NURSING 326 Mental Health Study Test1 | NURSING 326 Mental Health Study Exam1

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NURSING 326 Mental Health Study Test1 Chapter 2. Mental Health/Mental Illness: Historical and Theoretical Concepts Summary and Key Points ▀ Psychiatric care has its roots in ancient times, when ... etiology was based in superstition and ideas related to the supernatural. ▀ Treatments were often inhumane and included brutal beatings, starvation, or other torturous means. ▀ Hippocrates associated insanity and mental illness with an irregularity in the interaction of the four body fluids (humors)—blood, black bile, yellow bile, and phlegm. ▀ Conditions for care of the mentally ill have improved, largely because of the influence of leaders such as Benjamin Rush, Dorothea Dix, and Linda Richards, whose endeavors provided a model for more humanistic treatment. ▀ Maslow identified a ―hierarchy of needs‖ that individuals seek to fulfill on their quest to self-actualization (one's highest potential). ▀ For purposes of this text, the definition of mental health is viewed as ―the successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms.‖ ▀ In determining mental illness, individuals are influenced by incomprehensibility of the behavior; that is, whether or not they are able to understand the motivation behind the behavior. ▀ Another consideration is cultural relativity. The ―normality‖ of behavior is determined by cultural and societal norms. ▀ For purposes of this text, the definition of mental illness is viewed as ―maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms, and that interfere with the individual's social, occupational, and/or physical functioning.‖ ▀ Anxiety and grief have been described as two major, primary psychological response patterns to stress. ▀ Peplau defined anxiety by levels of symptom severity: mild, moderate, severe, and panic. ▀ Behaviors associated with levels of anxiety include coping mechanisms, ego defense mechanisms, psychophysiological responses, psychoneurotic responses, and psychotic responses. ▀ Grief is described as a response to loss of a valued entity. Loss is anything that is perceived as such by the individual. ▀ Kübler-Ross, in extensive research with terminally ill patients, identified five stages of feelings and behaviors that individuals experience in response to a real, perceived, or anticipated loss: denial, anger, bargaining, depression, and acceptance. ▀ Anticipatory grief is grief work that is begun, and sometimes completed, before the loss occurs. ▀ Resolution is thought to occur when an individual is able to remember and accept both the positive and negative aspects associated with the lost entity.▀ Grieving is thought to be maladaptive when the mourning process is prolonged, delayed or inhibited, or becomes distorted and exaggerated out of proportion to the situation. Pathological depression is considered to be a distorted reaction. Multiple Choice 1. A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client‘s appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client‘s behaviors? A. The client‘s behaviors demonstrate mental illness in the form of depression. B. The client‘s behaviors are extensive, which indicates the presence of mental illness. C. The client‘s behaviors are not congruent with cultural norms. D. The client‘s behaviors demonstrate no functional impairment, indicating no mental illness. ANS: D The nurse should assess that the client‘s daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the client‘s distress does not indicate a mental illness. 2. At what point should the nurse determine that a client is at risk for developing a mental disorder? A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria B. When maladaptive responses to stress are coupled with interference in daily functioning C. When the client communicates significant distress D. When the client uses defense mechanisms as ego protection ANS: B The nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These disorders are usually associated with significant distress or disability in social, occupational, or other important activities. The client‘s ability to communicate distress would be considered a positive attribute. 3. A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain these different responses to stress to the parents? A. Reactions to stress are relative rather than absolute; individual responses to stress vary. B. It is abnormal for identical twins to react differently to similar stressors. C. Identical twins should share the same temperament and respond similarly to stress.D. Environmental influences weigh more heavily than genetic influences on reactions to stress. ANS: A Responses to stress are variable among individuals and may be influenced by perception, past experience, and environmental factors in addition to genetic factors. 4. A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, ―I work hard to provide for my family. I don‘t see why I can‘t drink to relax.‖ The nurse recognizes the use of which defense mechanism? A. Projection B. Rationalization C. Regression D. Sublimation ANS: B The nurse should recognize that the client is using rationalization, a common defense mechanism. The client is attempting to make excuses and create logical reasons to justify unacceptable feelings or behaviors. 5. Which client should the nurse anticipate to be most receptive to psychiatric treatment? A. A Jewish, female journalist B. A Baptist, homeless male C. A Catholic, black male D. A Protestant, Swedish business executive ANS: A The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely than men to seek treatment for mental health problems. 6. A new psychiatric nurse states, ―This client‘s use of defense mechanisms should be eliminated.‖ Which is a correct evaluation of this nurse‘s statement? A. Defense mechanisms can be self-protective responses to stress and need not be eliminated. B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated. C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated. D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged. ANS: AThe nurse should know that defense mechanisms serve the purpose of reducing anxiety during times of stress. A client with no defense mechanisms may have a lower tolerance for stress, predisposing him or her to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills. 7. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, ―I‘m here for my heart, not my head problems.‖ Which is the nurse‘s best response? A. ―It‘s just a routine part of our assessment. All clients are asked these same questions.‖ B. ―Why are you concerned about these types of questions?‖ C. ―Psychological factors, like excessive stress, have been found to affect medical conditions.‖ D. ―We can skip these questions, if you like. It isn‘t imperative that we complete this section.‖ ANS: C The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip either physiological or psychosocial questions, as this would lead to an inaccurate assessment. 8. Which statement reflects a student nurse‘s accurate understanding of the concepts of mental health and mental illness? A. ―The concepts are rigid and religiously based.‖ B. ―The concepts are multidimensional and culturally defined.‖ C. ―The concepts are universal and unchanging.‖ D. ―The concepts are unidimensional and fixed.‖ ANS: B The student nurse should understand that mental health and mental illness are multidimensional and culturally defined. It is important for nurses to be aware of cultural norms when evaluating a client‘s mental state. 9. A mental health technician asks the nurse, ―How do psychiatrists determine which diagnosis to give a patient?‖ Which of these responses by the nurse would be most accurate? A. Psychiatrists use pre-established criteria from the APA‘s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). B. Hospital policy dictates how psychiatrists diagnose mental disorders. C. Psychiatrists assess the patient and identify diagnoses based on the patient‘s unhealthy responses and contributing factors. D. The American Medical Association identifies 10 diagnostic labels that psychiatrists can choose from. ANS: AThe DSM-5 is an organized manual describing mental disorders and the criteria that determine whether a given diagnosis is appropriate. It is published by the American Psychiatric Association (APA). It intends to facilitate accurate and reliable medical diagnosis and treatment. Item C describes nursing rather than medical diagnosis. 10. The nurse is preparing to provide medication instruction for a patient. Which of the following understandings about anxiety will be essential to effective instruction? A. Learning is best when anxiety is moderate to severe. B. Learning is enhanced when anxiety is mild. C. Panic level anxiety helps the nurse teach better. D. Severe anxiety is characterized by intense concentration and enhances the attention span. ANS: B Mild anxiety sharpens the senses, increases the perceptual field, and results in heightened awareness of the environment. Learning is enhanced. As anxiety increases, attention span decreases and learning becomes more difficult. 11. Which of the following are identified as psychoneurotic responses to severe anxiety as they appear in the DSM- 5? A. Somatic symptom disorders B. Grief responses C. Psychosis D. Bipolar disorder ANS: A Somatic symptom disorder is characterized by preoccupation with physical symptoms for which there is no demonstrable organic pathology. One of the diagnostic criteria is a high level of anxiety about health concerns or illness. 12. An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee? A. The employee assertively confronts the boss B. The employee leaves the staff meeting to work out in the gym C. The employee criticizes a coworker D. The employee takes the boss out to lunch ANS: C The client using the defense mechanism of displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target.13. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, ―I know she wants me.‖ This statement reflects which defense mechanism? A. Displacement B. Projection C. Rationalization D. Sublimation ANS: B The nurse should determine that the client‘s statement reflects the defense mechanism of projection. Projection refers to the attribution of one‘s unacceptable feelings or impulses to another person. When the client ―passes the blame‖ of the undesirable feelings, anxiety is reduced. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities. 14. A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism? A. Displacement B. Projection C. Reaction formation D. Sublimation ANS: C The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities. 15. Which nursing statement about the concept of neuroses is most accurate? A. ―An individual experiencing neurosis is unaware that he or she is experiencing distress.‖ B. ―An individual experiencing neurosis feels helpless to change his or her situation.‖ C. ―An individual experiencing neurosis is aware of psychological causes of his or her behavior.‖ D. ―An individual experiencing neurosis has a loss of contact with reality.‖ ANS: B The nurse should understand that the concept of neuroses includes the following characteristics. The client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality.16. Which nursing statement about the concept of psychoses is most accurate? A. ―Individuals experiencing psychoses are aware that their behaviors are maladaptive.‖ B. ―Individuals experiencing psychoses experience little distress.‖ C. “Individuals experiencing psychoses are aware of experiencing psychological problems.‖ D. ―Individuals experiencing psychoses are based in reality.‖ ANS: B The nurse should understand that the client with psychoses experiences little distress, because of his or her lack of awareness of reality. The client with psychoses is unaware that his or her behavior is maladaptive or that he or she has a psychological problem. 17. When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial? A. Hiding liquor bottles in a closet B. Yelling at their son for slouching in his chair C. Burning dinner on purpose D. Saying to the spouse, ―I don‘t drink too much!‖ ANS: D The nurse should associate the client statement ―I don‘t drink too much!‖ with the use of the defense mechanism of denial. The client who refuses to acknowledge the existence of a real situation and the feelings associated with it is using the defense mechanism of denial. 18. Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief? A. ―If only we could have tried again, things might have worked out.‖ B. ―I am so mad that the children and I had to put up with him as long as we did.‖ C. ―Yes, it was a difficult relationship, but I think I have learned from the experience.‖ D. ―I still don‘t have any appetite and continue to lose weight.‖ ANS: C The nurse should recognize that the client is in the acceptance stage of grief. During this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life. 19. A nurse is performing a mental health assessment on an adult client. According to Maslow‘s hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?A. Maintaining a long-term, faithful, intimate relationshipB. Achieving a sense of self-confidence C. Possessing a feeling of self-fulfillment and realizing full potential D. Developing a sense of purpose and the ability to direct activities ANS: C The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow‘s hierarchy of needs. 20. According to Maslow‘s hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse?A. A client rudely complaining about limited visiting hours B. A client exhibiting aggressive behavior toward another client C. A client stating that no one cares D. A client verbalizing feelings of failure ANS: B The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow‘s hierarchy of needs and must be fulfilled before other, higher-level needs can be met. Clients who complain, have feelings of failure, or state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem. 21. Which is an example of the ego defense mechanism of regression? A. A mother blames the teacher for her child‘s failure in school. B. A teenager becomes hysterical after seeing a friend killed in a car accident. C. A woman wants to marry a man exactly like her beloved father. D. An adult throws a temper tantrum when he does not get his own way. ANS: D Regression is the retreating to an earlier level of development and the comfort measures associated with that level of functioning. 22. Which is the most significant consequence of the excessive use of defense mechanisms? A. The superego will be suppressed. B. Emotions will be experienced intensely. C. Learning and the ability to grow will be enhanced. D. Problem-solving will be limited. ANS: DDefense mechanisms become maladaptive when they are used by an individual to such a degree that there is interference with the ability to deal with reality, effective interpersonal relations, or occupational performance. 23. A husband accuses his wife of infidelity. Which situation would indicate to the nurse the husband‘s use of the ego defense mechanism of projection? A. The husband cries and stamps his feet, demanding that his wife be true to her marriage vows. B. The husband ignores the wife‘s continued absence from the home. C. The husband has already admitted to having an affair with a coworker. D. The husband takes out his marital frustrations through employee abuse. ANS: C Projection is the attribution of feelings or impulses unacceptable to one‘s self to another person. In this situation, the husband attributes his infidelity to his wife. 24. Which should the nurse recognize as a DSM-5 disorder?A. Obesity B. Generalized anxiety disorder C. Hypertension D. Grief ANS: B The DSM-5 identifies several disorders that are related to anxiety, including generalized anxiety disorder, somatic symptom disorder, and dissociative disorders. 25. A nurse is educating a patient about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health? A. Mental health is the absence of any stressors. B. Mental health is successful adaptation to stressors in the internal and external environment. C. Mental health is incongruence between thoughts, feelings, and behavior D. Mental health is a diagnostic category in the DSM-5. ANS: B Several definitions of mental health exist, but this definition highlights concepts of successful adaptation to stressors, including thoughts, feelings, and behaviors that are age-appropriate and congruent with cultural and societal norms. 26. Most cultures label behavior as mental illness on the basis of which of the following criteria? A. Incomprehensibility and cultural relativity B. Strength of character and ethicsC. Goal directedness and high energy D. Creativity and good coping skills ANS: A Incomprehensibility and cultural relativity are most often the criteria used to define whether something is labeled mental illness. The other identified behaviors would be more associated with health than illness. 27. Which should the nurse recognize as an example of the defense mechanism of repression?A. A student aware of the need to study for tomorrow‘s test goes to a movie instead. B. A woman whose son was killed in Iraq does not believe the military report. C. A man who is unhappily married goes to school to become a marriage counselor. D. A woman was raped when she was 12 and no longer remembers the incident. ANS: D Repression is the involuntary blocking of unpleasant feelings and experiences from one‘s awareness. Multiple Response 28. Which of the following statements should a nurse recognize as true about defense mechanisms? Select all that apply. A. They are employed when there is a threat to biological or psychological integrity. B. They are controlled by the id and deal with primal urges. C. They are used in an effort to relieve mild to moderate anxiety. D. They are protective devices for the superego. E. They are mechanisms that are characteristically self-deceptive. ANS: A, C, E Defense mechanisms are employed by the ego in the face of threats to biological and psychological integrity, in an effort to relieve mild to moderate anxiety. Because they redirect focus, they are characteristically self-deceptive. 29. A nurse is assessing a client who appears to be experiencing moderate anxiety during questioning. Which symptoms might the client demonstrate? Select all that apply. A. Fidgeting B. Laughing inappropriately C. Palpitations D. Nail biting E. Extremely limited attention spanANS: A, B, D The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other areas of daily functioning. Other indicators of more serious anxiety are restlessness, difficulty concentrating, muscle tension, and sleep disturbance. 30. Which of the following are cultural aspects of mental illness? Select all that apply. A. Local or cultural norms define pathological behavior. B. The higher the social class the greater the recognition of mental illness behaviors. C. Psychiatrists typically see patients when the family can no longer deny the illness. D. The greater the cultural distance from the mainstream of society, the greater the likelihood that the illness will be treated with sensitivity and compassion. ANS: A, B, C The fewer ties that a group has with mainstream society, the greater the likelihood of a negative response by society to mental illness. Coercive treatments and involuntary hospitalizations are more common in this population. 31. How is the DSM-5 useful in the practice of psychiatric nursing? Select all that apply. A. It informs the nurse of accurate and reliable medical diagnosis. B. It represents progress toward a more holistic view of mind–body. C. It provides a framework for interdisciplinary communication. D. It provides a template for nursing care plans. E. It provides a framework for communication with the client. ANS: A, B, C The DSM-5 is useful in the practice of psychiatric nursing because it facilitates comprehensive evaluation of the client. In addition, it encourages a holistic view and provides a framework for interdisciplinary communication. Chapter 5. Ethical and Legal Issues in Psychiatric/Mental Health Nursing Summary and Key Points ▀ Ethics is a branch of philosophy that addresses methods for determining the rightness or wrongness of one's actions. ▀ Bioethics is the term applied to these principles when they refer to concepts within the scope of medicine, nursing, and allied health. ▀ Moral behavior is defined as conduct that results from serious critical thinking about how individuals ought to treat others. ▀ Values are personal beliefs about what is important or desirable.▀ A right is defined as ―a valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and an entitlement to a benefit or service.‖ ▀ The ethical theory of utilitarianism is based on the premise that what is right and good is that which produces the most happiness for the most people. ▀ The ethical theory of Kantianism suggests that actions are bound by a sense of duty, and that ethical decisions are made out of respect for moral law. ▀ The code of Christian ethics is that all decisions about right and wrong should be centered in love for God and in treating others with the same respect and dignity with which we would expect to be treated. ▀ The moral precept of the natural law theory is ―do good and avoid evil.‖ Good is viewed as that which is inscribed by God into the nature of things. Evil acts are never condoned, even if they are intended to advance the noblest of ends. ▀ Ethical egoism espouses that what is right and good is what is best for the individual making the decision. ▀ Ethical principles include autonomy, beneficence, nonmaleficence, veracity, and justice. ▀ An ethical dilemma is a situation that requires an individual to make a choice between two equally unfavorable alternatives. ▀ Ethical issues may arise in psychiatric/mental health nursing around the right to refuse medication and the right to the least-restrictive treatment alternative. ▀ Statutory laws are those that have been enacted by legislative bodies, and common laws are derived from decisions made in previous cases. Both types of laws have civil and criminal components. ▀ Civil law protects the private and property rights of individuals and businesses, and criminal law provides protection from conduct deemed injurious to the public welfare. ▀ Legal issues in psychiatric/mental health nursing center around confidentiality and the right to privacy, informed consent, restraints and seclusion, and commitment issues. ▀ Nurses are accountable for their own actions in relation to legal issues, and violation can result in malpractice lawsuits against the physician, the hospital, and the nurse. ▀ Developing and maintaining a good interpersonal relationship with the client and his or her family appears to be a positive factor when the question of malpractice is being considered. Multiple Choice 1. In response to a student‘s question regarding choosing a psychiatric specialty, a charge nurse states, ―Mentally ill clients need special care. If I were in that position, I‘d want a caring nurse also.