Chapter 41: Caring for Persons Who Are Experiencing Homelessness and Mental Illness

The nurse is working in a shelter for homeless men. When planning the care for

these clients, the nurse integrates understanding that men who have been

homeless for a long period of time often feel a sense of which assessment finding?

A) Depersonalization

B) Strong coping skills

C) Self-efficacy

D) Fear of failure

Ans: A

Feedback:

After being homeless for quite some time, individuals often feel a sense of de-

personalization and fragmented identity; a loss of self-esteem and self-efficacy;

and a stigma of being "nothing," "a bum," "lazy," and "stupid." However, most

people who are homeless describe themselves as resourceful, independent,

proud, and "survivors."

A nurse is presenting a talk on homelessness and its effect on individuals. The

nurse describes the resiliency and hope of homeless individuals based on which

factor?

A) Strong community supports

B) Available family resources

C) Coping with extreme stressors

D) Local governmental intervention

Ans: C

Feedback:

Persons who are (or have been) homeless and have mental illnesses can become

resilient because they typically have endured and coped with constraints or

problems, extreme stressors or catastrophes, and negative life events. Deprivation of needs, the sense of isolation and stigma, and the lack of accessible re-

sources may be of short- or long-term duration. In turn, self-confidence and a

sense of competence can be eroded. Yet many people who experience homelessness maintain hope and a positive attitude, which in turn helps them to reach

out for help, take advantage of opportunities, and become part of the housed

population.

The nurse is caring for a homeless client who has been seen in the mobile clinic

every week for the past month because of a foot infection. Which nursing diag-

nosis would the nurse most likely identify as the priority?

A) Social Isolation related to homelessness

B) Ineffective Health Maintenance related to homelessness

C) Chronic Low Self-Esteem related to foot disorder and homelessness

D) Imbalanced Nutrition, less than body requirements, related to poor eating

Ans: B

Feedback:

Although Social Isolation, Chronic Low Self-Esteem, and Imbalanced Nutrition

may be applicable nursing diagnoses, the existence of the foot infection requiring

treatment for the past month indicates Ineffective Health Maintenance.

A new graduate nurse is considering taking a job that focuses on meeting the

mental health needs of homeless populations. During the pre-employment in-

terview, the graduate nurse asks the interviewer what characteristics are com-

mon in this population. Which response by the interviewer would be most likely?

A) "Most of them have very little education and, consequently, they work in

menial jobs—when they can get them."

B) "They come from a variety of backgrounds, and they often experien

Ans: B

Feedback:

The homeless population includes people of all ages, economic levels, racial and

cultural backgrounds, and geographic areas. People who are homeless are often

chronically ill, jobless, or have recently lost all financial resources. Long-term

homeless people may have lived in poverty for years with no home site. Among

homeless people, the educational level varies greatly, from less than an

eighth-grade education to doctoral degrees.

A nurse is assessing a 49-year-old homeless client. The nurse fashions the

assessment process based on the understanding that the client would most likely

demonstrate which behavior?

A) Cooperation and talkativeness to share ideas

B) Agreement to allow a complete physical examination

C) Desire for in-depth discussion of the condition

D) Resistance and caution about the interaction

Ans: D

Feedback:

Because of negative past experiences with the health care system, health care

providers, or because of mental illness or substance use, the client may not allow

a thorough physical examination. The client may also refuse to answer questions

about personal history at the first visit. The client will most likely be resistant and

cautious with the nurse, resisting anything more than a superficial conversation

and observation.

A nurse has formulated several nursing diagnoses for a homeless client after a

thorough nursing assessment. Which diagnoses would the nurse determine as the

priority?

A) Anxiety

B) Powerlessness

C) Imbalanced nutrition

D) Impaired social interaction

Ans: C

Feedback:

The priority for people who are homeless is meeting the basic needs—food,

shelter, and so on. Care for the responses to the mental illness is secondary.

The nurse is helping a homeless 56-year-old client develop a plan for care after

discharge. Which action will be most appropriate to take to support a successful

transition?

A) Contact the client's daughter as a possible source of support after the client's

discharge.

B) Contact the client's parents as a possible source of support after the client's

discharge.

C) Provide the client with a three-ring binder full of resources that will promote

independent living.

D) Provide the client with

Ans: A

Feedback:

Nurses are in a key position to help clients re-establish family and other sup-

portive relationships. Clients who are homeless are likely to engage their children

as a main social support; parents and other family members are perceived as

unlikely to help. People with mental illness who have been homeless need assistance in using available resources, such as medical, psychiatric, substance

abuse, emergency department treatment, and other outpatient psychiatric services. However, providing the client with a binder full of resources or with tele-

phone numbers of insurance companies would be overwhelming and impractical.

