)

• How will the multidisciplinary team help Cindy and her family in the treatment of her schizophrenia?

Case Study, Mohr

CHAPTER 13, Individual Therapies and Nursing Interventions

In completing the case study, students will be addressing the following learning objective:

Discuss the goals of therapeutic modalities used with individual clients.

1. Frank, a 16-year-old adolescent, is a high school sophomore.  Frank is on the verge of failing his Spanish class.  After his grade fell to a “D” grade, Frank procrastinated about doing his Spanish homework, postponing it until last.  Then, saying he was tired, Frank played video games until bedtime and rationalized that he would get up early in the morning and do his homework. Frank often sleeps late and does not have time to complete his Spanish homework.  Frank is now very distressed over his grade in the Spanish class. His mother brought Frank to the counselor to help with his problem.  The counselor suggested a parent-teacher conference to explore any learning difficulties and the possibility of a tutor to help Frank.  The counselor also said that perhaps Frank’s mother could supervise the completion of his Spanish homework as the first step.  Frank appeared relieved at these suggestions, and said, “That sounds great! Maybe I can improve my Spanish grade and pass the class. Then I won’t be a loser!”

(Learning Objective: 2)

a. Using a cognitive-behavioral approach, write three goals for Frank’s individual counseling sessions.

b. Explain why cognitive-behavioral therapy (CBT) can be successful for Frank.

Case Study, Mohr

CHAPTER 14, Groups and Group Interventions

In completing the case study, students will be addressing the following learning objectives:

Discuss the advantages of group therapy.

Discuss the nurse’s role in working with groups.

1. Mary, a student nurse, is studying for an upcoming examination in her psychiatric–mental health nursing class.  Mary is reviewing group psychiatric therapy and made some practice test questions on this topic.  Help Mary study by answering the following questions.

(Learning Objectives: 7, 10)

a. Why does group therapy benefit clients with a psychiatric diagnosis?

• How can the psychiatric nurse best facilitate a community support group?

Case Study, Mohr

CHAPTER 15, Families and Family Interventions

In completing the case study, students will be addressing the following learning objective: 

Describe the family as a system adapting to change.

1. Wanda, a 17-year-old high school senior, has been rejected by a boy in her chemistry class whom she wanted to date for the senior prom.  Wanda became severely depressed and attempted suicide with an overdose of barbiturates.  Wanda’s mother found her unconscious and called an emergency ambulance to take her to the emergency department at the local hospital.  After Wanda’s recovery, she was in individual counseling, and the psychiatrist referred all family members for counseling.   Naomi, her younger sister, refused to go, saying that she did not have a problem and that Wanda was the one who had tried to commit suicide.  Her older brother, Matthew, had a similar response and added that Wanda had embarrassed the family.  Wanda’s parents stated that they would attend and urged both Naomi and Matthew to attend family counseling.

(Learning Objective: 1)

• Wanda’s family must reorganize to survive the disturbance created by the suicide attempt. Describe the family as a system adapting to change.

Case Study, Mohr

CHAPTER 16, Psychopharmacology

In completing the case study, students will be addressing the following learning objective:

Discuss the therapeutic indication, mechanism of action, recommended dosage, routes of administration, side effects, potential adverse effects, contraindications, and nursing implications for major psychotropic medications.

1. The student was reviewing the medication record for a client diagnosed with major depressive disorder with psychotic features. The client has been on medications for the past 12 years, has exhibited many side effects, and experienced multiple medication changes. On this admission, the client has developed abnormal movements of the tongue, a masklike face, shuffling gait, and constipation. The client is taking a selective serotonin reuptake inhibitor (SSRI) and an antipsychotic.

(Learning Objective: 6)

a. Identify the medication classification that may be responsible for the side effects and explain your choice.

b. Discuss the most important nursing implication related to the side effects the client is experiencing.

c. Explain why psychiatric clients experience multiple side effects and often need medication changes.

Case Study, Mohr

CHAPTER 17, Integrative Therapies

In completing the case study, students will be addressing the following learning objective:

Construct a list of complementary and alternative therapies used to treat specific psychiatric–mental health conditions.

• Marjorie Alin has been diagnosed with major depression and has recently been placed on antidepressants. Marjorie uses herbal medication and has always been interested in complementary and alternative medicine (CAM). She asks the nurse practitioner what CAM therapies might be effective for depression.