‖ From which ethical framework is the charge nurse operating? A. Kantianism B. Christian ethics C. Ethical egoism D. UtilitarianismANS: B The charge nurse is operating from a Christian ethics framework. A basic principle in Christian ethics is to ―do unto others as you would have them do unto you.‖ Kantianism states that decisions should be based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made with a focus on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual. 2. During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework? A. ―I would want to be treated in a caring manner if I were mentally ill.‖ B. ―This job will pay the bills, and the workload is light enough for me.‖ C. ―I will be happy caring for the mentally ill. Working in Med/Surg kills my back.‖ D. ―It is my duty in life to be a psychiatric nurse. It is the right thing to do.‖ ANS: B The applicant‘s comment reflects an ethical egoism framework. This framework promotes the idea that decisions are based on what is good for the individual and may not take the needs of others into account. 3. Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse‘s coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworker‘s lack of involvement? A. Taking no action is still considered an action by the coworker. B. Taking no action releases the coworker from ethical responsibility. C. Taking no action is advised when potential adverse consequences are foreseen. D. Taking no action is acceptable, because the coworker is only a bystander. ANS: A The coworker‘s lack of involvement can be interpreted as an action taken. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. Although the coworker may be struggling with ethical decision making, he or she has witnessed another nurse dispensing medication outside of the scope of practice; therefore, from a legal perspective, this should be reported. 4. Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit manager‘s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager‘s policy preserve? A. Justice B. Autonomy C. Veracity D. Beneficence ANS: BThe unit manager‘s policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions. 5. Which is an example of an intentional tort? A. A nurse fails to assess a client‘s obvious symptoms of neuroleptic malignant syndrome. B. A nurse physically places an irritating client in four-point restraints. C. A nurse makes a medication error and does not report the incident. D. A nurse gives patient information to an unauthorized person. ANS: B A tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. A nurse who physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort. Examples of unintentional torts are malpractice and negligence actions. 6. An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? A. Verbally redirect the client, and then limit one-on-one interaction. B. Involve the hospital‘s security division as soon as possible. C. Notify the client that documenting personal staff information is against hospital policy. D. Continue professional attempts to establish a positive working relationship with the client. ANS: D The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed. 7. Which statement should a nurse identify as correct regarding a client‘s right to refuse treatment? A. Clients can refuse pharmacological but not psychological treatment. B. Clients can refuse any treatment at any time. C. Clients can refuse only electroconvulsive therapy (ECT). D. Professionals can override treatment refusal if the client is actively suicidal or homicidal. ANS: D The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be a danger to self or others. This situation should be treated as an emergency, and treatment may be performed without informed consent.8. Which client should a nurse identify as a potential candidate for involuntarily commitment? A. A client living under a bridge in a cardboard box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can ANS: B The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is a danger to self and requires emergency treatment. 9. A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client‘s wishes? A. When the client makes inappropriate sexual innuendos to a staff member B. When the client constantly demands inappropriate attention from the nurse C. When the client physically attacks another client after being confronted in group therapy D. When the client refuses to bathe or perform hygienic activities ANS: C The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making rational choices. The client‘s refusal to accept treatment can be challenged because the client is endangering the safety of others. 10. A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? A. Refusing to give any information to the caller, citing rules of confidentiality B. Refusing to give any information to the caller by hanging up C. Affirming that the person has been seen at the facility but providing no further information D. Suggesting that the caller speak to the client‘s therapist ANS: A The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent. 11. A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? A. AutonomyB. Beneficence C. Nonmaleficence D. Justice ANS: A The nurse should provide the information to support the client‘s autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent. 12. An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice ANS: D The nurse should determine that the ethical principle of justice has been violated by the physician‘s actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief. 13. Which situation contradicts the ethical principle of veracity? A. A nurse provides a client with outpatient resources to benefit recovery. B. A nurse refuses to give information to a physician who is not responsible for the client‘s care. C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. D. A nurse treats all of the clients equally regardless of illness severity. ANS: C The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to one‘s duty to always be truthful and not intentionally deceive or mislead clients. 14. A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? A. The client is paranoid. B. The client is 87 years old. C. The client incorrectly reports his or her spouse‘s name, the date, and the time of day.D. The client relies on his or her spouse to interpret the information. ANS: C The nurse should question the validity of informed consent when the client incorrectly reports the spouse‘s name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices. 15. A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? A. Allow the client to decline the medication and document. B. Tell the client that if the medication is refused, hospitalization will occur. C. Arrange with a relative to add medication to the client‘s morning orange juice. D. Call for help to hold the client down while the injection is administered. ANS: A It is ethically and legally appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client‘s right to refuse treatment should be upheld unless the refusal puts the client or others in harm‘s way. 16. Which situation exemplifies both assault and battery? A. The nurse becomes angry, calls the client offensive names, and withholds treatment. B. The nurse threatens to ―tie down‖ the client and then does so against the client‘s wishes. C. The nurse hides the client‘s clothes and medicates the client to prevent elopement. D. The nurse restrains the client without just cause and communicates this to family. ANS: B The nurse in this situation has committed both the acts of assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent. 17. A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? A. The client is placed in seclusion. B. The client is placed in a geriatric chair with tray. C. The client is placed in soft Posey restraints. D. The client is monitored by an ankle bracelet. ANS: DThe least restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified. 18. A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the client‘s approved call list. What law has the nurse broken? A. The National Alliance for the Mentally Ill Act B. The Tarasoff Ruling C. The Health Insurance Portability and Accountability Act D. The Good Samaritan Law ANS: C The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client. 19. An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment team‘s next action? A. State law determines how long a psychiatric facility can hold a client. B. Federal law determines if the client is competent. C. The client‘s family involvement will determine if discharge is possible. D. Hospital policies will determine treatment team actions. ANS: A Most states commonly cite that in an emergency a client who is dangerous to self or others may be involuntarily hospitalized. 20. A client is concerned that information given to the nurse remains confidential. Which is the nurse‘s best response? A. ―Your information is confidential. It will be kept just between you and me.‖ B. ―I will share the information with staff members only with your approval.‖ C. ―If the information impacts your care, I will need to share it with the treatment team.‖ D. ―You can make the decision whether your physician needs this information or not.‖ ANS: C Basic to the psychiatric client‘s hospitalization is his or her right to confidentiality and privacy. When admitted to an inpatient psychiatric facility, a client gives implied consent for information to be shared with health-care workers specifically involved in the client‘s care.21. The nursing staff is discussing the concept of competency. Which information about competency should a nurse recognize as true? A. Competency is determined with a client‘s compliance with treatment. B. Refusal of medication can initiate an incompetency hearing leading to forced medications. C. A competent client has the ability to make reasonable judgments and decisions. D. Competency is a medical determination made by the client‘s physician. ANS: C A competent individual‘s cognition is not impaired to an extent that would interfere with decision making. 22. A nursing instructor is presenting content on the provisions of the Nurse Practice Act as it relates to their state. Which student statement indicates a need for further instruction? A. ―The Nurse Practice Act provides a list of definitions of important terms, including the definition of nursing.‖ B. ―The Nurse Practice Act lists education requirements for licensure and reciprocity.‖ C. ―The Nurse Practice Act contains detailed statements that describe the scope of practice for registered nurses (RNs).‖ D. ―The Nurse Practice Act lists the general authority and powers of the state board of nursing.‖ ANS: C The nurse practice act contains broad, not detailed, statements that describe the scope of practice for various levels of nursing (APN, RN, LPN), not just for the RN. This student statement indicates a need for further instruction. 23. Which is an accurate description of a common law? A. A common law would be invoked to deal with a nurse who, without justification, threatens a client with restraints. B. A common law would be invoked to deal with a nurse who touches a client without the client‘s consent. C. A common law would be invoked to deal with a hospital employee who steals drugs, hospital equipment, or both. D. A common law would be invoked to deal with a nurse‘s refusal to provide care for a specific client. ANS: D Common laws apply to a body of principles that evolve from court decisions resolving various controversies. Common law may vary from state to state. Assault (threats) and battery (touch) are governed by civil law. Stealing is governed by criminal law. 24. The experience of being physically restrained can be traumatic. Which nursing intervention would best help the client deal with this experience? A. Administering a tranquilizing medication before applying the restraints B. Talking to the client at brief but regular intervals while the client is restrainedC. Decreasing stimuli by leaving the client alone most of the time D. Checking on the client infrequently, in order to meet documentation requirements ANS: B Restraints are never to be used as punishment or for the convenience of the staff. Connecting with the client by maintaining communication during the period of restraint will help the client recognize this intervention as a therapeutic treatment versus a punishment. 25. There is one bed available on an inpatient psychiatric unit. For which client should a nurse advocate emergency commitment? A. An individual who is persistently mentally ill and evicted from an apartment B. An individual treated in the emergency department (ED) for generalized anxiety disorder C. An individual who is delusional and has a plan to kill his wife D. An individual who rates mood 4/10 and is participating in a no-harm safety plan ANS: C The criteria for involuntary emergency commitment include danger to self and/or others. Of the four clients considered, the client who is delusional and has a plan to kill his wife meets this criterion as a danger to others. 26. What is the legal significance of a nurse‘s action when a nurse threatens a demanding client with restraints? A. The nurse can be charged with assault. B. The nurse can be charged with negligence. C. The nurse can be charged with malpractice. D. The nurse can be charged with beneficence. ANS: A Assault is an act that results in a person‘s genuine fear and apprehension that he or she will be touched without consent. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 27. In the situation presented, which nursing intervention constitutes false imprisonment? A. The client is combative and will not redirect, stating, ―No one can stop me from leaving.‖ The nurse seeks the physician‘s order after the client is restrained. B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion. C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return.D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving. ANS: B False imprisonment is the deliberate and unauthorized commitment of a person within fixed limits by the use of verbal or physical means. Seclusion should only be used in an emergency situation to prevent harm after least restrictive means have been unsuccessfully attempted. Multiple Response 28. After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department by police. The client threatens suicide. Which criteria would enable a physician to consider involuntary commitment? Select all that apply. A. Being dangerous to others B. Being homeless C. Being disruptive to the community D. Being gravely disabled and unable to meet basic needs E. Being suicidal ANS: A, D, E The physician could consider involuntary commitment when a client is being dangerous to others, is gravely disabled, or is suicidal. If the client is determined to be mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator. A hospital administrator may give permission for involuntary commitment when time does not permit court intervention. Chapter 7. Relationship Development Summary and Key Points ▀ Nurses who work in the psychiatric/mental health field use special skills, or ―interpersonal techniques,‖ to assist clients in adapting to difficulties or changes in life experiences. ▀ Therapeutic nurse-client relationships are goal oriented, and the problem-solving model is used to try to bring about some type of change in the client's life. ▀ The instrument for delivery of the process of interpersonal nursing is the therapeutic use of self, which requires that the nurse possess a strong sense of self-awareness and self-understanding. ▀ Hildegard Peplau identified seven subroles within the role of nurse: stranger, resource person, teacher, leader, surrogate, technical expert, and counselor. ▀ Characteristics that enhance the achievement of a therapeutic relationship include rapport, trust, respect, genuineness, and empathy. ▀ Phases of a therapeutic nurse-client relationship include the preinteraction phase, the orientation (introductory) phase, the working phase, and the termination phase.▀ Transference occurs when the client unconsciously displaces (or ―transfers‖) to the nurse feelings formed toward a person from the past. ▀ Countertransference refers to the nurse's behavioral and emotional response to the client. These responses may be related to unresolved feelings toward significant others from the nurse's past, or they may be generated in response to transference feelings on the part of the client. ▀ Types of boundaries include material, social, personal, and professional. ▀ Concerns associated with professional boundaries include self-disclosure, gift-giving, touch, and developing a friendship or romantic association. ▀ Boundary crossings can threaten the integrity of the nurse-client relationship. Multiple Choice 1. What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? A. To clarify personal attitudes, values, and beliefs B. To obtain thorough assessment data C. To determine the client‘s length of stay D. To establish personal goals for the interaction ANS: A The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding one‘s own attitudes, values, and beliefs is called selfawareness. 2. A hungry, homeless client, diagnosed with schizophrenia, refuses to participate in an admission interview. When the nurse postpones the admission interview, verbally assures safety, and provides a warm meal, he or she is promoting which of the following? A. Sympathy B. Trust C. Veracity D. Manipulation ANS: B The nurse is promoting trust by postponing the admission interview, assuring safety, and providing a warm meal. Trust implies a feeling of confidence that a person is reliable and sincere and has integrity and veracity. Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the client. 3. Which is the best nursing action when a client demonstrates transference toward a nurse? A. Promoting safety and immediately terminating the relationship with the clientB. Encouraging the client to ignore these thoughts and feelings C. Immediately reassigning the client to another staff member D. Helping the client to clarify the meaning of the current nurse–client relationship ANS: D The nurse should respond to a client‘s transference by clarifying the meaning of the nurse–client relationship, based on the current situation. Transference occurs when the client unconsciously displaces feelings toward the nurse about a person from the past. The nurse should assist the client in separating the past from the present. 4. What is the priority nursing action during the orientation (introductory) phase of the nurse–client relationship? A. Acknowledge the client‘s actions and generate alternative behaviors. B. Establish rapport and develop treatment goals. C. Attempt to find alternative placement. D. Explore how thoughts and feelings about this client may adversely impact care. ANS: B The priority nursing action during the orientation phase of the nurse–client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurse–client relationship. 5. Which client response should a nurse expect during the working phase of the nurse–client relationship? A. The client gains insight and incorporates alternative behaviors. B. The client and nurse establish rapport and mutually develop treatment goals. C. The client explores feelings related to reentering the community. D. The client explores personal strengths and weaknesses that impact behaviors. ANS: A The nurse should expect that the client would gain insight and incorporate alternative behaviors during the working phase of the nurse–client relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals. 6. What should be the nurse‘s primary goal during the preinteraction phase of the nurse–client relationship? A. To evaluate goal attainment and ensure therapeutic closure B. To establish trust and formulate a contract for intervention C. To explore self-perceptions D. To promote client changeANS: C The nurse‘s primary goal of the preinteraction phase should be to explore self-perceptions. The nurse should be aware of how any preconceptions may affect his or her ability to care for individual clients. Another goal of the preinteraction phase is to obtain available client information. 7. Which phase of the nurse–client relationship begins when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals? A. Preinteraction B. Orientation C. Working D. Termination ANS: B The orientation phase is when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals. There are four phases of relationship development: preinteraction, orientation, working, and termination. 8. Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurse–client relationship? A. ―I can‘t bear the thought of leaving here and failing.‖ B. ―I might have a hard time working with you. You remind me of my mother.‖ C. ―I can‘t tell my husband how I feel; he wouldn‘t listen anyway.‖ D. ―I‘m not sure that I can count on you to protect my confidentiality.‖ ANS: C The nurse should identify that the client statement ―I can‘t tell my husband how I feel; he wouldn‘t listen anyway‖ reflects resistance to change, which is a common behavior in the working phase of the nurse–client relationship. The working phase includes overcoming resistant behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues. 9. A client has made the decision to leave her alcoholic husband. She is feeling very depressed. Which nontherapeutic statement by the nurse conveys sympathy? A. ―You are feeling very depressed. I felt the same way when I decided to leave my husband.‖ B. ―I can understand you are feeling depressed. It was a difficult decision. I‘ll sit with you.‖ C. ―You seem depressed. It was a difficult decision to make. Would you like to talk about it?‖ D. ―I know this is a difficult time for you. Would you like a prn medication for anxiety?‖ ANS: AThe nurse‘s statement, ―You are feeling very depressed. I felt the same when I decided to leave my husband,‖ is a nontherapeutic statement that conveys sympathy. Sympathy implies that the nurse shares what the client is feeling and by this personal expression alleviates the client‘s distress. 