Information should be as portable as possible; legible; concise; and be able to fit

in a pocket, purse, shoe, or boot.

A nursing instructor is preparing an education plan for a group of nursing

students who will be working with homeless populations. As part of the class, the

instructor will be including information about barriers to successful treatment of

homeless clients who are mentally ill. Which reason would the instructor include

as contributing to lack of compliance with psychotropic medications?

A) Mistrust of medical personnel

B) Lack of proper medication storage

C) Chemical dependence on prescription m

Ans: B

Feedback:

Compliance with medication and treatment regimens is difficult for homeless

individuals because successful treatment requires collaboration, monitoring, time

for medication and other measures to be effective, and a secure place to keep

medication.

A nurse is working for a mobile homeless treatment program. Which method

would the nurse most likely use to provide follow-up care to clients?

A) Seeing them by appointment at a clinic office

B) Riding a bicycle to wherever the client happens to be

C) Meeting the client in a public place easily accessible by taxi

D) Using the telephone to determine how well the clients are doing

Ans: B

Feedback:

Some agencies provide a street or mobile outreach program. As part of this

program, a van travels the streets to areas where people who are homeless are

found outdoors. Food, warm coffee, hygiene kits, and blankets are the first steps

in building trust between staff and homeless persons. People who are homeless

may accept an offer to be driven to a local shelter for the night. Follow-up the next

day by van or bicycle provides a way to reconnect with the individual and invite

him or her to the agency programs, or to other social or health care services.

A nurse is providing an in-service education class on caring for homeless

populations. When explaining the difference between the care provided by Safe

Havens and Shelter Plus Care, which statement would the nurse include?

A) "Shelter Plus Care offers more services to a larger population than does Safe

Havens."

B) "Safe Havens provides shelter for as many as 100 people at a time."

C) "Safe Havens provides traditional support services as well as short-term

housing."

D) "Shelter Plus

Ans: D

Feedback:

A Safe Haven, in addition to serving hard-to-reach people with severe mental

illness who are on the streets and have been unwilling or unable to participate in

traditional supportive services, meets the following criteria: it provides 24-hour

residence for an unspecified duration; it provides private or semiprivate accommodations; and it limits overnight occupancy to 25 persons. Shelter Plus Care

provides long-term housing and supportive services for people who are homeless

with disabilities, primarily those with serious mental illness, chronic problems with

alcohol or drug use, or AIDS or related diseases.

After describing the various legislative efforts to address the issue of

homelessness in the United States, a nursing instructor determines that the

education was successful when the students identify which legislation as ad-

dressing the need for a continuum of care approach?

A) Bringing Home America Act

B) Affordable Care Act

C) American Recovery and Reinvestment Act

D) McKinney-Vento Homeless Assistance Act

Ans: D

Feedback:

The McKinney-Vento Homeless Assistance Act (Public Law 100-77, first passed in

1987 as the McKinney Act), a landmark legislation, reflected concern in the United

States about people who are homeless and provided the first comprehensive,

federal funding program targeted specifically to address the health, education,

and welfare needs of the homeless population. Subsequent revisions to the

McKinney Act incorporated a continuum of care approach, including emergency

shelter, transitional or rehabilitative services, and permanent housing or sup-

portive living arrangements. Because of the gap in services for people who are

homeless and mentally ill, amendments were made to the McKinney Act in 1992

that included a provision for the creation of Safe Havens, which are a form of

supportive housing that serves hard-to-reach people with severe mental ill-

nesses. The Bringing Home America Act (HR 4347) includes housing develop-

ment, support for living income, rental assistan

A nurse working in an emergency homeless shelter is interviewing a woman

who has just arrived with her two small children. When assessing this client, the

nurse would expect the woman to report which reason for seeking shelter?

A) Substance abuse

B) Domestic violence

C) Unemployment

D) Imprisonment

Ans: B

Feedback:

Fifty percent of all women and children who experience homelessness are fleeing

from domestic violence. Studies show that men tend to report that their homelessness is caused by unemployment, alcohol and drug abuse, or imprisonment.

A nurse is developing a plan of care for a client who is homeless. Which action

would the nurse take first?

A) Refer the client to social services to access necessary benefits.

B) Provide the client with a list of facilities that are safe.

C) Discuss how the client can maintain privacy.

D) Stabilize the client's physical health status.

Ans: D

Feedback:

The priority with any homeless client is meeting the basic needs. Thus, the nurse

would work on stabilizing the client's physical health status first. Referrals,

suggestions for safe facilities, and education or counseling related to maintaining

privacy would follow.