(Learning Objective: 4)

a. Develop an educational handout for Ms. Alin listing the CAM therapies that might be helpful with the treatment of depression and providing a description of how the therapy might be beneficial.

b. What CAM therapy might be harmful for an individual with depression being treated with antidepressants? Why?

Case Study, Mohr

CHAPTER 18, Somatic Therapies

In completing the case study, students will be addressing the following learning objectives:

Identify the nurse’s role in caring for people undergoing electroconvulsive therapy (ECT) and their families.

Describe the procedure for ECT, its indications, and its potential side effects.

1.  Julie Abrams, a married 45-year-old African American client, is admitted to the hospital for severe depression.  Although Julie is taking her antidepressant medication, she seldom leaves her bed, sleeps most of the time, and has refused to eat for 6 days.  Her psychiatrist has decided that ECT treatments are necessary to improve Julie’s depression.  Mr. Abrams, Julie’s husband, is alarmed to learn that Julie will receive ECT. The psychiatric nurse practitioner explains the ECT procedure and treatment that Julie will receive. Mr. Abrams asked the nurse practitioner what ECT is, how it will help Julie, and if there will be any harmful effects for her.

(Learning Objectives: 2, 3)

a. What information will you provide to Mr. Abrams concerning ECT, how it works, and any adverse effects?

b. Prioritize the nursing care responsibilities for Julie.

Case Study, Mohr

CHAPTER 19, Inpatient Care Settings

In completing the case study, students will be addressing the following learning objectives:

Define the various levels of care within inpatient treatment settings.

Explain elements and methods of fostering a therapeutic milieu.

1. Robert Woods has been admitted to an inpatient psychiatric facility due to a resurgence of his manic symptoms because he has not been taking his psychiatric medications. His sister has been trying to supervise Robert, who lives in a small apartment a few miles away. The sister is very frustrated and feels she cannot continue to monitor Robert successfully any longer. She asks what kinds of inpatient care options are available to assist in caring for Robert and voices concern about Robert’s noncompliance with his psychiatric medications.

(Learning Objectives: 1, 4)

a. Review the levels of inpatient care and offer some suggestions to Robert’s sister concerning ongoing psychiatric care.

b. The nurse is responsible for medication administration for Robert. How can a therapeutic environment and strategies assist the nurse in ensuring that Robert takes his psychiatric medications?

Case Study, Mohr

CHAPTER 20, Community and Home Psychiatric Care

In completing the case study, students will be addressing the following learning objectives:

Identify the levels of prevention of mental illness.

Describe potential interventions for primary, secondary, and tertiary prevention of mental health problems.

1. Jim is a 10-year-old student in elementary school.  The teacher is concerned that Jim may need psychological counseling and possibly psychiatric care since the recent suicide of his father.  Jim had formerly been an outgoing child who had excellence performance in schoolwork.  Jim is now withdrawn, does not socialize, and is doing poor work in school.  Jim’s mother has not responded to a call from the teacher to come to school for a conference to explore ways to help Jim. The teacher consults the school nurse for assistance.

(Learning Objectives: 1, 2)

• Identify how the school nurse can help Jim and his family in the prevention of mental illness. Discuss each level of prevention in your answer.

Case Study, Mohr

CHAPTER 21, Forensic Psychiatric Nursing

In completing the case study, students will be addressing the following learning objectives:

Describe the nurse’s role in the forensic milieu.

Describe characteristics of psychiatric and mental health concerns specific to forensic populations, addressing implications for nursing care.

1. Two student nurses are assigned to the forensic unit for their psychiatric learning experiences.  They are both slightly apprehensive but want to learn from the nursing staff the role of the nurse in forensic psychiatric nursing.

 (Learning Objectives: 1, 2)

a. What will the nurse manager tell the students about the role of the nurse in forensic psychiatric nursing?

b. In addition, what do the student nurses know about the difference between the traditional mental health setting and the forensic milieu?

Case Study, Mohr

CHAPTER 22, Sleep Disorders

In completing the case study, students will be addressing the following learning objectives:

Explain normal changes in sleep across the human lifespan.

1. James, a 12-year-old middle-school student, is having problems with his schoolwork.  James cannot sleep until late at night and has been unable to arrive at school until later in the morning due to excessive morning sleepiness and difficulty awakening.   James is concerned and depressed over this considerable insomnia with subsequent tardiness in arriving at school.  The teacher referred James to the school psychologist, who recommended psychological testing to determine if James has a learning disability. The results of the test show that James does have a learning disability and needs special placement for his English class. James continues to have insomnia.  The pediatrician recommended that James have a study at a sleep clinic. After the test, James was given a sleep schedule and was able to return to his normal sleep schedule.  His schoolwork improved after he was able to achieve adequate sleep. 