10. A mother who has learned that her child was killed in a tragic car accident states, ―I can‘t bear to go on with my life.‖ Which nursing statement conveys empathy? A. ―This situation is very sad, but time is a great healer.‖ B. ―You are sad, but you must be strong for your other children.‖ C. ―Once you cry it all out, things will seem so much better.‖ D. ―It must be horrible to lose a child; I‘ll stay with you until your husband arrives.‖ ANS: D The nurse‘s response, ―It must be horrible to lose a child; I‘ll stay with you until your husband arrives,‖ conveys empathy to the client. Empathy is the ability to see the situation from the client‘s point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship. 11. If an individual is ―two-faced,‖ which characteristic essential to the development of a therapeutic relationship should a nurse identify as missing? A. Respect B. Genuineness C. Sympathy D. Rapport ANS: B The nurse should identify that genuineness is missing in the relationship. Genuineness refers to an individual‘s ability to be open and honest and maintain congruence between what is felt and what is communicated. Genuineness is essential to establishing trust in a relationship. 12. On which task should a nurse place priority during the working phase of relationship development? A. Establishing a contract for intervention B. Examining feelings about working with a particular client C. Establishing a plan for continuing aftercare D. Promoting the client‘s insight and perception of reality ANS: D The nurse should place priority on promoting the client‘s insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the preinteraction phase. Establishing a plan for aftercare would occur in the termination phase.13. A client diagnosed with paranoid schizophrenia becomes agitated when asked to play a game. The client responds, ―Do you want to be my girlfriend?‖ Which nursing response is most appropriate? A. ―You are upset now. It would be best if you go to your room until you feel better.‖ B. ―Remember, we have a professional relationship. Are you feeling uncomfortable?‖ C. ―We have discussed this before. I am not allowed to date clients.‖ D. ―I think you should discuss your fantasies with your therapist.‖ ANS: B The nurse should promote the client‘s insight and perception of reality by confirming appropriate roles in the nurse– client relationship and identifying what is troubling the client in this situation. 14. A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, ―I‘m not well enough to switch to a different nurse.‖ What does this client response indicate to the nurse? A. The client is using manipulation to receive secondary gain. B. The client is using the defense mechanism of denial. C. The client is having trouble terminating the relationship. D. The client is using ―splitting‖ as a way to remain dependent on the nurse. ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurse–client relationship ends. When a client feels sadness and loss, behaviors to delay termination may become evident. 15. According to Peplau, which nursing action demonstrates the nurse‘s role as a resource person? A. The nurse balances a safe therapeutic environment to increase the client‘s sense of belonging. B. The nurse holds a group meeting with the clients on the unit to discuss common feelings about mental illness. C. The nurse monitors the administration of medications and watches for signs of ―cheeking.‖ D. The nurse explains, in language the client can understand, information related to the client‘s health care. ANS: D According to Peplau, a resource person provides specific answers to questions usually formulated with relation to a larger problem. 16. According to Peplau, which nursing intervention is most appropriate when the nurse is functioning in the role of a surrogate? A. The nurse functions as a nurturing parent in order to build a trusting relationship. B. The nurse plays cards with a small group of clients.C. The nurse discusses childhood events that may affect personality development. D. The nurse provides a safe social environment. ANS: A According to Peplau, when a client is acutely ill, he or she may incur the role of infant or child, while the nurse is perceived as the mother surrogate. 17. As the client and nurse move from the orientation stage to the working stage of the therapeutic relationship, which is the nurse‘s most therapeutic statement? A. ―I want to assure you that I will maintain your confidentiality.‖ B. ―A long-term goal for someone your age would be to develop better job skills.‖ C. ―Which identified problems would you like for us to initially address?‖ D. ―I think first we need to focus on your relationship issues.‖ ANS: C When moving on a continuum from the orientation to working phase of the nurse–client relationship, the client‘s identified goals are addressed through mutual therapeutic work to promote client behavioral change. 18. What is the main goal of the working phase of the nurse–client therapeutic relationship? A. Role modeling to improve interaction with others B. Resolution of the client‘s problems C. Using therapeutic communication to clarify perceptions D. Helping the client access outpatient treatment ANS: B The goal of the working phase of the nurse–client therapeutic relationship is to resolve client problems by promoting behavioral change. 19. Which client statement may indicate a transference reaction? A. ―I need a real nurse. You are young enough to be my daughter and I don‘t want to tell you about my personal life.‖ B. ―I deserve more than I am getting here. Do you know who I am and what I do? Let me talk to your supervisor.‖ C. ―I don‘t seem to be able to relate to people. I would rather stay in my room and be by myself.‖ D. ―My mother is the source of my problems. She has always told me what to do and what to say.‖ ANS: A Transference occurs when a client unconsciously displaces or ―transfers‖ to the nurse feelings formed toward a person from the past.20. Which nursing action demonstrates the role of the teacher in a therapeutic milieu? A. The nurse implements a self-affirmation exercise during a one-to-one client interaction. B. The nurse holds a group meeting to present common side effects of psychiatric medications. C. The nurse introduces the concept of fair play while playing cards with a group of clients. D. The nurse models adaptive and effective coping mechanisms with clients on the psychiatric unit. ANS: B The nurse, in the role of teacher, identifies learning needs and provides information required by the client or family to improve the client‘s health. 21. Which client statement indicates that termination of the therapeutic nurse–client relationship has been handled successfully? A. ―I know I can count on you for continued support.‖ B. ―I am looking forward to discharge, but I am surprised that we will no longer work together.‖ C. ―Reviewing the changes that have happened during our time together has helped me put things in perspective.‖ D. ―I don‘t know how comfortable I will feel when talking to someone else.‖ ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurse–client relationship ends. Bringing a therapeutic conclusion to the relationship occurs when progress has been made toward attainment of mutually set goals. 22. When is self-disclosure by the nurse appropriate in a therapeutic nurse–client relationship? A. When it is judged that the information may benefit the nurse and client B. When the nurse has a duty to warn C. When the nurse feels emotionally indebted toward the client D. When it is judged that the information may benefit the client ANS: D Self-disclosure on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the client. It should never be undertaken for the purpose of meeting the nurse‘s needs. Multiple Response 23. The nurse–client therapeutic relationship includes which of the following characteristics? Select all that apply. A. Meeting the psychological needs of the nurse and the client B. Ensuring therapeutic terminationC. Promoting client insight into problematic behavior D. Collaborating to set appropriate goals E. Meeting both the physical and psychological needs of the client ANS: B, C, D, E The nurse–client therapeutic relationship should include promoting client insight into problematic behavior, collaboration to set appropriate goals, meeting the physical and psychological needs of the client, and ensuring therapeutic termination. The nurse‘s psychological needs should not be addressed within the nurse–client relationship. Chapter 8. Therapeutic Communication Summary and Key Points ▀ Interpersonal communication is a transaction between the sender and the receiver. ▀ In all interpersonal transactions, both the sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted. ▀ Examples of these preexisting conditions include one's value system, internalized attitudes and beliefs, culture or religion, social status, gender, background knowledge and experience, age or developmental level, and the type of environment in which the communication takes place. ▀ Nonverbal expression is a primary communication system in which meaning is assigned to various gestures and patterns of behavior. ▀ Some components of nonverbal communication include physical appearance and dress, body movement and posture, touch, facial expressions, eye behavior, and vocal cues or paralanguage. ▀ Meaning of the nonverbal components of communication is culturally determined. ▀ Therapeutic communication includes verbal and nonverbal techniques that focus on the care receiver's needs and advance the promotion of healing and change. ▀ Nurses must also be aware of and avoid a number of techniques that are considered to be barriers to effective communication. ▀ Active listening is described as being attentive to what the client is saying, through both verbal and nonverbal cues. Skills associated with active listening include sitting squarely facing the client, observing an open posture, leaning forward toward the client, establishing eye contact, and being relaxed. ▀ Process recordings are written reports of verbal interactions with clients. They are used as learning tools for professional development. ▀ Feedback is a method of communication for helping the client consider a modification of behavior. ▀ The nurse must be aware of the therapeutic or nontherapeutic value of the communication techniques used with the client because they are the ―tools‖ of psychosocial intervention. Multiple Choice 1. Which therapeutic communication technique is being used in this nurse–client interaction?Client: ―When I get angry, I get into a fistfight with my wife or I take it out on the kids.‖ Nurse: ―I notice that you are smiling as you talk about this physical violence.‖ A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations ANS: D The nurse is using the therapeutic communication technique of making observations when noting that the client smiles when talking about physical violence. The technique of making observations encourages the client to compare personal perceptions with those of the nurse. 2. Which therapeutic communication technique is being used in this nurse–client interaction? Client: ―My father spanked me often.‖ Nurse: ―Your father was a harsh disciplinarian.‖ A. Restatement B. Offering general leads C. Focusing D. Accepting ANS: A The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. The nurse uses this technique to communicate that the client‘s statement has been heard and understood. 3. Which therapeutic communication technique is being used in this nurse–client interaction? Client: ―When I am anxious, the only thing that calms me down is alcohol.‖ Nurse: ―Other than drinking, what alternatives have you explored to decrease anxiety?‖ A. Reflecting B. Making observations C. Formulating a plan of action D. Giving recognition ANS: CThe nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of this technique, rather than direct confrontation regarding the client‘s poor coping choice, may serve to prevent anger or anxiety from escalating. 4. The nurse is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a ―general lead‖? A. ―Do you know why you are here?‖ B. ―Are you feeling depressed or anxious?‖ C. ―Yes, I see. Go on.‖ D. ―Can you chronologically order the events that led to your admission?‖ ANS: C The nurse‘s statement, ―Yes, I see. Go on,‖ is an example of the therapeutic communication technique of a general lead. Offering a general lead encourages the client to continue sharing information. 5. A nurse states to a client, ―Things will look better tomorrow after a good night‘s sleep.‖ This is an example of which communication technique? A. The therapeutic technique of ―giving advice‖ B. The therapeutic technique of ―defending‖ C. The nontherapeutic technique of ―presenting reality‖ D. The nontherapeutic technique of ―giving false reassurance‖ ANS: D The nurse‘s statement, ―Things will look better tomorrow after a good night‘s sleep,‖ is an example of the nontherapeutic technique of giving false reassurance. Giving false reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client‘s feelings. 6. A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening? A. ―What occurred prior to the rape, and when did you go to the emergency department?‖ B. ―What would you like to talk about?‖ C. ―I notice you seem uncomfortable discussing this.‖ D. ―How can we help you feel safe during your stay here?‖ ANS: B The nurse‘s statement, ―What would you like to talk about?‖ is an example of the therapeutic communication technique of giving broad openings. Using a broad opening allows the client to take the initiative in introducing the topic and emphasizes the importance of the client‘s role in the interaction.7. A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations? A. ―You appear to be talking to someone I do not see.‖ B. ―Please describe what you are seeing.‖ C. ―Why do you continually look in the corner of this room?‖ D. ―If you hum a tune, the voices may not be so distracting.‖ ANS: A The nurse is making an observation when stating, ―You appear to be talking to someone I do not see.‖ Making observations involves verbalizing what is observed or perceived. This encourages the client to recognize specific behaviors and make comparisons with the nurse‘s perceptions. 8. A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? A. S B. O C. L D. E E. R ANS: B The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the ―O‖ in the active-listening acronym SOLER. The acronym SOLER includes sitting squarely facing the client (S), open posture when interacting with the client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R). 9. An instructor is correcting a nursing student‘s clinical worksheet. Which instructor statement is the best example of effective feedback? A. ―Why did you use the client‘s name on your clinical worksheet?‖ B. ―You were very careless to refer to your client by name on your clinical worksheet.‖ C. ―I noticed that you used the client‘s name in your written process recording. That is a breach of confidentiality.‖ D. ―It is disappointing that after being told, you‘re still using client names on your worksheet.‖ ANS: C The instructor‘s statement, ―I noticed that you used the client‘s name in your written process recording,‖ is an example of effective feedback. Feedback is a method of communication to help others consider a modification of behavior. Feedback should be descriptive, specific, and directed toward a behavior that the person has the capacity to modify and should impart information rather than offer advice or criticism.10. After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, ―I‘m so proud of you for being assertive. You are so good!‖ Which communication technique has the leader employed? A. The nontherapeutic technique of giving approval B. The nontherapeutic technique of interpreting C. The therapeutic technique of presenting reality D. The therapeutic technique of making observations ANS: A The group leader has employed the nontherapeutic technique of giving approval. Giving approval implies that the nurse has the right to pass judgment on whether the client‘s ideas or behaviors are ―good‖ or ―bad.‖ This creates a conditional acceptance of the client. 11. What is the purpose of a nurse providing appropriate feedback? A. To give the client good advice B. To advise the client on appropriate behaviors C. To evaluate the client‘s behavior D. To give the client critical information ANS: D The purpose of providing appropriate feedback is to give the client critical information. Feedback should not be used to give advice or evaluate behaviors. 12. A client who frequently exhibits angry outbursts is diagnosed with antisocial personality disorder. Which appropriate feedback should a nurse provide when this client experiences an angry outburst? A. ―Why do you continue to alienate your peers by your angry outbursts?‖ B. ―You accomplish nothing when you lose your temper like that.‖ C. ―Showing your anger in that manner is very childish and insensitive.‖ D. ―During group, you raised your voice, yelled at a peer, and slammed the door.‖ ANS: D The nurse is providing appropriate feedback when stating, ―During group, you raised your voice, yelled at a peer, and slammed the door.‖ Giving appropriate feedback involves helping the client consider a modification of behavior. Feedback should give information to the client about how he or she is perceived by others. Feedback should not be evaluative or be used to give advice. 13. A client diagnosed with dependent personality disorder states, ―Do you think I should move from my parent‘s house and get a job?‖ Which nursing response is most appropriate?A. ―It would be best to do that in order to increase independence.‖ B. ―Why would you want to leave a secure home?‖ C. ―Let‘s discuss and explore all of your options.‖ D. ―I‘m afraid you would feel very guilty leaving your parents.‖ ANS: C The most appropriate response by the nurse is, ―Let‘s discuss and explore all of your options.‖ In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action. 14. When interviewing a client, which nonverbal behavior should a nurse employ? A. Maintaining indirect eye contact with the client B. Providing space by leaning back away from the client C. Sitting squarely, facing the client D. Maintaining open posture with arms and legs crossed ANS: C When interviewing a client, the nurse should employ the nonverbal behavior of sitting squarely, facing the client. Facilitative skills for active listening can be identified by the acronym SOLER. SOLER includes sitting squarely facing the client (S), open posture when interacting with a client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R). 15. A mother rescues two of her four children from a house fire. In an emergency department, she cries, ―I should have gone back in to get them. I should have died, not them.‖ Which of the following responses by the nurse is an example of reflection? A. ―The smoke was too thick. You couldn‘t have gone back in.‖ B. ―You‘re feeling guilty because you weren‘t able to save your children.‖ C. ―Focus on the fact that you could have lost all four of your children.‖ D. ―It‘s best if you try not to think about what happened. Try to move on.‖ ANS: B The best response by the nurse is, ―You‘re experiencing feelings of guilt because you weren‘t able to save your children.‖ This response utilizes the therapeutic communication technique of reflection, which identifies a client‘s emotional response and reflects these feelings back to the client so that they may be recognized and accepted. 16. A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? A. ―Everyone diagnosed with OCD needs to control their ritualistic behaviors.‖ B. ―It is important for you to discontinue these ritualistic behaviors.‖C. ―Why are you asking for help if you won‘t participate in unit therapy?‖ D. ―Let‘s figure out a way for you to attend unit activities and still wash your hands.‖ ANS: D The most appropriate statement by the nurse is, ―Let‘s figure out a way for you to attend unit activities and still wash your hands.‖ This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship or increasing the client‘s anxiety. 17. Which example of a therapeutic communication technique would be effective in the planning phase of the nursing process? A. ―We‘ve discussed past coping skills. Let‘s see if these coping skills can be effective now.‖ B. ―Please tell me in your own words what brought you to the hospital.‖ C. ―This new approach worked for you. Keep it up.‖ D. ―I notice that you seem to be responding to voices that I do not hear.‖ ANS: A This is an example of the therapeutic communication technique of formulating a plan of action. By the use of this technique the nurse can help the client plan in advance to deal with a stressful situation, which may prevent anger and/or anxiety from escalating to an unmanageable level. 18. A client tells the nurse, ―I feel bad because my mother does not want me to return home after I leave the hospital.‖ Which nursing response is therapeutic? A. ―It‘s quite common for clients to feel that way after a lengthy hospitalization.‖ B. ―Why don‘t you talk to your mother? You may find out she doesn‘t feel that way.‖ C. ―Your mother seems like an understanding person. I‘ll help you approach her.‖ D. ―You feel that your mother does not want you to come back home?‖ ANS: D This is an example of the therapeutic communication technique of restatement. Restatement is the repeating of the main idea that the client has verbalized. This lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue, or clarify if necessary. 19. A client‘s younger daughter is ignoring curfew. The client states, ―I‘m afraid she will get pregnant.‖ The nurse responds, ―Hang in there. Don‘t you think she has a lot to learn about life?‖ This is an example of which communication block? A. Requesting an explanation B. Belittling the client C. Making stereotyped commentsD. Probing ANS: C This is an example of the nontherapeutic communication block of making stereotyped comments. Clichés and trite expressions are meaningless in a therapeutic nurse–client relationship. 20. Which nursing statement is a good example of the therapeutic communication technique of giving recognition? A. ―You did not attend group today. Can we talk about that?‖ B. ―I‘ll sit with you until it is time for your family session.‖ C. ―I notice you are wearing a new dress and you have washed your hair.‖ D. ―I‘m happy that you are now taking your medications. They will really help.