Ans: C

Feedback:

It is a myth that street dwellers are unwilling to accept services. Most people who

are homeless recognize the need for help, but survival needs take priority over

the need for mental health treatment. People who are homeless come from all

walks of life and must be creative to secure resources and constantly change life

ways to survive. In addition, about 110,000 people are estimated to be chronically homeless; most are homeless for a relatively short period of time.

Before caring for homeless clients, nurses need to examine their own myths

and feelings about homelessness. What is this type of reflection called?

A) Nursing care

B) Caring behaviors

C) Personal identity

D) Self-awareness

Ans: D

Feedback:

A self-aware nurse reflects on myths and feelings the nurse has about clients who

are homeless and mentally ill. Relating to people who are homeless requires

gentle and compassionate nursing care.

A nurse completed a health history on a homeless client who was sexually

assaulted in a shelter. What is the priority nursing diagnosis for the client?

A) Impaired dentition

B) Fatigue

C) Anxiety

D) Impaired verbal communication

Ans: C

Feedback:

The client has suffered from a sexual assault and will be anxious and upset. The

nurse should be prepared to provide a very comforting and safe environment for

the client with minimal interruptions to reduce the anxiety the client is eliciting.

Imperative to this assessment is a psychosocial evaluation during the immediate

interaction and later to assess for post-traumatic stress. The client is able to

discuss the event; no impaired verbal communication is the nursing diagnosis.

Fatigue can be occurring but anxiety is the priority nursing diagnosis.

A psychiatric-mental health nurse is preparing a class for a group of staff

nurses on individuals who are homeless and mentally ill. When describing the

characteristics of this population, which finding would the nurse most likely include? Select all that apply.

A) Individuals usually receive psychiatric care in outpatient units.

B) Their physical health is likely to be worse than that of other homeless individuals.

C) Most of these individuals have easy access to disability or other types of

Ans: B, D

Feedback:

Individuals who are homeless and mentally ill often experience poorer physical

health than other individuals who are homeless, and they have more contacts

with the legal system than other homeless or housed people. They have at least

one psychiatric service encounter annually, usually in an emergency department

rather than inpatient or outpatient units. Although most are eligible for benefits,

they have difficulty obtaining them. Seriously mentally ill people are at greater

risk for homelessness than the general population.

The nurse is developing a plan of care for a client who has been admitted to

the inpatient unit after being brought to the emergency department by law en-

forcement. Assessment in the emergency department reveals that the client is

homeless and has been diagnosed with posttraumatic stress syndrome. The client

also has a history of substance abuse. When reviewing the client's medical record,

which factor would the nurse identify as contributing to the client's homeless-

ness? Select all that

Ans: A, C, D, E

Feedback:

Homelessness has no single cause. Many factors typically combine, with time, to

cause the person or family to lose permanent housing. Risk factors for homelessness include mental illness, substance abuse, lack of needed services, lack of

family support, low-paying job, unemployment, and changes or reductions in

public assistance programs.

A client who is homeless and mentally ill is being discharged to an Assertive

Community Treatment (ACT) program. The nurse interprets discharge as including which services? Select all that apply.

A) Substance abuse management

B) Medication monitoring

C) Counseling

D) Living skills classes

E) Shelter for one night

Ans: A, B, C

Feedback:

Assertive Community Treatment (ACT) programs focus on service delivery to the

homeless and mentally ill population by a transdisciplinary team of 10 to 12

specialists with a 1:10 staff-client ratio. A single, integrated, mobile staff team

uses outreach, case management, practical assistance and support, and rehabilitation services to maximize the possibility that the most disabled consumers

will live independently in the community and have a good quality of life. The team

provides counseling and advocacy; monitors the person's management of

housing, income, medication use, and leisure activities; and provides opportunities for employment, if appropriate. Substance abuse management and physical

health care are provided as needed. Living skills classes are often provided in day

treatment programs. Shelter for one night would be provided by emergency

services programs.

A nurse is completing an admission assessment of a client admitted for an

infection. The client states that the client lives in a homeless shelter. What additional assessments should the nurse complete on the client? Select all that

apply.

A) Nutrition

B) Mental illness

C) Substance abuse

D) Medication intake

E) Vision

Ans: A, B, C

Feedback:

When a client identifies living in a shelter, additional assessments should be

obtained. Shelters are run by federal or state agencies and received limited

donations on food. Nutrition should be assessed during the interaction. There is

also a high risk of mental illness and substance abuse with those who are

homeless. The nurse should be aware of these potential problems and assist in

assessment. Vision is not a priority at this time. The stem of the question does not

address medication issue so assessment of adherence is not warranted at this

time.