 (Learning Objectives: 1)

a. Why did James’ sleep schedule change from his normal routine? Revised Question: “What factors could have contributed to the alterations in James’ sleep pattern and subsequent insomnia?”

b. How do sleep patterns change for people over the lifespan?

Case Study, Mohr

CHAPTER 23, Anxiety Disorders

In completing the case study, students will be addressing the following learning objectives:

Explain what is meant by anxiety disorder.

Identify symptoms of anxiety disorders.

1. Amy is a 33-year-old housewife who has been saying that she is worried but cannot explain why she feels worried.  Amy and her husband have two children, and the family members are healthy and financially secure and have no identified problems.  Amy has resigned from her volunteer position at her children’s school, stating that she is tired.  Amy always had great pride in keeping an immaculate home and preparing nutritional meals for her family.  For the past month, she has neglected her housework and seldom cooks meals for her family.  For the past 3 weeks, Amy has told her husband that she is afraid that “something bad is going to happen to us.”  Amy is now afraid for her children to leave the home to attend school and for her husband to go to his office to work.

(Learning Objectives: 1, 2)

a. What is an anxiety disorder, and does Amy have this disorder?

b. What other differential diagnoses would you consider? OR What predisposing factors or etiologies are associated with anxiety disorders?

Case Study, Mohr

CHAPTER 24, Somatoform, Dissociative, and Sexual Disorders

In completing the case study, students will be addressing the following learning objectives:

Describe possible etiologies of somatoform disorders.

Explain the features of various somatoform disorders.

Identify the most common interdisciplinary goals and treatments for clients with somatoform disorders.

1. Roger is a 60-year-old, twice-divorced, Hispanic man who is retired.  His only support system is two adult sons with whom he has a distant relationship.  Roger has medical insurance from his retirement and constantly complains that he has some medical problem. He “doctor shops” by seeing different doctors for his various complaints.  Roger is always asking the doctors if he needs surgery.  In the past 5 years, he has undergone an exploratory laparotomy for complaints of abdominal pain, three colonoscopies for complaints of alternate diarrhea and constipation, and numerous diagnostic tests for his many physical complaints.  All tests and procedures have negative findings for any physical basis.  Roger remains convinced that he has multiple problems that the doctors are unable to diagnose.

 (Learning Objectives: 1, 3)

a. What are somatoform disorders, and what are the types of this disorder?

b. Based on the information given in the case study, what contributing factors do you believe Roger has? What other factors, not included, could contribute to somatoform disorders? Name the appropriate disciplines involved in the treatment of Roger and the interdisciplinary goals and interventions in treating his somatoform disorder.

Case Study, Mohr

CHAPTER 25, Personality Disorders

In completing the case study, students will be addressing the following learning objectives:

Explain what is meant by personality disorder.

Define personality disorder.

Apply the nursing process to the care of clients with personality disorders.

1.   Charles, a 29-year-old white man, has been admitted to the psychiatric hospital.  Charles does not seem depressed and openly discusses that he had attempted suicide after he had burned his employer’s office and truck.  Charles told the student nurse that he had been mad at his boss because he was a “slave driver” and shows no remorse for destroying his employer’s office and truck.  Charles has limited contact with his mother, who is his only family support.  Charles is divorced and states that his ex-wife just got pregnant so that he would marry her.  They have one child, and he is several months behind in child support. Other information that Charles gave the student nurse in an interview included that he was an ex-marine but had a dishonorable discharge due to stealing some extra government supplies that he said no one needed. In the treatment team, the psychiatrist stated that Charles was not suicidal and diagnoses him with antisocial personality disorder.

(Learning Objectives: 1, 3)

a.    What is an antisocial personality disorder, and what are its symptoms?

b.     Applying the nurse process to the treatment of Charles, what specific interventions would be most appropriate for the individual with antisocial personality disorder?

Case Study, Mohr

CHAPTER26, Eating Disorders

In completing the case study, students will be addressing the following learning objectives:

Discuss possible etiologies for eating disorders.

Differentiate anorexia nervosa, bulimia, and binge eating disorder.