‖ ANS: C This is an example of the therapeutic communication technique of giving recognition. Giving recognition acknowledges and indicates awareness. This technique is more appropriate than complimenting the client, which reflects the nurse‘s judgment. 21. A client is trying to explore and solve a problem. Which nursing statement would be an example of verbalizing the implied? A. ―You seem to be motivated to change your behavior.‖ B. ―How will these changes affect your family relationships?‖ C. ―Why don‘t you make a list of the behaviors you need to change.‖ D. ―The team recommends that you make only one behavioral change at a time.‖ ANS: A This is an example of the therapeutic communication technique of verbalizing the implied. Verbalizing the implied puts into words what the client has only implied or said indirectly. 22. The nurse says to a newly admitted client, ―Tell me more about what led up to your hospitalization.‖ What is the purpose of this therapeutic communication technique? A. To reframe the client‘s thoughts about mental health treatment B. To put the client at ease C. To explore a subject, idea, experience, or relationship D. To communicate that the nurse is listening to the conversation ANS: CThis is an example of the therapeutic communication technique of exploring. The purpose of exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication. 23. A student nurse tells the instructor, ―I‘m concerned that when a client asks me for advice I won‘t have a good solution.‖ Which should be the nursing instructor‘s best response? A. ―It‘s scary to feel put on the spot by a client. Nurses don‘t always have the answer.‖ B. ―Remember, clients, not nurses, are responsible for their own choices and decisions.‖ C. ―Just keep the client‘s best interests in mind and do the best that you can.‖ D. ―Set a goal to continue to work on this aspect of your practice.‖ ANS: B Giving advice tells the client what to do or how to behave. It implies that the nurse knows what is best and that the client is incapable of any self-direction. It discourages independent thinking. 24. A student nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the instructor best provides information about this aspect of therapeutic communication? A. ―Touch carries a different meaning for different individuals.‖ B. ―Touch is often used when deescalating volatile client situations.‖ C. ―Touch is used to convey interest and warmth.‖ D. ―Touch is best combined with empathy when dealing with anxious clients.‖ ANS: A Touch can elicit both negative and positive reactions, depending on the people involved and the circumstances of the interaction. 25. Which nursing statement is a good example of the therapeutic communication technique of focusing? A. ―Describe one of the best things that happened to you this week.‖ B. ―I‘m having a difficult time understanding what you mean.‖ C. ―Your counseling session is in 30 minutes. I‘ll stay with you until then.‖ D. ―You mentioned your relationship with your father. Let‘s discuss that further.‖ ANS: D This is an example of the therapeutic communication technique of focusing. Focusing takes notice of a single idea or even a single word and works especially well with a client who is moving rapidly from one thought to another. 26. After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, ―You are incompetent!‖ Which is the nurse‘s best response?A. ―Do you believe that I was the cause of your blood test being canceled?‖ B. ―I see that you are upset, but I feel uncomfortable when you swear at me.‖ C. ―Have you ever thought about ways to express anger appropriately?‖ D. ―I‘ll give you some space. Let me know if you need anything.‖ ANS: B This is an example of the appropriate use of feedback. Feedback should be directed toward behavior that the client has the capacity to modify. 27. During a nurse–client interaction, which nursing statement may belittle the client‘s feelings and concerns? A. ―Don‘t worry. Everything will be alright.‖ B. ―You appear uptight.‖ C. ―I notice you have bitten your nails to the quick.‖ D. ―You are jumping to conclusions.‖ ANS: A This nursing statement is an example of the nontherapeutic communication block of belittling feelings. Belittling feelings occurs when the nurse misjudges the degree of the client‘s discomfort, suggesting a lack of empathy and understanding. 28. A client on an inpatient psychiatric unit tells the nurse, ―I should have died, because I am totally worthless.‖ In order to encourage the client to continue talking about feelings, which should be the nursing initial response? A. ―How would your family feel if you died?‖ B. ―You feel worthless now, but that can change with time.‖ C. ―You‘ve been feeling sad and alone for some time now?‖ D. ―It is great that you have come in for help.‖ ANS: C This nursing statement is an example of the therapeutic communication technique of reflection. When reflection is used, questions and feelings are referred back to the client so that they may be recognized and accepted. 29. Which nursing response is an example of the nontherapeutic communication block of requesting an explanation? A. ―Can you tell me why you said that?‖ B. ―Keep your chin up. I‘ll explain the procedure to you.‖ C. ―There is always an explanation for both good and bad behaviors.‖ D. ―Are you not understanding the explanation I provided?‖ANS: A This nursing statement is an example of the nontherapeutic communication block of requesting an explanation. Requesting an explanation is when the client is asked to provide the reason for thoughts, feelings, behaviors, and events. Asking ―why‖ a client did something or feels a certain way can be very intimidating and implies that the client must defend his or her behavior or feelings. 30. A client states, ―You won‘t believe what my husband said to me during visiting hours. He has no right treating me that way.‖ Which nursing response would best assess the situation that occurred? A. ―Does your husband treat you like this very often?‖ B. ―What do you think is your role in this relationship?‖ C. ―Why do you think he behaved like that?‖ D. ―Describe what happened during your time with your husband.‖ ANS: D This is an example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication. 31. Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations? A. ―My sister has the same diagnosis as you and she also hears voices.‖ B. ―I understand that the voices seem real to you, but I do not hear any voices.‖ C. ―Why not turn up the radio so that the voices are muted.‖ D. ―I wouldn‘t worry about these voices. The medication will make them disappear.‖ ANS: B This is an example of the therapeutic communication technique of presenting reality. Presenting reality is when the client has a misperception of the environment. The nurse defines reality or indicates his or her perception of the situation for the client. 32. Which nursing statement is a good example of the therapeutic communication technique of offering self? A. ―I think it would be great if you talked about that problem during our next group session.‖ B. ―Would you like me to accompany you to your electroconvulsive therapy treatment?‖ C. ―I notice that you are offering help to other peers in the milieu.‖ D. ―After discharge, would you like to meet me for lunch to review your outpatient progress?‖ ANS: BThis is an example of the therapeutic communication technique of offering self. Offering self makes the nurse available on an unconditional basis, increasing client‘s feelings of self-worth. Professional boundaries must be maintained when using the technique of offering self. 33. A client slammed a door on the unit several times. The nurse responds, ―You seem angry.‖ The client states, ―I‘m not angry.‖ What therapeutic communication technique has the nurse employed, and what defense mechanism is the client unconsciously demonstrating? A. Making observations and the defense mechanism of suppression B. Verbalizing the implied and the defense mechanism of denial C. Reflection and the defense mechanism of projection D. Encouraging descriptions of perceptions and the defense mechanism of displacement ANS: B This is an example of the therapeutic communication technique of verbalizing the implied. The nurse is putting into words what the client has only implied by words or actions. Denial is the refusal of the client to acknowledge the existence of a real situation, the feelings associated with it, or both. Multiple Response 34. Which of the following individuals are communicating a message? Select all that apply. A. A mother spanking her son for playing with matches B. A teenage boy isolating himself and playing loud music C. A biker sporting an eagle tattoo on his biceps D. A teenage girl writing, ―No one understands me‖ E. A father checking for new e-mail on a regular basis ANS: A, B, C, D The nurse should determine that spanking, isolating, getting tattoos, and writing are all ways in which people communicate messages to others. It is estimated that about 70% to 90% of communication is nonverbal. Chapter 3. Theoretical Models of Personality Development Summary and Key Points ▀ Growth and development are unique with each individual and continue throughout the life span. ▀ Personality is defined as the combination of character, behavioral, temperamental, emotional, and mental traits that are unique to each specific individual. ▀ Sigmund Freud, who has been called the father of psychiatry, believed the basic character has been formed by the age of 5.▀ Freud's personality theory can be conceptualized according to structure and dynamics of the personality, topography of the mind, and stages of personality development. ▀ Freud's structure of the personality includes the id, ego, and superego. ▀ Freud classified all mental contents and operations into three categories: the conscious, the preconscious, and the unconscious. ▀ Harry Stack Sullivan, author of the Interpersonal Theory of Psychiatry, believed that individual behavior and personality development are the direct result of interpersonal relationships. Major concepts include anxiety, satisfaction of needs, interpersonal security, and self-system. ▀ Erik Erikson studied the influence of social processes on the development of the personality. ▀ Erikson described eight stages of the life cycle from birth to death. He believed that individuals struggled with developmental ―crises,‖ and that each must be resolved for emotional growth to occur. ▀ Margaret Mahler formulated a theory that describes the separation-individuation process of the infant from the maternal figure (primary caregiver). Stages of development describe the progression of the child from birth to object constancy at age 36 months. ▀ Jean Piaget has been called the father of child psychology. He believed that human intelligence progresses through a series of stages that are related to age, demonstrating at each successive stage a higher level of logical organization than at the previous stages. ▀ Lawrence Kohlberg outlined stages of moral development. His stages are not closely tied to specific age groups or the maturational process. He believed that moral stages emerge out of our own thinking and the stimulation of our mental processes. ▀ Hildegard Peplau provided a framework for ―psychodynamic nursing,‖ the interpersonal involvement of the nurse with a client in a given nursing situation. ▀ Peplau identified the nursing roles of stranger, resource person, counselor, teacher, leader, technical expert, and surrogate. ▀ Peplau described four psychological tasks that she associated with the stages of infancy and childhood as identified by Freud and Sullivan. ▀ Peplau believed that nursing is helpful when both the patient and the nurse grow as a result of the learning that occurs in the nursing situation. Multiple Choice 1. According to Erikson‘s developmental theory, when planning care for a 47-year-old client, which developmental task should a nurse identify as appropriate for this client? A. To develop a basic trust in others B. To achieve a sense of self-confidence and recognition from others C. To reflect back on life events to derive pleasure and meaning D. To achieve established life goals and consider the welfare of future generations ANS: DThe nurse should identify that an appropriate developmental task for a 47-year-old client would be to achieve established life goals and consider the welfare of future generations. According to Erikson, the client would be in the generativity versus stagnation stage of development. 2. A jilted college student is admitted to a hospital following a suicide attempt and states, ―No one will ever love a loser like me.‖ According to Erikson‘s theory of personality development, a nurse should recognize a deficit in which developmental stage? A. Trust versus mistrust B. Initiative versus guilt C. Intimacy versus isolation D. Ego integrity versus despair ANS: C The nurse should recognize that the client who states, ―No one will ever love a loser like me‖ has not adequately completed the intimacy versus isolation stage of development. The intimacy versus isolation stage is presumed to occur in young adulthood between the ages of 20 and 30 years. The major developmental task in this stage is to establish intense, lasting relationships or commitment to another person, cause, institution, or creative effort. 3. A nurse observes a 3-year-old client willingly sharing candy with a sibling. According to Peplau, which psychological stage of development should the nurse recognize that this child has completed? A. ―Learning to count on others‖ B. ―Learning to delay satisfaction‖ C. ―Identifying oneself‖ D. ―Developing skills in participation‖ ANS: B The nurse should recognize that this client has completed the ―Learning to delay satisfaction‖ stage of development according to Peplau‘s interpersonal theory. This stage typically occurs in toddlerhood when one learns the satisfaction of pleasing others. 4. When a mother brings her 9-month-old to daycare, the child smiles and reaches for the daycare caregiver. The nurse should recognize that according to Mahler‘s developmental theory, this child‘s development is at which phase? A. The autistic phase B. The symbiotic phase C. The differentiation subphase of the separation–individuation phase D. The rapprochement subphase of the separation–individuation phase ANS: CThe nurse should understand that this client is in the differentiation subphase of the separation–individuation phase. This subphase begins with the child‘s initial physical movements away from the mothering figure. A primary recognition of separateness commences. 5. A 12-year-old girl becomes hysterical every time she strikes out in softball, falls down when roller-skating, or loses when playing games. According to Peplau‘s interpersonal theory, in which stage of development should the nurse identify a need for improvement? A. ―Learning to count on others‖ B. ―Learning to delay satisfaction‖ C. ―Identifying oneself‖ D. ―Developing skills in participation‖ ANS: D The nurse should identify that this client needs to improve in the ―Developing skills in participation‖ stage of Peplau‘s interpersonal theory. Older children in this phase learn the skills of compromise, competition, and cooperation with others. 6. According to Peplau, a nurse who provides an abandoned child with parental guidance and praise following small accomplishments is serving which therapeutic role?A. The role of technical expert B. The role of resource person C. The role of surrogate D. The role of leader ANS: C The nurse who provides an abandoned child with parental guidance and praise is serving the role of the surrogate according to Peplau‘s interpersonal theory. A surrogate serves as a substitute for another person—in this case, the child‘s parent. 7. A nurse directs the client interaction and plans for interventions to achieve client goals. According to Peplau‘s framework for psychodynamic nursing, what therapeutic role is this nurse assuming? A. The role of technical expert B. The role of resource person C. The role of teacher D. The role of leader ANS: D The nurse who directs client interaction and plans for interventions is assuming the role of leader. According to Peplau, a leader directs the nurse–client interaction and ensures that actions are taken to achieve goals. 8. When assessing clients, a psychiatric nurse should understand that psychoanalytic theory is based on which underlying concept?A. A possible genetic basis for the client problems B. The structure and dynamics of the personality C. Behavioral responses to stressors D. Maladaptive cognitions ANS: B The nurse should understand that psychoanalytic theory is based on the underlying concepts of the structure and dynamics of personality. Psychoanalytic theory was developed by Sigmund Freud and explains the structure of personality in three different components: the id, ego, and superego. 9. Which underlying concept should a nurse associate with interpersonal theory when assessing clients? A. The effects of social processes on personality development B. The effects of unconscious processes and personality structures C. The effects on thoughts and perceptual processes D. The effects of chemical and genetic influences ANS: A The nurse should associate interpersonal theory with the underlying concept of effects of social process on personality development. Sullivan developed stages of personality development based on his theory of interpersonal relationships and their effect on personality and individual behavior. 10. A physically healthy, 35-year-old single client lives with parents who provide total financial support. According to Erikson‘s theory, which developmental task should a nurse assist the client to accomplish?A. Establishing the ability to control emotional reactions B. Establishing a strong sense of ethics and character structure C. Establishing and maintaining self-esteem D. Establishing a career, personal relationships, and societal connections ANS: D The nurse should assist the client in establishing a career, personal relationships, and societal connections. According to Erikson, nonachievement in the generativity versus stagnation stage results in self-absorption, including withdrawal from others and having no capacity for giving of the self to others. 11. A 1-month-old infant is left alone for extended periods, has little physical stimulation, and is malnourished. Based on this infant‘s history, in which phase of development according to Mahler‘s theory should a nurse expect to see a potential deficit? A. The symbiotic phase B. The autistic phaseC. The consolidation phase D. The rapprochement phase ANS: B The nurse should expect that a 1-month-old infant who is left alone, has little physical stimulation, and is malnourished would not meet the autistic phase of development. The autistic phase of development usually occurs from birth to 1 month, at which time the infant‘s focus is on basic needs and comfort. 12. A 6-year-old boy uses his father‘s flashlight to explore his 3-year-old sister‘s genitalia. According to Freud, in which stage of psychosocial development should a nurse identify this behavior as normal? A. Oral B. Anal C. Phallic D. Latency ANS: C The nurse should identify this behavior as normal because the 6-year-old client who focuses on genital organs is in the phallic stage of Freud‘s stages of psychosexual stages of development. Children in the phallic stage of development focus on genital organs and develop a sense of sexual identity. Identification with the same-sex parent also occurs at this stage. 13. A married, 26-year-old client works as a schoolteacher. She and her husband have just had their first child. A nurse should recognize that this client is successfully accomplishing which stage of Erikson‘s developmental theory? A. Industry versus inferiority B. Identity versus role confusion C. Intimacy versus isolation D. Generativity versus stagnation ANS: C The nurse should recognize that a 26-year-old client who is married and has a child has successfully accomplished the intimacy versus isolation stage of Erikson‘s developmental theory. The intimacy versus isolation stage of young adulthood involves forming lasting relationships. Achievement of this task results in the capacity for mutual love and respect. 14. A 10-year-old child wins the science fair competition and is chosen as a cheerleader for the basketball team. A nurse should recognize that this child is in the process of successfully accomplishing which stage of Erikson‘s developmental theory? A. Industry versus inferiority B. Identity versus role confusion C. Intimacy versus isolationD. Generativity versus stagnation ANS: A The nurse should recognize that a 10-year-old child who is successful in school both academically and socially has successfully accomplished the industry versus inferiority developmental stage of Erikson‘s psychosocial theory. The industry versus inferiority stage of development usually occurs between 6 and 12 years of age, at which time individuals achieve a sense of self-confidence by learning, competing, performing successfully, and receiving recognition from others. 15. A client has flashbacks of sexual abuse by her uncle. She had not been aware of these memories until recently, when she became sexually active with her boyfriend. A nurse should identify this experience as which part of Sullivan‘s concept of the self-system? A. The ―good me‖ B. The ―bad me‖ C. The ―not me‖ D. The ―bad you‖ ANS: C The nurse should identify a client remembering sexual abuse when becoming sexually active with her boyfriend as experiencing the ―not me‖ part of the personality. According to Sullivan, the ―not me‖ part of the personality develops in response to situations that produced intense anxiety in childhood. 16. According to Freud, which statement should a nurse associate with predominance of the superego? A. ―No one is looking, so I will take three cigarettes from Mom‘s pack.‖B. ―I don‘t ever cheat on tests; it is wrong.‖C. ―If I skip school I will get in trouble and fail my test.‖D. ―Dad won‘t miss this little bit of vodka.‖ ANS: B The nurse should associate the statement ―I don‘t ever cheat on tests; it is wrong‖ as indicative of the predominance of the superego. Freud described the superego as the part of the personality that internalizes the values and morals set forth by primary caregivers. The superego can be referred to as the ―perfection principle.