1. Anna is a 20-year-old college student who is slightly overweight.  Anna is neat and orderly and considered to be a perfectionist. Anna has a sister, Margie, who is 2 years younger and has always been very slim.  Anna thinks that she is ugly and that her sister is pretty.  Anna began a daily diet of 500 calories with a rigid exercise program to lose weight rapidly.  Anna’s weight decreased below the normal amount for her height.  Anna continued to diet by reducing her daily caloric intake to 250 calories and then to 100 calories and began to look emaciated.  Anna’s parents asked her to increase her food intake, but Anna said that she was “still fat and ugly.”  Anna’s parents intervened by taking her to a psychiatrist for treatment. Anna’s diagnosis was anorexia nervosa.

(Learning Objectives:  1)

a. What is the probable cause of Anna’s eating disorder? 

b. What specific eating disorder does Anna most likely have?

Case Study, Mohr

CHAPTER 27, Depressive Disorders

In completing the case study, students will be addressing the following learning objectives:

Analyze different theories about the etiology of depressive disorders.

Discuss interdisciplinary treatment modalities for clients with depressive disorders.

• Sarah, a 37-year-old bank employee, has developed a depressive disorder.   Sarah was engaged and planned to be married next month.  Her fiancé suddenly broke off their engagement and told Sarah that he had accepted a job in Europe and was moving there immediately.  Sarah’s depression began shortly after this and has progressed to the point that she is now seeing a psychiatrist for treatment. Sarah’s family has a history of depressive disorders.  Her father has experienced recurrent episodes of depression for 20 years.   Sarah’s paternal aunt and great uncle both committed suicide.

 (Learning Objectives: 1, 2)

a. Identify and discuss the major theories for the etiology of depressive disorders.

b. What different interdisciplinary treatment modalities would be appropriate to incorporate into the plan of care for Sarah?

Case Study, Mohr

CHAPTER 29,

In completing the case study, the student will be addressing the following objectives:

Identify signs and symptoms of schizophrenia.

Explain the subtypes of schizophrenia.

• Joyce Mullins is a 31 years old client whose diagnosis is schizophrenia, disorganized type. Joyce is in the state mental hospital for a long term commitment. The student nurse is escorting Joyce and a group of patients to an art class. Suddenly, Joyce stop and look down at the sidewalk and then says “there are many brains down there on the sidewalk” later, the student is reviewing the symptoms of schizophrenia for a nursing care plan.

Learning objectives:

a Discuss the symptoms of schizophrenia

b Compare and contrast schizophrenia, disorganized type to other types of schizophrenia.

 

Case Study, Mohr

CHAPTER 30, Substance Use Disorders

In completing the case study, students will be addressing the following learning objectives:

Identify the two main components of interdisciplinary treatment for clients with substance abuse disorders.

Explain the importance of recognizing co-occurring disorders.

1. John, a 23-year-old unemployed man, is addicted to cocaine.  John lives with his mother and sister and has been stealing money from them to pay for his cocaine.  His mother persuaded John to voluntarily commit himself to the hospital for treatment of his substance abuse. In the initial assessment interview, the nurse learns that John began smoking marijuana at age 19 and occasionally consumes alcohol. John said that he started on cocaine after his father, who had a history of alcoholism, committed suicide.  John says that he began to feel anxious then and still has periods of anxiety.  John is cooperative with his treatment program and stated that he wants to get completely off drugs and get a good job to help his mother and sister.  John also said that if he experienced anxiety, he would take a stiff drink like his father had done when he was anxious.

 (Learning Objectives: 2)

a. How can the psychiatric staff counsel with John to avoid his turning to alcohol as substance?

b. With what other co-occurring disorders could John be diagnosed?

Case Study, Mohr

CHAPTER 31, Cognitive Disorders

In completing the case study, students will be addressing the following learning objectives:

Identify clinical features or behaviors associated with cognitive disorders.

Compare possible etiologies of various cognitive disorders, especially Alzheimer’s disease.

1.   Will Lunsford is a 78-year-old widower who lives with his daughter.  Mr. Lunsford has been increasingly irritable and has lost many personal items during the past few weeks.  Today, he returned from a trip around the neighborhood to say that he had lost his truck and could not remember where he parked it.  The preceding week, Mr. Lunsford declared that the telephone was broken when he could not remember how to dial the number of his friend.   He also asked his daughter when they would have breakfast one morning an hour after they had eaten breakfast.  Mr. Lunsford’s daughter made an appointment for him to be seen by his doctor.  The doctor diagnosed Mr. Lunsford with Alzheimer’s disease. 