‖ 17. A female complains that her husband only meets his sexual needs and never her needs. According to Freud, which personality structure should a nurse identify as predominantly driving the husband‘s actions? A. The id B. The superid C. The ego D. The superego ANS: A The nurse should identify that the husband‘s actions are driven by the predominance of the id. According to Freud, the id is the part of the personality that is identified as the pleasure principle. The id is the locus of instinctual drives.KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 18. A father of a 5-year-old demeans and curses at his child for disobedience. In turn, when upset, the child uses swear words in kindergarten. A school nurse recognizes this behavior as unsuccessful completion of which stage of development according to Peplau? A. ―Learning to count on others‖ B. ―Learning to delay satisfaction‖ C. ―Identifying oneself‖ D. ―Developing skills in participation‖ ANS: C The nurse should identify that the child using swear words in kindergarten has not successfully completed the ―identifying oneself‖ stage according to Peplau‘s interpersonal theory. During this stage of early childhood, a child learns to structure self-concept by observing how others interact with him or her. 19. A nurse is caring for a hospitalized client who is quarrelsome and opinionated and has little regard for others. According to Sullivan‘s interpersonal theory, the nurse should associate the client‘s behaviors with a previous deficit in which stage of development? A. Infancy B. Childhood C. Early adolescence D. Late adolescence ANS: B The nurse should associate the client‘s behavior with a deficit in the childhood stage of Sullivan‘s interpersonal theory. The childhood stage in Sullivan‘s interpersonal theory typically occurs from the ages of 18 months to 6 years of age, during which the child learns to experience a delay in personal gratification without undue anxiety. 20. According to psychoanalytic theory, treatment of symptoms should involve which nursing action?A. Modifying client behaviors by manipulating the environment B. Expressing empathy and presenting reality C. Encouraging the client to note cause and effects of actions D. Recognizing and discussing the client‘s use of ego defense mechanisms ANS: D From a psychoanalytic perspective, understanding the use of ego defense mechanisms is important in making determinations about maladaptive behaviors, in planning care for clients to assist in creating change, or in helping clients accept themselves as unique individuals.21. A 29-year-old client living with parents has few interpersonal relationships. The client states, ―I have trouble trusting people.‖ Based on Erikson‘s developmental theory, which should the nurse recognize as a true statement about this client? A. The client has not progressed beyond the trust versus mistrust developmental stage. B. Developmental deficits in earlier life stages have impaired the client‘s adult functioning. C. The client cannot move to the next developmental stage until mastering all earlier stages. D. The client‘s developmental problems began in the intimacy versus isolation stage. ANS: B Many individuals with mental health problems are still struggling to achieve tasks from a number of developmental stages. Nurses can plan care to assist these individuals to complete these tasks and move on to a higher developmental level. 22. Which statement is most likely to be made by a nurse practitioner who shares the philosophy of an interpersonal theorist? A. ―Let‘s discuss your use of defense mechanisms.‖ B. ―We need to examine how your relationships affect your ability to cope.‖ C. ―It is important that you take the medications that I have prescribed for you.‖ D. ―Your genetic background is a factor in your predisposition to mental illness.‖ ANS: B Sullivan, an interpersonal theorist, believed that individual behavior and personality development are the direct result of interpersonal relationships. 23. Which statement describes achievement of Erikson‘s generativity versus stagnation developmental stage? A. ―I‘ve been a girl scout leader for troop 259 for 7 years.‖ B. ―I feel great that I could pay for my bike with my paper route money.‖ C. ―My parents are so pleased that John and I are going to be married.‖ D. ―I‘ve had a very full life. I‘m not afraid to leave this world.‖ ANS: A The major task of generativity versus stagnation is to achieve the life goals established for oneself while also considering the welfare of future generations. 24. A psychiatric nurse uses Sullivan‘s theories in group and individual therapy. According to Sullivan and other theorists like him, how are client symptoms viewed? A. Client symptoms are viewed as learned behaviors that are maintained because they are reinforced.B. Client symptoms are viewed as responses to anxiety arising from interpersonal relationships. C. Client symptoms are viewed as internal conflicts arising from early childhood trauma. D. Client symptoms are viewed as the misinterpretations of experiences. ANS: B Sullivan believed that anxiety is the chief disruptive force in interpersonal relations and the main factor in the development of serious difficulty in living. 25. A nursing instructor is teaching about the application of Peplau‘s theory to nursing care. Which student statement indicates that learning has occurred? A. ―The nurse assumes the role of a parenting figure, instructing the client in good health practices.‖ B. ―The nurse is concerned more about psychosocial functioning than physiological functioning.‖ C. ―The nurse bases the client care plan on standardized nursing approaches and physician orders.‖ D. ―The nurse applies principles of human relations to the problems that arise at all levels of experience.‖ ANS: D Peplau applied interpersonal theory to nursing practice and, most specifically, to nurse–client relationship development. 26. According to Peplau, treatment of client symptoms should involve which nursing action? A. Establishing a therapeutic nurse–client relationship B. Using the technique of desensitization C. Challenging clients‘ negative thoughts D. Uncovering clients‘ past experiences ANS: A Peplau applied interpersonal theory to nursing practice and, most specifically, to nurse–client relationship development. 27. The nurse practitioner plans to use a psychoanalytical framework when treating a client diagnosed with an anxiety disorder. Which would be the focus of this nursing intervention? A. Correcting inappropriate learning patterns B. Changing a dysfunctional social environment C. Exploring the ―here and now‖ with the client and family D. Exploring behaviors and defense mechanisms associated with the superego. ANS: DFreud identified the superego as the component of the personality that strives for perfection. Violation of the superego‘s standards generates guilt and anxiety in a person with a strong superego and understanding of these defense mechanisms is identified as important to assisting the client in achieving desired changes or accepting themselves as unique individuals. 28. Which is a nursing intervention to assist a client to achieve Erikson‘s developmental task of ego integrity? A. Encourage a life review of triumphs and disappointments. B. Provide opportunities for success experiences. C. Focus on embracing the future. D. Foster the development of creativity. ANS: A Erikson believed that between the age of 65 years and death, the goal is to review one‘s life and derive meaning from both positive and negative events, while achieving a positive sense of self. 29. From an interpersonal theory perspective, which intervention would a nurse use to assist a client diagnosed with major depressive disorder? A. Encourage discussion of feelings B. Offer family therapy sessions C. Discuss childhood events D. Teach alternate coping skills ANS: B Sullivan, an interpersonal theorist, believed that individual behavior and personality development are the direct result of interpersonal relationships. Family therapy would assist the client to deal with relationships within the family system. Multiple Response 30. Which concepts are included in the definition of personality? Select all that apply. A. Personality is the characteristic way in which a person thinks, feels, and behaves. B. Personality is the ingrained pattern of behavior that evolves as one‘s style of life. C. Personality is developed in sporadic stages that vary from person to person. D. Personality develops both consciously and unconsciously. E. Personality is inborn and cannot be influenced by developmental progression. ANS: A, B, DBlack and Andreasen (2011) offer a definition of personality that includes each of the concepts in answers A, B, and D. Various theorists have identified stages in the development of personality; none identify personality development as sporadic or variable. Chapter 4. Concepts of Psychobiology Summary and Key Points ▀ It is important for nurses to understand the interaction between biological and behavioral factors in the development and management of mental illness. ▀ Psychobiology is the study of the biological foundations of cognitive, emotional, and behavioral processes. ▀ The limbic system has been called ―the emotional brain.‖ It is associated with feelings of fear and anxiety; anger, rage, and aggression; love, joy, and hope; and with sexuality and social behavior. ▀ The three classes of neurons include afferent (sensory), efferent (motor), and interneurons. The junction between two neurons is called a synapse. ▀ Neurotransmitters are chemicals that convey information across synaptic clefts to neighboring target cells. Many neurotransmitters have implications in the etiology of emotional disorders and in the pharmacological treatment of those disorders. ▀ Major categories of neurotransmitters include cholinergics, monoamines, amino acids, and neuropeptides. ▀ The endocrine system plays an important role in human behavior through the hypothalamic-pituitary axis. ▀ Hormones and their circadian rhythm of regulation significantly influence a number of physiological and psychological life cycle phenomena, such as moods, sleep and arousal, stress response, appetite, libido, and fertility. ▀ Research continues to validate the role of genetics in psychiatric illness. ▀ Familial, twin, and adoption studies suggest that genetics may be implicated in the etiology of schizophrenia, bipolar disorder, depressive disorder, panic disorder, anorexia nervosa, alcoholism, and obsessive-compulsive disorder. ▀ Psychoimmunology examines the impact of psychological factors on the immune system. ▀ Evidence exists to support a link between psychosocial stressors and suppression of the immune response. ▀ Technologies such as magnetic resonance imagery (MRI), computed tomographic (CT) scan, positron emission tomography (PET), and electroencephalography (EEG) are used as diagnostic tools for detecting alterations in psychobiological functioning. ▀ Psychotropic medications have given many individuals a chance to function effectively. ▀ Nurses must understand the ethical and legal implications associated with the administration of psychotropic medications, and knowledge of the physiological mechanisms by which psychotropic medications exert their effects. ▀ Integrating knowledge of the expanding biological focus into psychiatric nursing is essential if nurses are to meet the changing needs of today's psychiatric clients. Multiple Choice1. A depressed client states, ―I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again.‖ Which nursing response is appropriate? A. ―Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors.‖ B. ―Because biological factors are the sole cause of depression, medications will improve your mood.‖ C. ―Environmental factors have been shown to exert the most influence in the development of depression.‖ D. ―Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment).‖ ANS: A The nurse should advise the client that medications are one treatment approach to address biological factors, but there are other factors that affect mood. The nurse should educate the client on environmental and interpersonal factors that can lead to depression and the potential for psychological treatments to have a positive impact on biological factors. 2. A client diagnosed with major depressive disorder asks, ―What part of my brain controls my emotions?‖ Which nursing response is appropriate? A. ―The occipital lobe governs perceptions, judging them as positive or negative.‖ B. ―The parietal lobe has been linked to depression.‖ C. ―The medulla regulates key biological and psychological activities.‖ D. ―The limbic system is largely responsible for one‘s emotional state.‖ ANS: D The nurse should explain to the client that the limbic system is largely responsible for one‘s emotional state. This system is often called the ―emotional brain‖ and is associated with feelings, sexuality, and social behavior. The occipital lobes are the area of visual reception and interpretation. Somatosensory input (touch, taste, temperature, etc.) occurs in the parietal lobes. The medulla contains vital centers that regulate heart rate and reflexes. 3. Which part of the nervous system should a nurse identify as playing a major role during stressful situations? A. Peripheral nervous system B. Somatic nervous system C. Sympathetic nervous system D. Parasympathetic nervous system ANS: C The nurse should identify that the sympathetic nervous system plays a major role during stressful situations. The sympathetic nervous system prepares the body for the fight-or-flight response. The parasympathetic nervous system is dominant when an individual is in a nonstressful state. 4. Which client statement reflects an understanding of the effect of circadian rhythms on a person‘s ability to function?A. ―When I dream about my mother‘s horrible train accident, I become hysterical.‖ B. ―I get really irritable during my menstrual cycle.‖ C. ―I‘m a morning person. I get my best work done in the a.m.‖ D. ―Every February, I tend to experience periods of sadness.‖ ANS: C By stating, ―I am a morning person,‖ the client demonstrates an understanding that circadian rhythms may influence a variety of regulatory functions, including the sleep–wake cycle, regulation of body temperature, and patterns of activity. Most humans follow a 24-hour cycle that is largely affected by light and darkness. 5. Which types of adoption studies should a nurse recognize as providing useful information for the psychiatric community? A. Studies in which children with mentally ill biological parents are raised by adoptive parents who were mentally healthy B. Studies in which children with mentally healthy biological parents are raised by adoptive parents who were mentally ill C. Studies in which monozygotic twins from mentally ill parents were raised separately by different adoptive parents D. Studies in which monozygotic twins were raised together by mentally ill biological parents E. All of the above ANS: E The nurse should determine that all of the studies could possibly benefit the psychiatric community. The studies may reveal research findings relating genetic links to mental illness. Adoption studies allow comparisons to be made of the influences of the environment versus genetics. 6. Six months after her husband and children were killed in a car accident, a client is diagnosed with ulcerative colitis. The nurse should recognize that this situation validates which study perspective? A. The study of neuroendocrinology B. The study of psychoimmunology C. The study of diagnostic technology D. The study of neurophysiology ANS: B Psychoimmunology is the branch of medicine that studies the effects of social and psychological factors on the functioning of the immune system. Studies of the biological response to stress hypothesize that individuals become more susceptible to physical illness following exposure to stressful stimuli. 7. A withdrawn client diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy. What altered component of the nervous system should a nurse recognize as being implicated in this behavior?A. Dendrites B. Axons C. Neurotransmitters D. Synapses ANS: C The nurse should recognize that neurotransmitters play an essential function in the role of human emotion and behavior. Neurotransmitters are targeted and affected by many psychotropic medications. 8. An instructor is teaching nursing students about neurotransmitters. Which term best explains the process of how neurotransmitters released into the synaptic cleft may return to the presynaptic neuron? A. Regeneration B. Reuptake C. Recycling D. Retransmission ANS: B The nursing instructor should best explain that the process by which neurotransmitters are released into the synaptic cleft and returned to the presynaptic neuron is by reuptake. Reuptake is the process by which neurotransmitters are stored for reuse. 9. A nurse concludes that a restless, agitated client is manifesting a ―fight-or-flight‖ response. The nurse should associate this response with which neurotransmitter? A. Acetylcholine B. Dopamine C. Serotonin D. Norepinephrine ANS: D The nurse should associate the neurotransmitter norepinephrine with the ―fight-or-flight‖ response. Norepinephrine produces activity in the sympathetic postsynaptic nerve terminal and is associated with the regulation of mood, cognition, perception, locomotion, sleep, and arousal. 10. A client is admitted to a psychiatric unit with the diagnosis of catatonic schizophrenia. Which of the client‘s neurotransmitters should a nurse expect to be elevated? A. Serotonin B. DopamineC. Gamma-aminobutyric acid (GABA) D. Histamine ANS: B The nurse should expect that elevated dopamine levels might be an attributing factor to the client‘s current level of functioning. Dopamine functions include regulation of movements and coordination, emotions, and voluntary decision-making ability. 11. A client‘s wife of 34 years dies unexpectedly. The client cries often and becomes socially isolated. The client‘s therapist stresses the importance of proper sleep, nutrition, and exercise. What is the best rationale for the therapist‘s advice? A. The therapist is using an interpersonal approach. B. The client has an alteration in neurotransmitters. C. It is routine practice to remind clients about nutrition, exercise, and rest. D. The client is susceptible to illness due to effects of stress on the immune system. ANS: D The therapist‘s advice should be based on the knowledge that the client has been exposed to stressful stimuli and is at an increased risk of developing illness due to the effects of stress on the immune system. The study of this branch of medicine is called psychoimmunology. 12. Which mental illness should a nurse identify as being associated with a decrease in prolactin hormone level? A. Major depression B. Schizophrenia C. Anorexia nervosa D. Alzheimer‘s disease ANS: B Although the exact mechanism is unknown, there may be some correlation between decreased levels of the hormone prolactin and the diagnosis of schizophrenia. Some studies have shown an inverse relationship between prolactin concentrations and symptoms of schizophrenia. 13. Which cerebral structure should a nursing instructor describe to students as the ―emotional brain‖? A. The cerebellum B. The limbic system C. The cortex D. The left temporal lobeANS: B The limbic system is often referred to as the ―emotional brain.‖ The limbic system is largely responsible for one‘s emotional state and is associated with feelings, sexuality, and social behavior. 14. A nurse understands that the abnormal secretion of growth hormone may play a role in which illness? A. Acute mania B. Schizophrenia C. Anorexia nervosa D. Alzheimer‘s disease ANS: C A nurse should understand that research has found a correlation between abnormal levels of growth hormone and anorexia nervosa. The growth hormone is responsible for growth in children, as well as continued protein synthesis throughout life. 15. A client is admitted to an emergency department experiencing memory deficits and decreased motor function. What alteration in brain chemistry should a nurse correlate with the presentation of these symptoms? A. Abnormal levels of serotonin B. Decreased levels of dopamine C. Increased levels of norepinephrine D. Decreased levels of acetylcholine ANS: D The nurse should correlate memory deficits and decreased motor function with decreased levels of acetylcholine. Acetylcholine is a major effector chemical of the autonomic nervous system. Functions of acetylcholine include sleep regulation, pain perception, the modulation and coordination of movement, and memory. 16. A nurse should recognize that a decrease in norepinephrine levels would play a significant role in which mental illness? A. Mania B. Schizophrenia C. Anxiety D. Depression ANS: D The nurse should recognize that a decrease in norepinephrine levels would play a significant role in generating the symptoms of depression. The functions of norepinephrine include the regulation of mood, cognition, perception, locomotion, cardiovascular functioning, and sleep and arousal.17. Which client diagnosis should a nurse associate with a decrease in gamma-aminobutyric acid (GABA)? A. Alzheimer‘s disease B. Schizophrenia C. Panic disorder D. Depression ANS: C The nurse should associate a decrease in GABA with panic disorder. Enhancement of the GABA system is the mechanism of action by which benzodiazepines produce a calming effect, thus reducing anxiety. Alterations in the GABA system are also associated with movement disorders and epilepsy. 18. A nurse should expect that an increase in dopamine activity might play a significant role in the development of which mental illness? A. Schizophrenia B. Depression C. Body dysmorphic disorder D. Parkinson‘s disease ANS: A The nurse should expect that an increase in dopamine activity might play a significant role in the development of schizophrenia. Dopamine functions include regulation of emotions, coordination, and voluntary decision-making ability. Increased dopamine activity is also associated with mania. 19. A nursing instructor is teaching about the monoamine category of neurotransmitters. Which student statement indicates that learning about the function of norepinephrine has occurred? A. Norepinephrine functions to regulate movement, coordination, and emotions. B. Norepinephrine functions to regulate mood, cognition, and perception. C. Norepinephrine functions to regulate arousal, libido, and appetite. D. Norepinephrine functions to regulate pain, inflammatory response, and wakefulness. ANS: B The functions of norepinephrine include the regulation of mood, cognition, perception, locomotion, and cardiovascular function. Norepinephrine has also been implicated in certain mood disorders such as depression and mania, anxiety states, and schizophrenia. 