(Learning Objectives: 1, 2)

a. What are the clinical features or behaviors associated with cognitive disorders?

b. What possible etiologies can be applied to Mr. Lunsford’s new diagnosis of Alzheimer’s disease?

Case Study, Mohr

CHAPTER 32, Anger and Aggression

In completing the case study, students will be addressing the following learning objectives:

Discuss various interventions to manage anger and aggression.

Define broad factors that can increase risk for anger, aggression, and violence.

1. Frances, a 49-year-old African American client, is a newly admitted patient to the psychiatric hospital.  Frances has the dual diagnoses of Bipolar I and Borderline Personality Disorder.  Frances refuses to abide by the unit rules of being out in the day room after breakfast and is staying in her room.  Her treatment level permits her to make two telephone calls daily, and Frances is demanding unlimited access to the telephone Frances is becoming increasingly frustrated and angry at the staff and has used some expletives in telling them what she thinks of the unit rules.  The primary nurse attempts to defuse Frances’ anger but finally becomes frustrated and angry herself, and she commented to Frances that if she did not cooperate with unit rules, she could expect to be in the hospital longer than usual.  Frances then lunged at the nurse, striking her on the head with her fist.  Frances was taken to the calming room and given a medication for her aggressive behavior.

 (Learning Objectives:  2)

a. What therapeutic communication techniques could the nurse have used with Frances to prevent her from becoming angry and aggressive?

b. What factors could have contributed to an increase in Frances’ level of anger?

Case Study, Mohr

Chapter 33, Violence and Abuse

In completing the case study, students will be addressing the following learning objectives:

Discuss the effects of maltreatment on child development.

Describe an organizational model for the multiple conditions that support community violence. 

1. Nita’s mother died when she was an infant.  Her father married a young woman 1 year after the death of Nita’s mother.  A baby girl was born to the stepmother 2 years later, followed by the birth of a baby boy 4 years later. The stepmother showed much preferential treatment to her own children, while she basically ignored Nita except to routinely ridicule her.  The most difficult household chores were given to Nita, with no chores given to her own daughter. The stepmother frequently severely punished Nita without reason. Publicly, the stepmother insisted that she treated Nita and her daughter alike in every way.  However, she always praised her own daughter, while continuing to verbally abuse Nita.  Nita’s father put his wife in full charge and had almost no interaction with Nita.  He, too, showed preferential treatment for his two children with his second wife.  When Nita was 14 years old, her aunt insisted that Nita move to live with her.  The aunt was very nurturing, and Nita’s life improved tremendously.  Nita was very intelligent and excelled in school.  Nevertheless, she was slow to make close friends and lacked confidence in social situations.  Nita became a successful professional as a college professor.  Nita appeared afraid to form a close relationship and was 31 years old when she married.                          

(Learning Objectives:  1) a. Is maltreatment of children a problem, and what are the effects on their development and functioning?

b.Discuss the Ecological Model of Violence and how it applies to the case of Nita

Case Study, Mohr

CHAPTER 34, Suicide and Suicidal Behavior

In completing the case study, students will be addressing the following learning objectives: List the warning signs of suicide.

Explain factors contributing to suicidal risk, including the relationship to culture and ethnicity, age, and gender.

1. Kate, a 35-year-old white woman, who moved to another city to take a new job.  Kate has a depressive disorder and has no friends in her new city; her only family support is one brother.   Kate has lost her new job and is without insurance or funds to purchase her prescribed antidepressants.  Kate formerly had excellent credit but now realizes that since she has no money, she may have to declare bankruptcy.  Kate became extremely depressed, purchased a gun, wrote suicide letters to her friends, and decided to commit suicide.  Kate then called 911 just before pulling the trigger on the gun.  However, the gun jammed and did not eject bullets.  A policeman came to her apartment in response to the 911 call and took Kate to the local psychiatric hospital.  After discharge, Kate went to live with her brother.  Kate’s brother is concerned that she is a continued suicide risk.

(Learning Objectives: 1)

a. What are the warning signs of suicide?

b. What factors could have contributed to Kate’s desire to commit suicide?.

Case Study, Mohr

CHAPTER 35, Crisis Intervention

In completing the case study, students will be addressing the following learning objectives:

Differentiate maturational, situational, and adventitious crisis.

Apply the nursing process to a client, family, or community in crisis.