20. A student nurse is studying the effect of the drug isocarboxazid (Marplan) on neurobiology. The student should recognize that the neurotransmitter serotonin is catabolized by which enzyme? A. GlycosyltransferaseB. Peptidase C. Polymerase D. Monoamine oxidase ANS: D Serotonin that is not returned to be stored in the axon terminal vesicles is catabolized by the enzyme monoamine oxidase. A monoamine oxidase inhibitor, such as Marplan, inhibits this catabolism, providing more available serotonin at the neuron synapse. 21. During a sleep study, a delta rhythm has been recorded for a client experiencing sleep apnea. The nurse recognizes that which characteristic is associated with this rhythm, and what stage of sleep activity would be documented? A. Delta rhythm is a period of dozing, occurring in stage 1 of sleep activity. B. Delta rhythm is a period of deep and restful sleep, occurring in stage 3 of sleep activity. C. Delta rhythm is a period of relaxed waking, occurring in stage 0 of sleep activity. D. Delta rhythm is a period of dreaming, occurring in stage 2 of sleep activity. ANS: B Stage 3–delta rhythm is a period of deep and restful sleep. Muscles are relaxed, heart rate and blood pressure fall, and breathing slows. No eye movement occurs. Multiple Response 22. Which of the following information should a nurse include when explaining causes of anorexia nervosa to a client? Select all that apply. A. There is a possible correlation between abnormal secretion of growth hormone and anorexia nervosa. B. There is a possible correlation between antidiuretic hormone levels and anorexia nervosa. C. There is a possible correlation between low levels of gonadotropin and anorexia nervosa. D. There is a possible correlation between increased levels of prolactin and anorexia nervosa. E. There is a possible correlation between altered levels of oxytocin and anorexia nervosa. ANS: A, C The nurse should explain to the client that there is a possible correlation between anorexia nervosa and decreased levels of growth hormones and gonadotropin. Anorexia nervosa has also been correlated with increased cortisol levels. 23. Which of the following symptoms should a nurse associate with increased levels of thyroid-stimulating hormone (TSH) in a newly admitted client? Select all that apply. A. DepressionB. Fatigue C. Increased libido D. Mania E. Hyperexcitability ANS: A, B The nurse should associate depression and fatigue with increased levels of TSH. TSH is only increased when thyroid levels are low, as in the diagnosis of hypothyroidism. In addition to depression and fatigue, other symptoms such as decreased libido, memory impairment, and suicidal ideation are also associated with chronic hypothyroidism. 24. Which of the following symptoms should a nurse expect to assess in a client experiencing elevated levels of thyroid hormone? Select all that apply. A. Emotional lability B. Depression C. Insomnia D. Restlessness E. Apathy ANS: A, C, D The nurse should assess the client with an elevated level of thyroid hormone for evidence of emotional lability, insomnia, and restlessness. Elevated levels of thyroid hormone indicate a diagnosis of hyperthyroidism or Grave‘s disease, which is also associated with the symptoms of irritability, anxiety, and weight loss. Chapter 13. Crisis Intervention Summary and Key Points ▀ A crisis is defined as ―a sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem‖ (Lagerquist, 2006, p. 393). ▀ All individuals experience crises at one time or another. This does not necessarily indicate psychopathology. ▀ Crises are precipitated by specific identifiable events and are determined by an individual's personal perception of the situation. ▀ Crises are acute rather than chronic and generally last no more than a few weeks to a few months. ▀ Crises occur when an individual is exposed to a stressor and previous problem-solving techniques are ineffective. This causes the level of anxiety to rise. Panic may ensue when new techniques are tried and resolution fails to occur. ▀ Six types of crises have been identified. They include dispositional crises, crises of anticipated life transitions, crises resulting from traumatic stress, maturation/developmental crises, crises reflecting psychopathology, and psychiatric emergencies. The type of crisis determines the method of intervention selected.▀ Crisis intervention is designed to provide rapid assistance for individuals who have an urgent need. ▀ The minimum therapeutic goal of crisis intervention is psychological resolution of the individual's immediate crisis and restoration to at least the level of functioning that existed before the crisis period. A maximum goal is improvement in functioning above the precrisis level. ▀ Nurses regularly respond to individuals in crisis in all types of settings. Nursing process is the vehicle by which nurses assist individuals in crisis with a short-term problem-solving approach to change. ▀ A four-phase technique of crisis intervention includes assessment/analysis, planning of therapeutic intervention, intervention, and evaluation of crisis resolution and anticipatory planning. ▀ Through this structured method of assistance, nurses help individuals in crisis to develop more adaptive coping strategies for dealing with stressful situations in the future. ▀ Nurses have many important skills that can assist individuals and communities in the wake of traumatic events. Nursing interventions presented in this chapter were developed for the nursing diagnoses of panic anxiety/fear, spiritual distress, risk for post-trauma syndrome, and ineffective community coping. Multiple Choice 1. A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis? A. This type of crisis is precipitated by unexpected external stressors. B. This type of crisis is precipitated by preexisting psychopathology. C. This type of crisis is precipitated by an acute response to an external situational stressor. D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. ANS: D The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance. 2. A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, ―I can‘t function any longer under all this stress.‖ Which type of crisis is the client experiencing? A. Maturational/developmental crisis B. Psychiatric emergency crisis C. Anticipated life transition crisis D. Traumatic stress crisis ANS: B The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or inability to assume personal responsibility.3. A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this client‘s crisis? A. The client will change his or her type A personality traits to more adaptive ones by week 1. B. The client will list five positive self-attributes. C. The client will examine how childhood events led to an overachieving orientation. D. The client will return to previous adaptive levels of functioning by week 6. ANS: D The nurse should identify that a realistic long-term outcome for this client would be to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect the immediacy of the situation. To be correctly written, an outcome must be client-centered, specific, measurable, realistic, and contain a time frame. 4. A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client? A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations ANS: C The priority nursing diagnosis for this client is ―Risk for self-directed violence R/T hopelessness.‖ Nurses should prioritize diagnoses and outcomes on the basis of potential safety risk to the client and/or others. Nursing diagnoses should be correctly written to include evidence if actual and no evidence if the diagnosis is determined to be potential. 5. After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? A. ―Are you currently thinking about harming yourself?‖ B. ―Why do you want to harm yourself?‖ C. ―Have you thought about the consequences of your actions?‖ D. ―Who is your emergency contact person?‖ ANS: A The nurse should first assess the client for current suicidal thoughts to minimize risk of harm and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team should prioritize safety by assessing the client for thoughts of self-harm.6. An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which intervention should a nurse prioritize to address this behavior? A. Initiate forced medication protocol. B. Help the client to explore the source of anger. C. Ignore the act to avoid reinforcing the behavior. D. With staff support and a show of solidarity, set firm limits on the behavior. ANS: D The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor does not warrant forced medication because the behavior is not a direct safety concern. Exploring the source of anger may be appropriate after the client has gained emotional control. Ignoring the act may further upset the client and does not reinforce appropriate behavior. 7. A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? A. ―You‘ve really been helpful. Can I count on you for continued support?‖ B. ―I don‘t work out anymore.‖ C. ―I‘m really glad I didn‘t go home. It would have been hard to come back.‖ D. ―I carry mace when I jog. It makes me feel safe and secure.‖ ANS: D The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. 8. A despondent client, who has recently lost her husband of 30 years, tearfully states, ―I‘ll feel a lot better if I sell my house and move away.‖ Which nursing reply is most appropriate? A. ―I‘m confident you know what‘s best for you.‖ B. ―This may not be the best time for you to make such an important decision.‖ C. ―Your children will be terribly disappointed.‖ D. ―Tell me why you want to make this change.‖ ANS: B During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic and if timing of change is appropriate. This response encourages the client to think through what may be an impulsive decision. 9. An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression?A. The client requests prn medications. B. The client has a tense facial expression and body language. C. The client refuses to eat lunch. D. The client sits in group therapy with back to peers. ANS: B The nurse should assess that tense facial expressions and body language may indicate that a client‘s anger is escalating. The nurse should conduct a thorough assessment of the client‘s past and current violent behaviors and develop interventions for de-escalation. 10. What is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being ―taken down‖ after a violent outburst? A. To reinforce unit rules with the client population B. To create protocols for the future release of tensions associated with anger C. To process feelings and concerns related to the witnessed intervention D. To discuss the client problems that led to inappropriate expressions of anger ANS: C The nurse should determine that the purpose for holding a debriefing session with clients and staff after clients have witnessed a peer being ―taken down‖ after a violent outburst is to process feelings and concerns related to the witnessed intervention. Multiple Response 11. Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply. A. ―Tell me what happened.‖ B. ―What coping methods have you used, and did they work?‖ C. ―Describe to me what your life was like before this happened.‖ D. ―Let‘s focus on the current problem.‖ E. ―I‘ll assist you in selecting functional coping strategies.‖ ANS: A, B, C In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies are nursing interventions rather than assessments. 12. Which of the following are effective interventions that a nurse should utilize when caring for an inpatient client who expresses anger inappropriately? Select all that apply.A. Maintain a calm demeanor. B. Clearly delineate the consequences of the behavior. C. Use therapeutic touch to convey empathy. D. Set limits on the behavior. E. Teach the client to avoid ―I‖ statements related to expression of feelings. ANS: A, B, D The nurse should determine that when working with an inpatient client who expresses anger inappropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could escalate the client‘s anger. Chapter 14. Assertiveness Training Summary and Key Points ▀ Assertive behavior helps individuals feel better about themselves by encouraging them to stand up for their own basic human rights. ▀ Basic human rights have equal representation for all individuals. ▀ Along with rights comes an equal number of responsibilities. Part of being assertive includes living up to these responsibilities. ▀ Assertive behavior increases self-esteem and the ability to develop satisfying interpersonal relationships. This is accomplished through honesty, directness, appropriateness, and respecting one's own rights, and the rights of others. ▀ Individuals develop patterns of responding in various ways, such as role modeling, by receiving positive or negative reinforcement, or by conscious choice. ▀ Patterns of responding can take the form of non-assertiveness, assertiveness, aggressiveness, or passiveaggressiveness. ▀ Nonassertive individuals seek to please others at the expense of denying their own basic human rights. ▀ Assertive individuals stand up for their own rights while protecting the rights of others. ▀ Those who respond aggressively defend their own rights by violating the basic rights of others. ▀ Individuals who respond in a passive-aggressive manner defend their own rights by expressing resistance to social and occupational demands. ▀ Some important behavioral considerations of assertive behavior include eye contact, body posture, distance/physical contact, gestures, facial expression, voice, fluency, timing, listening, thoughts, content, and persistence. ▀ A discussion of techniques that have been developed to assist individuals in the process of becoming more assertive was presented.▀ Negative thinking can sometimes interfere with one's ability to respond assertively. Thought-stopping techniques help individuals remove negative, unwanted thoughts from awareness and promote the development of a more assertive attitude. ▀ Nurses can assist individuals to learn and practice assertiveness techniques. ▀ The nursing process is an effective vehicle for providing the information and support to clients as they strive to create positive change in their lives. 1. During a psychoeducational group on assertiveness training, a client asks, ―Why do we need to learn about this stuff?‖ Which is the most appropriate nursing reply? A. ―Because your doctor requires you to attend this group.‖ B. ―Being assertive is the ability to stand up for yourself while respecting the rights of others.‖ C. ―Assertiveness training teaches you how to ask for what you want, when you want it.‖ D. ―Assertive people place the needs and rights of others before their own.‖ ANS: B Assertiveness training assists people to maintain their own self-respect and meet their needs while respecting the rights of others. 2. Two clients are roommates on an inpatient psychiatric unit. At breakfast, client ―A,‖ who had been missing her gold locket, notices client ―B‖ wearing it. Which should a nurse recognize as a nonassertive or passive behavioral response from client ―A‖? A. Client ―A‖ ignores the situation. B. Client ―A‖ discusses the situation with her nurse and develops a plan of action. C. Client ―A‖ immediately approaches client ―B‖ and pulls the necklace off her neck. D. Client ―A‖ offers to wash client ―B‘s‖ clothes and ―accidentally‖ spills bleach in the water. ANS: A By ignoring the situation, client ―A‖ avoids conflict, denies her feelings, and does not assertively resolve the problem. This is an example of nonassertive behavior. 3. A client on an inpatient unit is angry with a peer. During lunch, when the peer is not looking, the client spits into his soup. How would the nurse document this interaction? A. ―Client is displaying assertive behaviors.‖ B. ―Client is displaying aggressive behaviors.‖ C. ―Client is displaying passive behaviors.‖ D. ―Client is displaying passive–aggressive behaviors.‖ ANS: DThis response is passive–aggressive. The client‘s anger is expressed indirectly by spitting in the soup when the peer is not looking. 4. A client continually waits more than an hour before being seen at the mental health clinic. The client approaches the nurse and states, ―When I have to wait for more than an hour to be seen, I feel like my time is not important.‖ The nurse recognizes this as what type of behavior? A. Aggressive behavior B. Assertive behavior C. Passive–aggressive behavior D. Passive behavior ANS: B This response is assertive. The client is openly expressing feelings and attempting to correct a stressful situation. 5. During an assertiveness training group, a client admits to aggressive behaviors. The client asks for suggestions for how to become more assertive and less aggressive. Which is the most appropriate nursing reply? A. ―Several techniques, including meditation and progressive muscle relaxation, appear helpful.‖ B. ―There‘s not much that can be done about aggressive behavior because of biological responses.‖ C. ―Certain types of medications have been proven effective in promoting assertive communication.‖ D. ―There are several techniques, including ‗I statements,‘ role playing, and thought stopping, that can help promote assertive behaviors and decrease aggressive behaviors.‖ ANS: D These techniques promote assertive behaviors and would help diminish aggressive responses. 6. During an assertiveness training group, a nurse suggests using ―I statements.‖ The group questions the usefulness of this communication technique. Which explanation by the nurse is most appropriate? A. ―When ‗I statements‘ are used, opinions are communicated without blaming others.‖ B. ―When ‗I statements‘ are used, anger is displaced by using indirect means.‖ C. ―When ‗I statements‘ are used, responsibility for one‘s behavior is attributed to another.‖ D. ―When ‗I statements‘ are used, eye contact is promoted.‖ ANS: A ―I statements‖ clearly state one‘s feelings and needs without blaming or demeaning others. 7. While trying to control aggressive behavior, a client asks an assertiveness training nurse to give an example of an ―I statement.‖ Which of the following statements is the best example of this assertive communication technique? A. ―I would like to know why you came home late without calling me.‖B. ―I hate it when you think you can just come home late without calling anyone to let them know where you are.‖ C. ―I feel angry when you come home late without calling.‖ D. ―I think you don‘t care about me, because if you did, you‘d call me if you were planning on coming home late.‖ ANS: C This response clearly states feelings about a situation without blaming another. 8. After vying for a nurse management position, nurse ―A‖ is chosen over nurse ―B.‖ When nurse manager ―A‖ calls for staff meetings, nurse ―B‖ is chronically late or absent. Nurse ―B‖ is exhibiting which type of behavior? A. Passive B. Assertive C. Aggressive D. Passive–aggressive ANS: D This response is passive–aggressive. The colleague is expressing anger indirectly by being late or absent from the meetings. 9. A nurse should assign which nursing diagnosis to a client needing assistance with assertiveness? A. Disturbed personal identity B. Disturbed thought processes C. Defensive coping D. Impaired verbal communication ANS: C Defensive coping reflects a self-protective pattern that defends against underlying perceived threats to positive selfregard. Clients who are utilizing defensive coping lack assertiveness skills. 10. Two clients get into a heated argument regarding TV program selections. The nurse turns off the TV and asks the clients to go to their rooms to cool off, after which they will discuss and attempt to resolve the problem. The nurse‘s action is promoting which assertive technique? A. Defusing B. Clouding or fogging C. Responding as a broken record D. Shifting from content to process ANS: ADefusing is a technique that delays further discussion with an angry individual until a calm demeanor has been achieved. In the situation presented, the nurse is allowing the clients to calm down prior to addressing their issues. 11. An emergency department nurse, who has worked 10 straight days, is pulled to the psychiatric unit. Which represents a passive–aggressive statement by the emergency department nurse? A. ―Get someone else to work 3 to 11! I‘ve been working 10 days straight, and I need a break!‖ B. ―Okay. I‘ll do it,‖ then purposefully leaves paperwork undone when leaving the unit at 11 p.m. C. ―I have worked 10 days straight, and I cannot work tonight. I will work for you tomorrow if you need me.‖ D. ―Yes, I‘ll do it. Anything to keep peace with the hospital administration is a good thing.‖ ANS: B This response is passive–aggressive. The staff nurse‘s anger is expressed indirectly. 12. Which best describes a nurse‘s use of assertive behavior? A. When a nurse attempts to please others and apologizes for awkwardness in a new role B. When a nurse becomes defensive and angry when peers offer suggestions for improvement C. When a nurse has problems making decisions and has a tendency to procrastinate D. When a nurse is open and direct when asked by the nurse manager to complete assignments ANS: D This is an assertive response. There is clear expression of needs and feelings. 13. Which is the most appropriate nursing reply when a client asks what the goal and benefit are of assertive skills training? A. ―It protects the client from others who express aggressive feelings.‖ B. ―It gives reliable, expert information so that clients may correct faulty behaviors.‖ C. ―It clarifies misperceptions that have caused clients to distort reality.‖ D. ―It improves communication skills in order to improve interpersonal relationships.‖ ANS: D Assertiveness training helps to develop satisfying interpersonal relationships by teaching people how to communicate in a manner to meet their own needs while respecting the rights and needs of others. 14. An instructor is teaching about assertive rights. Which student statement indicates a need for further instruction? A. ―The right to be treated with respect is an assertive right.‖ B. ―The right to say ―no‖ without feeling guilty is an assertive right.‖C. ―The right to change your mind is an assertive right.‖ D. ―The right to always put oneself first is an assertive right.‖ ANS: D This is not an assertive right. An assertive right is ―to consider others as well as yourself.‖ This student statement indicates a need for further instruction. 15. One nurse confronts another and says, ―You are always so talkative in the meetings. I don‘t know why you can‘t stay quiet sometimes.‖ Which reply by the other nurse reflects the technique of ―clouding/fogging?‖ A. ―You‘re right. I do speak up a lot.‖ B. ―Sounds to me like you‘re agitated and we need to talk. What are you truly angry about?‖ C. ―Are you offended that I speak up, or because my thoughts are in opposition to yours?‖ D. ―I have the right to express my opinion.‖ ANS: A This response reflects the use of clouding/fogging. When clouding/fogging is used it concurs with the critic‘s argument without becoming defensive and without agreeing to change. 16. A teenager gets a ―C‖ in algebra. The mother angrily states, ―All you ever do is listen to music and text your friends.‖ The teenager replies, ―What is it that you‘re really upset about, mom?‖ Which response pattern is the teenager expressing? A. Clouding and fogging B. Shifting from content to process C. Delaying assertively D. Assuming responsibility for one‘s own statements ANS: B This response reflects the use of shifting from content to process. The teenager is changing the focus of the communication from discussing the topic at hand to analyzing what is actually going on in the interaction. 17. The dean of nursing criticizes a faculty member about views on academic freedom. The faculty member states, ―Are you upset because I believe in academic freedom or because you don‘t?‖ The faculty member is using which technique to promote assertive behavior? A. Standing up for one‘s basic human rights B. Delaying assertively C. Inquiring assertively D. Responding assertively with ironyANS: C This response reflects the use of inquiring assertively. Inquiring assertively is an attempt to seek additional information about critical statements. 18. An aggressive nurse manager tells a staff nurse she has no business rallying staff to change the schedule. What would be an example of a technique that the staff nurse could use to stand up for her basic human rights? A. ―What is the real reason that you don‘t want the schedule changed?‖ B. ―Sounds to me like you‘re threatened by this change.‖ C. ―Are you upset because you don‘t want to redo the schedule?‖ D. ―I have the right to express my opinion about the schedule.‖ ANS: D This response reflects the use of standing up for one‘s basic human rights. 19. A nursing supervisor is scheduling holiday hours. When the supervisor tells the staff nurse that she needs to work Christmas day, the staff nurse calmly states, ―I worked last Christmas and will not work this Christmas.‖ When the supervisor says ‗But I need you to work,‖ the nurse repeats ―I worked last Christmas and will not work this Christmas.‖ This is an example of which assertive behavior technique? A. Shifting from content to process B. Standing up for one‘s basic rights C. Responding as a broken record D. Defusing ANS: C ―Responding as a broken record‖ is an assertive behavior technique that consists of persistently repeating in a calm voice what is wanted. 20. A nurse has identified the following nursing diagnosis: ―ineffective communication R/T lack of assertiveness skills AEB inability to state needs.‖ Which statement encourages the client to acknowledge the priority of this problem? A. ―Are you having thoughts of harming yourself or others?‖ B. ―With whom are you least assertive?‖ C. ―On a scale of 1 to 10, rank the importance of being assertive.‖ D. ―When are you available to attend the assertiveness training class?‖ ANS: C This nursing statement encourages the client to objectively evaluate the priority of being assertive. It is important in patient-centered care for the client to prioritize his or her goals for treatment.21. Which of the following are behavioral components of assertive communication? A. Listening B. ―You‖ statements C. Closed posture D. Continuous direct eye contact ANS: A One part of assertiveness communication and behavior is to listen and take time to understand what is being said before giving a response. 22. A client is experiencing high stress. The client states, ―My boss treats me like a doormat and thinks nothing of demanding frequent overtime.‖ Which nursing intervention would be appropriate? A. To incorporate the family support system into the client‘s plan of care B. To teach thought-reframing techniques C. To encourage the client to seek other employment D. To teach the client how to use ―I‖ statements ANS: D The ability to use ―I‖ statements is essential in assertive communication. The situation presented indicates that the client needs assertiveness training. Multiple Response 23. A nurse is caring for four clients. Which of the following clients should the nurse identify as likely to experience difficulty in being assertive? Select all that apply. A. A 20-year-old woman who is completing college homework assignments for several peers. B. A 69-year-old widow who is socially isolated C. A 17-year-old boy with conduct disorder D. A 45-year-old successful executive E. A 50-year-old diagnosed with narcissistic personality disorder ANS: A, B, C The woman who is taking on the work of others in addition to her own may be having difficulty assertively saying ―no‖; the widow who is socially isolated may lack the necessary skills to communicate her needs; and the boy with a conduct disorder is likely to demonstrate aggressive behaviors. The business executive and an individual diagnosed with narcissistic personality disorder are the least likely to have difficulty being assertive. Chapter 16. Anger/Aggression ManagementSummary and Key Points ▀ Statistics show that violence is rampant in the United States. ▀ The precursor to violence is anger, which is a normal human emotion, and need not necessarily be a negative response. ▀ When used appropriately, anger can provide positive assistance with problem solving and decision-making in everyday life situations. ▀ Violence occurs when individuals lose control of their anger. ▀ Anger is viewed as the emotional response to one's perception of a situation. ▀ Anger is a very powerful emotion and, when denied or buried, can precipitate a number of psychophysiological disorders. ▀ When anger is turned inward on the self, it can result in depression. ▀ When expressed inappropriately, anger commonly interferes with interpersonal relationships. ▀ When anger is suppressed, it often turns to resentment. ▀ Anger generates a physiological arousal comparable to the stress response discussed in Chapter 1. ▀ Aggression is one way in which individuals express anger. ▀ Aggression is behavior intended to threaten or injure the victim's security or self-esteem. ▀ Aggression can be physical or verbal, but it is virtually always designed to punish. ▀ Aggression is a negative function or destructive use of anger. ▀ Various predisposing factors to the way individuals express anger have been implicated. Some theorists suggest that the etiology is purely biological, whereas others believe it depends on psychological and environmental factors. ▀ Some possible predisposing factors include role modeling, operant conditioning, neurophysiological disorders (e.g., brain tumors, trauma, or diseases), biochemical factors (e.g., increased levels of androgens or other alterations in hormone levels and neurotransmitter involvement), socioeconomic factors (e.g., living in poverty), and environmental factors (e.g., physical crowding, uncomfortable temperature, use of alcohol or drugs, and availability of firearms). ▀ Nurses must be aware of the symptoms associated with anger and aggression in order to make an accurate assessment. ▀ Prevention is the key issue in the management of aggressive or violent behavior. ▀ Three elements have been identified as key risk factors in the potential for violence: (1) past history of violence, (2) client diagnosis, and (3) current behaviors. Multiple Choice 1. A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, ―How will we know if someone may get violent?‖ Which is the most appropriate reply by the nursing instructor?A. ―You can‘t really say for sure. There are limited indicators of potential violence.‖ B. ―Certain behaviors indicate a potential for violence. They are labeled as a ‗prodromal syndrome‘ and include rigid posture, clenched fists, and raised voice.‖ C. ―Any client can become violent, so it is best to be aware of your surroundings at all times.‖ D. ―When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this is an indicator of potential violence.‖ ANS: B These behaviors have been identified as predictors of violent behavior. 2. A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction? A. ―Anger is physiological arousal.‖ B. ―Anger and aggression are essentially the same.‖ C. ―Anger expression is a learned response.‖ D. ―Anger is not a primary emotion.‖ ANS: B Further teaching is necessary when the student states that anger and aggression are essentially the same. Anger and aggression are significantly different. 3. Which client statement demonstrates improvement in anger/aggression management? A. ―I realize I have a problem expressing my anger appropriately.‖ B. ―I know I can‘t use physical force anymore, but I can intimidate someone with my words.‖ C. ―It‘s bad to feel as angry as I feel. I‘m working on eliminating this poisonous emotion entirely.‖ D. ―Because my wife seems to be the one to set me off, I‘ve decided to remain separated from her.‖ ANS: A The client is recognizing and taking responsibility for personal anger. 4. A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises his fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited? A. The defense mechanism of projection B. The defense mechanism of reaction formation C. The defense mechanism of sublimationD. The defense mechanism of displacement ANS: D Anger can lead to aggression when the coping response is displacement. This client has discharged anger against a person (the nurse) unrelated to the true target of the anger (the spouse). 5. A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression? A. A child raised by a physically abusive parent B. An adult with a history of epilepsy C. A young adult living in the ghetto of an inner city D. An adolescent raised by Scandinavian immigrant parents ANS: D An adolescent raised by Scandinavian immigrant parents would be least prone to developing problems with anger and aggression as compared with the other clients presented. A history of abuse, epilepsy, overcrowding, and poverty all contribute as predisposing factors to anger and aggression. 6. After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal? A. 1 hour B. 2 hours C. 3 hours D. 4 hours ANS: D The Joint Commission (JCAHO) requires that a physician or licensed independent provider (LIP) must reissue a new order for restraints every 4 hours for adults, every 1 hour for clients younger than 9, and every 2 hours for clients 9 to 17 years. 7. An adult client assaults another client and is placed in restraints. Which statement from the client while in restraints should alert a nurse that further assessment is necessary? A. ―I hate all of you!‖ B. ―My fingers are tingly.‖ C. ―You wait until I tell my lawyer.‖ D. ―I have a sinus headache.‖ ANS: BThis statement may mean that the restraints are excessively tight and impeding circulation. 8. After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the client‘s return to the therapeutic milieu. Which unit procedure is the staff implementing? A. Milieu reenactment B. Treatment planning C. Crisis intervention D. Debriefing ANS: D Debriefing is an important part of restraint/seclusion. It allows the staff an opportunity to review and learn from the experience and to express feelings generated by the incident. 9. Once the nurse initiates restraint for an out-of-control 45-year-old patient, what must occur within 1 hour, according to JCAHO standards? A. The patient must be let out of restraint. B. A physician or other licensed independent practitioner must conduct an in-person evaluation. C. The patient must be bathed and fed. D. The patient must be included in debriefing. ANS: B Joint Commission (JCAHO) standards require that a physician or other licensed independent practitioner conduct an in-person evaluation of the client within 1 hour of the initiation of restraint. 10. For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise? A. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit setting. B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others. C. Clients with antisocial tendencies need to submit to authority. D. Clients with behavioral dysfunction need behavioral interventions. ANS: B Restraints are used for clients who are unable to control their behavior in order to prevent harming themselves or others. 11. A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns ―Risk for other-directed violence‖ as the client‘s priority nursing diagnosis. Based on this diagnosis, which would be an appropriate, correctly written outcome for this client?A. The client will not verbalize anger or hit anyone. B. The client will verbalize anger rather than hit others. C. The client will not inflict harm on others during this shift. D. The client will be restrained if verbal or physical abuse is observed during this shift. ANS: C Preventing injury to others is the appropriate outcome. Outcomes must be client centered, specific, realistic, and measureable and contain a time frame. Answer ―A‖ does not contain a time frame. 12. At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client. To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation? A. No later than 8 a.m., by a licensed independent practitioner or a clinical nurse specialist B. No later than 4 a.m., by a physician or a licensed independent practitioner (LIP) C. No later than 3:30 a.m., by a physician or the client‘s case manager D. No later than 6 a.m., by the psychiatrist or a clinical nurse specialist ANS: B To meet Joint Commission standards, an in-person evaluation by a physician or LIP should be conducted within 1 hour of the initiation of restraints. 13. Which risk factor should a nurse recognize as the most reliable indicator of potential client violence?A. A diagnosis of schizotypal personality disorder B. History of assaultive behavior C. Family history of violence D. Recent eviction from a homeless shelter ANS: B A prior history of assault is the most widely recognized risk factor for client violence. 14. A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction? A. ―Administering psychotropic medications can be a part of violence-intervention protocols.‖ B. ―Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols.‖ C. ―Applying leather restraints can be a part of violence-intervention protocols.‖ D. ―Calling for assistance is a part of violence-intervention protocols.‖ ANS: BTouching the client could be seen by him or her as threatening and provoke further violence. 15. A client begins to smash furniture, cannot be ―talked down,‖ and refuses medications. Which is the most appropriate nursing intervention? A. Call a violence code. B. Ask the ward clerk to put in a call for the physician. C. Place the client in seclusion. D. Place the client in four-point restraints. ANS: A In this situation the nurse must have adequate, trained help to prevent injury to the client or staff. Calling a violence code will access this help. 16. On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the client‘s restraint order? A. Within 1 hour of the original restraint order B. Within 2 hours of the original restraint order C. Within 3 hours of the original restraint order D. Within 4 hours of the original restraint order ANS: B The Joint Commission (JCAHO) requires that a physician or a licensed independent practitioner reissue a new order for restraints every 4 hours for adults, every 2 hours for adolescents, and every 1 hour for children. 17. A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action? A. Assertively instruct the client to stop punching the wall. B. Encourage the client to write down feelings in a journal. C. With the help of staff, initiate seclusion protocol. D. Ensure adequate physical space between the nurse and the client. ANS: D To maintain a safe environment, it is important to initially assure that there is adequate physical space between the nurse and the client. Violence can be related to increased contact and decreased defensible space. 18. The nurse observes a client‘s escalating anger. The client begins to pace the hall and shouts, ―You all better watch out. I‘m going to hurt anyone who gets in my way.‖ Which should be the priority nursing intervention?A. Calmly tell the client, ―Staff will help you to control your impulse to hurt others.‖ B. Remove other clients from the area and maintain milieu safety. C. Gather a show of force by contacting security for assistance. D. Calmly tell the client, ―You will need to be medicated and secluded.‖ ANS: B During an emergent situation on an inpatient unit, the nurse‘s priority action should be to keep all clients safe by removing them from the area of conflict. 19. The client states, ―I get into trouble because I respond violently without thinking. That usually gets me into a mess.‖ Which nursing reply would be most therapeutic to address this client‘s problem? A. ―Everybody loses their temper. It‘s good that you know that about yourself.‖ B. ―I‘ll bet you have some interesting stories to share about overreacting.‖ C. ―Let‘s explore methods to help you stop and think before taking action.‖ D. ―It‘s good that you are showing readiness for behavioral change.‖ ANS: C Helping the client to find alternative ways to release tension by more appropriate problem-solving behaviors is a therapeutic nursing intervention. 20. Which initial nursing approach makes limit-setting better accepted by clients who are aggressively acting out? A. Confronting clients with their needs for secondary gains B. Teaching relaxation techniques C. Reflecting back to the client empathy about the client‘s distress D. Presenting appropriate values that need to be modified ANS: C Reflecting back to the client empathy about the client‘s distress promotes a trusting relationship and may prevent the client‘s anxiety from escalating when limits are set. 21. Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client? A. Place a hand on the client‘s shoulder and state, ―I will help you to your room.‖ B. Slowly and matter-of-factly state, ―I am your nurse and I will show you to your room.‖ C. Firmly set limits by stating, ―If your behavior does not improve you will be secluded.‖ D. Smile and state, ―I am your nurse. When do you want to go to your room?‖ANS: B It is important to maintain an unemotional tone of voice when dealing with a hostile client. The client might misinterpret touch and become violent. Multiple Response 22. A nurse notices a client clenching fists periodically and pacing the hallway. Which of the following nursing interventions would best assist the client at this time? Select all that apply. A. Acknowledge the client‘s behavior. B. Initiate forced medication protocol. C. Assist the client to a quiet area. D. Initiate confinement measures. E. Speak with a soft and calming voice. ANS: A, C, E The nurse should remain calm when dealing with an angry client. It is important to acknowledge the client‘s behavior and assist the client to a less stimulating environment. Chapter 9. The Nursing Process in Psychiatric/Mental Health Nursing Summary and Key Points ▀ The nursing process provides a methodology by which nurses may deliver care using a systematic, scientific approach. ▀ The focus of nursing process is goal directed and based on a decision-making or problem-solving model, consisting of six steps: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. ▀ Assessment is a systematic, dynamic process by which the nurse, through interaction with the client, significant others, and health-care providers, collects and analyzes data about the client. ▀ Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems/life processes. ▀ Outcomes are measurable, expected, patient-focused goals that translate into observable behaviors. ▀ Evaluation is the process of determining both the client's progress toward the attainment of expected outcomes and the effectiveness of nursing care. Multiple Choice 1. Which data-gathering technique is employed during the assessment phase of the nursing process? A. Asking the client to rate mood after administering an antidepressant B. Asking the client to verbalize understanding of previously explained unit rulesC. Asking the client to describe any thoughts of self-harm D. Asking the client if the group on assertiveness skills was helpful ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. The other three options are employed during the evaluation phase of the nursing process. 2. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems? A. Medical history is of little significance and can be eliminated from the nursing assessment. B. Assessment provides a holistic view of the client, including biopsychosocial aspects. C. Comprehensive assessments can be performed only by advanced practice nurses. D. Psychosocial evaluations are gained by subjective reports rather than objective observations. ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. 3. Which nursing diagnosis should a nurse identify as being correctly formulated? A. Schizophrenia R/T biochemical alterations AEB altered thought B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance C. Depressed mood R/T multiple life stressors D. Developmental disability R/T early-onset schizophrenia AEB hallucinations ANS: B The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the unhealthy response (inference), the contributing factors, and the data that support the inference. 4. Which expected client outcome should a nurse identify as being correctly formulated? A. Client will feel happier by discharge. B. Client will demonstrate two relaxation techniques. C. Client will verbalize triggers to anger by end of session. D. Client will initiate interaction with one peer during free time within 2 days.ANS: D The statement ―Client will initiate interaction with one peer during free time within 2 days‖ is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes. 5. Which statement regarding nursing interventions should a nurse identify as accurate? A. Nursing interventions are independent from the treatment team‘s goals. B. Nursing interventions are directed solely by written physician orders. C. Nursing interventions occur independently but in concert with overall treatment team goals. D. Nursing interventions are standardized by policies and procedures. ANS: C The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client‘s care. 6. Within the nurse‘s scope of practice, which function is exclusive to the advance practice psychiatric nurse? A. Teaching about the side effects of neuroleptic medications B. Using psychotherapy to improve mental health status C. Using milieu therapy to structure a therapeutic environment D. Providing case management to coordinate continuity of health services ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy. 7. A nurse charts ―Verbalizes understanding of the side effects of Prozac.