1.  Frances Gordon is a 42-year-old divorced school teacher.  Her 20-year-old daughter, Sarah, has developed schizophrenia and has withdrawn from college.  Her youngest daughter, Glenda, is a 19-year-old unmarried mother who is living at home.  Glenda has just given birth to a baby boy who has a heart defect.  The baby’s father refuses to pay for any of the healthcare costs.  Frances’ dire economic situation is very stressful to her.  Her ex-husband refuses to help financially, and the bank has refused a second loan to Frances.

(Learning Objectives: 1) a. Can you differentiate between maturational, situational, and adventitious crises?   What type of crisis is Frances experiencing?

• Discuss how to apply the nursing process in the care of Frances.

Case Study, Mohr

CHAPTER 36, Pediatric Clients

In completing the case study, students will be addressing the following learning objectives:

 Identify factors that contribute to psychiatric disorders in children and adolescents.

Discuss general interventions available for children or adolescents with psychiatric disorders.

1.  Jeremy is a 9-year-old child hospitalized in the children’s unit of a psychiatric hospital.  Jeremy’s biological father died 2 years ago, and the mother now has a live-in boyfriend who has repeatedly sexually abused Jeremy.  Jeremy’s teacher reported this abuse to the Children’s Protective Services, and Jeremy was removed from the home.  Jeremy’s biological mother has experienced a depressive disorder for several years.  Since he has been living with his foster parents, Jeremy has exhibited numerous problems of angry outbursts with physical violence toward other children living in his foster home.  The foster parents are seeking help from the psychiatrist to continue to care for Jeremy in their home.

(Learning Objectives: 1, 2)

a. Identify some of the factors that contribute to psychiatric disorders in children and adolescents.

b. What interventions would be most appropriate in the treatment of Jeremy?

Case Study, Mohr

CHAPTER 37, Older Adult Clients

In completing the case study, students will be addressing the following learning objectives:  Differentiate communication approaches when working with older adults.

Discuss attitudes that many in society hold toward older people.

1. Molly Brewster is a 79-year-old white widow who is admitted to the hospital for diagnostic studies.  Mrs. Brewster has been feeling fatigued with slight depression that has been increasing for the past 2 weeks prior to admission.  The student nurse is assigned to care for Molly and explain some of the preparation for the diagnostic studies. 

(Learning Objectives: 1)

a. What are some effective communication techniques that the student nurse should use in therapeutic communication with Mrs. Brewster?

b. Discuss different societal attitudes that individuals may have in reaction to someone in Mrs. Brewster’s position.

Case Study, Mohr

CHAPTER 38, Homeless Clients

In completing the case study, students will be addressing the following learning objectives:

Discuss factors that contribute to homelessness in people with mental illness.

Discuss barriers that prevent homeless people with mental illness from receiving care measures to promote access.

• Kevin, a 39-year-old unemployed homeless male who has paranoid schizophrenia, was brought to the psychiatric hospital by the police.  Citizens called the police because Kevin was in the street directing pedestrians and traffic in opposition to the traffic lights and verbally abusing everyone who did not follow his directions.  Kevin is known to the police since he is often homeless, and states that his family does not want him.  Kevin also has a history of poly substance abuse with alcohol, heroin, and crack cocaine, and he has been jailed for public intoxication several times.  The nursing assessment reveals that Kevin has not been taking his prescribed psychotropic medications for 3 weeks.  Kevin states that he does not have any money, and he does not remember where to go for mental health care (Learning Objectives: 2)

a. What are the major factors that contribute to Kevin’s frequent homelessness?

b. What barriers does Kevin face in the receiving treatment? How can these barriers be addressed?

Case Study, Mohr

CHAPTER 39, Clients with Medical Illnesses

In completing the case study, students will be addressing the following learning objectives:

Identify common medical conditions that can have accompanying psychiatric complications or symptoms. Describe general nursing implications for clients experiencing psychiatric disorders that are intertwined with other nonpsychiatric illnesses.

1. Carla, a 27-year-old white single mother of two preschool-age children, is in the psychiatric hospital for treatment of anxiety and depression.   Carla has a cardiac condition that requires surgery.  Carla is concerned over the financial cost of the surgery and caretakers for her children while she is in the hospital and undergoing rehabilitation. Carla is also worried that she may be unable to continue in her present employment as a salesperson due to the physical demands of this position.  Carla’s case is representative of many patients with medical conditions who develop psychiatric symptoms.

(Learning Objectives: 1, 2)

a. What are some prevalent medical conditions that can also be accompanied by psychiatric symptoms or complications?

b.What are some nursing implications for Carla that address both the psychiatric and nonpsychiatric illnesses?