‖ This is an example of which category of focused charting? A. Data B. Problem C. Action D. Response ANS: D ―Verbalizes understanding of the side effects of Prozac‖ is an example of the response category of focused charting. The response is a description of the client‘s reaction to any part of medical or nursing care.8. The nurse should recognize which acronym as representing problem-oriented charting? A. SOAPIE B. SOLER C. DAR D. PQRST ANS: A The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. This type of charting identifies nursing diagnoses (client problems) on a written plan of care with appropriate nursing interventions described for each. 9. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)? A. CIWA scale B. GGT C. MMSE D. CAPS scale ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism. 10. What is being assessed when a nurse asks a client to identify name, date, residential address, and situation? A. Mood B. Perception C. Orientation D. Affect ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the client‘s orientation. Assessment of the client‘s orientation to reality is part of a mental status evaluation. 11. What is the purpose when a nurse gathers client information? A. It enables the nurse to modify client behaviors related to personality disorders.B. It enables the nurse to make sound clinical judgments and plan appropriate client care. C. It enables the nurse to prescribe the appropriate medications. D. It enables the nurse to assign the appropriate Axis I diagnosis. ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical nursing judgments and plan appropriate care. The nurse should complete a thorough assessment of the client, including information collected from the client, significant others, and health-care providers (consistent with HIPAA laws and the client‘s right to confidentiality). 12. A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse? A. Health teacher B. Case manager C. Milieu manager D. Psychotherapist ANS: C The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe environment. Case management is utilized to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling. 13. The following outcome was developed for a client: ―Client will list five personal strengths by the end of day 1.‖ Which correctly written nursing diagnostic statement most likely generated the development of this outcome? A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements B. Self-care deficit R/T altered thought processes C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written. 14. How should a nurse prioritize nursing diagnoses? A. By the established goal of care B. By the life-threatening potentialC. By the physician‘s priority of care D. By the client‘s preference ANS: B The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety is always the nurse‘s first priority. 15. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client‘s problem? A. The client will avoid daytime napping and attend all groups. B. The client will exercise, as needed, before bedtime. C. The client will sleep 7 uninterrupted hours by day four of hospitalization. D. The client‘s sleep habits will improve during hospitalization. ANS: C The outcome ―The client will sleep 7 uninterrupted hours by day four of hospitalization‖ is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, clientfocused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes. 16. The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement? A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. B. The client has a history of four suicide attempts in adolescence. C. The client expresses hopelessness and helplessness and isolates self. D. The client has disorganized thought processes and delusional thinking. ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of nursing diagnosis of risk for suicide. Disorganized thoughts and delusional thinking would lead to the development of a nursing diagnosis of altered thought processes. 17. A student nurse asks an instructor which resource is best to use when developing nursing outcomes for clients. Which reply by the instructor most accurately answers the student‘s question? A. ―Use the Nursing Interventions Classification (NIC), as a reference for nursing outcomes.‖ B. ―Use the NANDA resource to identify appropriate outcomes.‖ C. ―Use the Nursing Outcomes Classification (NOC), as a reference for nursing outcomes.‖D. ―Copy your standard outcomes from a nursing care plan textbook.‖ ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions. NANDA is a resource for identifying approved nursing diagnoses. 18. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client‘s problem? A. Altered thought processes B. Altered sensory perception C. Anxiety D. Chronic confusion ANS: B The nursing diagnosis altered sensory perception accurately reflects the client‘s symptoms of hearing things that others do not. A nursing diagnosis describes a client‘s condition and facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes. 19. A nursing instructor is teaching students about the purpose of using the nursing process in the care of psychiatric patients. Which of the following statements by the student indicates that learning has occurred? A. The nursing process is a method for interviewing the patient in a systematic way. B. The nursing process is used to assist patients to adapt successfully to stressors within the environment. C. The nursing process is used to provide support for the psychiatric diagnosis. D. The nursing process is used primarily to minimize allegations of negligence. ANS: B The nursing process is a method for nursing care delivery in which the patient’s unhealthy responses are identified and interventions are planned, which are designed to assist the patient to adapt more successfully in their environment. 20. A client is diagnosed with generalized anxiety disorder. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse? A. Assessing the client‘s level of anxiety B. Assessing and documenting the client‘s vital signs C. Assessing suicide risk D. Assessing availability of support systems ANS: AAnxiety at a moderate or higher level will interfere with the learning process. 21. During the implementation phase of the nursing process, a nurse is teaching an adult depressed patient with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? A. Using repetition B. Speaking directly face-to-face C. Employing the use of sign language D. Providing large-print materials ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing. 22. A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation? A. Provide warm milk and a backrub. B. Give a sleep medication. C. Hold a relaxation group before bedtime. D. Review the client‘s normal sleep pattern. ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client‘s health or situation. In this situation the nurse must initially determine the client‘s normal sleep patterns in order to evaluate if a true problem exists. 23. An instructor overhears a student say, ―That family seems to disagree more than agree. The family seems to be dysfunctional.‖ To further assess the family‘s situation, which would be an appropriate instructor reply? A. ―Families who disagree can be a challenge to the treatment team.‖ B. ―You seem very critical of the family. Do you believe that you are unable to help them?‖ C. ―Let‘s bring the family in for an educational session to improve their communication.‖ D. ―What appears to trigger family disagreements?‖ ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client‘s health or situation. In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts. 24. Which nursing response would be appropriately used in the evaluation phase of the nursing process?A. ―If I were in your situation, I would not repeat a behavior that has caused problems.‖ B. ―What do you think needs changing, and what do you want to do differently?‖ C. ―What exactly will it take to carry out your plan, and what else do you need to do?‖ D. ―It sounds like you‘re saying this new approach is working for you.‖ ANS: D In the evaluation phase of the nursing process, the nurse and the client evaluate progress toward attainment of the expected outcomes. 25. A client diagnosed with major depressive disorder states, ―Why should I keep trying to get a job? I mess up everything I do.‖ Which correctly written nursing diagnosis best reflects the content and mood themes in this client‘s statement? A. Hopelessness R/T poor job performance B. Risk for impaired adjustment R/T inadequate social skills AEB isolation C. Altered role performance R/T the fear of failure AEB not seeking employment D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred ANS: C An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A ―risk for‖ diagnosis does not contain AEB because there is only a potential for the problem; it doesn‘t yet exist. The client‘s statement indicates that role performance is altered because fear of failure prevents seeking employment. 26. During an intake interview, which question would assist the nurse in gathering data about the client‘s judgment? A. ―What brought you to the hospital? Do you know what day and season it is now?‖ B. ―On a scale of 1 to 10, how would you rate your stress level?‖ C. ―What does the phrase ‗a rolling stone gathers no moss‘ mean to you?‖ D. ―If you found a stamped, addressed envelope in the street, what would you do?‖ ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client‘s health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment on the basis of the client‘s action choice. 27. An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals? A. ―What do you think needs to change about how you express anger?‖ B. ―How did you feel after attending the anger management session?‖C. ―On a scale of 1 to 10, please rate your current level of anger.‖ D. ―What bothers you about the actions of others when you get angry?‖ ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation. 28. The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview? A. ―Appears uncooperative. Exhibits characteristics of depression.‖ B. ―Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression.‖ C. ―States ‗I don‘t need to be here‘ when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission.‖ D. ―Unwilling to respond openly during interview.‖ ANS: C Documentation occurs in the implementation phase of the nursing process. All charting entries to the client‘s legal record should be objective and based on assessed data. Implications and generalizations should be avoided. 29. A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural differences AEB client stating, ―Although I‘d like to, I don‘t join in because I don‘t speak the language so good.‖ Which correctly written outcome addresses this client‘s problem? A. The client will collaborate with nursing staff to set specific goals by day 3. B. The client will participate in one group activity of choice by day 2. C. The client will express a desire to interact with others. D. The client will become increasingly independent by discharge. ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation. 30. The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted? A. The client who is experiencing tremors and has a need for medication adjustment B. The client who is experiencing anxiety and a sad mood after separation from spouse C. The client who is a single parent and hears voices stating, ―Kill your infant son.‖ D. The client who argued with her boyfriend and inflicted a superficial cut on her armANS: C In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client‘s health or situation. These data are prioritized to meet client needs, with an emphasis on safety. Multiple Response 31. Which of the following nursing interventions fall within the standards of psychiatric–mental health clinical nursing practice for a nurse generalist? Select all that apply. A. Assist clients to perform activities of daily living. B. Act as a consultant with other clinicians to provide services for clients and effect system change C. Encourage clients to discuss triggers for relapse D. Use prescriptive authority in accordance with state and federal laws E. Educate families about signs and symptoms of alcohol dependence and withdrawal ANS: A, C, E Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric–mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority. 32. Which of the following are characteristics of accurately developed client outcomes? Select all that apply. A. Client outcomes are formulated by nurses independent from other team members. B. Client outcomes are not restricted by time frames. C. Client outcomes are specific and measurable. D. Client outcomes are realistically based on client capability. E. Client outcomes are formally approved by the psychiatrist. ANS: C, D The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others. 33. After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? Select all that apply. A. Medical judgments related to the psychiatric disorder B. Unmet client needs present at the moment C. Supporting data that validate the diagnosisD. Outcomes that will be targets for nursing interventions E. Statements of client problems of a functional nature ANS: B, C, E A nursing diagnosis is a statement of a client‘s functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A ―risk for‖ diagnosis does not contain AEB because there is only a potential for the problem; it does not yet exist. Chapter 10. Therapeutic Groups Summary and Key Points ▀ A group has been defined as a collection of individuals whose association is founded on shared commonalities of interest, values, norms, or purpose. ▀ Eight group functions have been identified: socialization, support, task completion, camaraderie, informational, normative, empowerment, and governance. ▀ There are three major types of groups: task groups, teaching groups, and supportive/therapeutic groups. ▀ The function of task groups is to solve problems, make decisions, and achieve a specific outcome. ▀ In teaching groups, knowledge and information are conveyed to a number of individuals. ▀ The function of supportive/therapeutic groups is to educate people to deal effectively with emotional stress in their lives. ▀ In self-help groups, individuals share a common problem. Members of the group provide each other with mutual support as they deal with, or possibly try to recover from, the problem. ▀ Therapeutic groups differ from group therapy in that group therapy is more theory based and the leaders generally have advanced degrees in psychology, social work, nursing, or medicine. ▀ Placement of the seating and size of the group can influence group interaction. ▀ Groups can be open-ended (when members leave and others join at any time while the group is active) or closed-ended (when groups have a predetermined, fixed time frame and all members join at the same time and leave when the group disbands). ▀ Yalom and Leszcz (2005) describe the following curative factors that individuals derive from participation in therapeutic groups: the instillation of hope, universality, the imparting of information, altruism, the corrective recapitulation of the primary family group, the development of socializing techniques, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors. ▀ Groups progress through three phases: the initial (orientation) phase, the working phase, and the termination phase. ▀ Group leadership styles include autocratic, democratic, and laissez-faire. ▀ Members play various roles within groups. These roles are categorized according to task roles, maintenance roles, and personal roles.▀ Psychodrama is a specialized type of group therapy that uses a dramatic approach in which clients become ―actors‖ in life-situation scenarios. ▀ The psychodrama setting provides the client with a safer and less threatening atmosphere than the real situation in which to express and work through unresolved conflicts. ▀ Nurses lead various types of therapeutic groups in the psychiatric setting. Knowledge of human behavior in general and the group process in particular is essential to effective group leadership. ▀ Specialized training, in addition to a master's degree, is required for nurses to serve as group psychotherapists or psycho-dramatists. Multiple Choice 1. During a therapeutic group, a client talks about personal accomplishments in an effort to gain attention. Which group role, assumed by this client, should the nurse identify? A. The task role of gatekeeper B. The individual role of recognition seeker C. The maintenance role of dominator D. The task role of elaborator ANS: B The nurse should evaluate that the client is assuming the individual role of the recognition seeker. Other individual roles include the aggressor, the blocker, the dominator, the help seeker, the monopolizer, and the seducer. 2. During a therapeutic group, two clients engage in an angry verbal exchange. The nurse leader interrupts the exchange and excuses both of the clients from the group. The nurse has demonstrated which leadership style? A. Autocratic B. Democratic C. Laissez-faire D. Bureaucratic ANS: A The nurse who excuses clients from the group has demonstrated an autocratic leadership style. An autocratic leadership style may be useful in certain situations that require structure and limit-setting. Democratic leaders focus on the members of the group and group-selected goals. Laissez-faire leaders provide no direction to group members. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 3. During a therapeutic group, which nursing action demonstrates a laissez-faire leadership style? A. The nurse mandates that all group members reveal an embarrassing personal situation.B. The nurse asks for a show of hands to determine group topic preference. C. The nurse sits silently as the group members stray from the assigned topic. D. The nurse shuffles through papers to determine the facility policy on length of group. ANS: C The nurse leader who sits silently and allows group members to stray from the assigned topic is demonstrating a laissez-faire leadership style. This style allows group members to do as they please with no direction from the leader. Group members often become frustrated and confused in reaction to a laissez-faire leadership style. 4. During a community meeting, a nurse encourages clients to present unit problems and discuss possible solutions. Which type of leadership style is the nurse demonstrating? A. Democratic B. Autocratic C. Laissez-faire D. Bureaucratic ANS: A The nurse who encourages clients to present problems and discuss solutions is demonstrating a democratic leadership style. Democratic leaders share information with group members and promote decision making by the members of the group. The leader provides guidance and expertise as needed. 5. Which situation should a nurse identify as an example of an autocratic leadership style? A. The president of Sigma Theta Tau assigns members to committees to research problems. B. Without faculty input, the dean mandates that all course content be delivered via the Internet. C. During a community meeting, a nurse listens as clients generate solutions. D. The student nurses‘ association advertises for candidates for president. ANS: B The nurse should identify that mandating decisions without consulting the group is considered an autocratic leadership style. Autocratic leadership increases productivity but often reduces morale and motivation due to lack of member input and creativity. 6. A single, pregnant teenager in a parenting class discloses her ambivalence toward the pregnancy and the subsequent guilt that these thoughts generate. A mother of three admits to having felt that way herself. Which of Yalom‘s curative group factors does this illustrate? A. Imparting of information B. Instillation of hope C. AltruismD. Universality ANS: D The scenario is an example of the curative group factor of universality. Universality occurs when individuals realize that they are not alone in the problems, thoughts, and feelings they are experiencing. This realization reduces anxiety by the support and understanding of others. 7. A man diagnosed with alcohol dependence experiences his first relapse. During his AA meeting, another group member states, ―I relapsed three times, but now have been sober for 15 years.‖ Which of Yalom‘s curative group factors does this illustrate? A. Imparting of information B. Instillation of hope C. Catharsis D. Universality ANS: B This scenario is an example of the curative group factor of instillation of hope. This occurs when members observe the progress of others in the group with similar problems and begin to believe that personal problems can also be resolved. 8. During a group discussion, members freely interact with each other. Which member statement is an example of Yalom‘s curative group factor of imparting information? A. ―I found a Web site explaining the different types of brain tumors and their treatment.‖ B. ―My brother also had a brain tumor and now is completely cured.‖ C. ―I understand your fear and will be by your side during this time.‖ D. ―My mother was also diagnosed with cancer of the brain.‖ ANS: A Yalom‘s curative group factor of imparting information involves sharing knowledge gained through formal instruction as well as by advice and suggestions given by other group members. 9. Prayer group members at a local Baptist church are meeting with a poor, homeless family they are supporting. Which member statement is an example of Yalom‘s curative group factor of altruism? A. ―I‘ll give you the name of a friend that rents inexpensive rooms.‖ B. ―The last time we helped a family, they got back on their feet and prospered.‖ C. ―I can give you all of my baby clothes for your little one.‖ D. ―I can appreciate your situation. I had to declare bankruptcy last year.‖ ANS: CYalom‘s curative group factor of altruism occurs when group members provide assistance and support to each other, creating a positive self-image and promoting self-growth. Individuals increase self-esteem through mutual caring and concern. 10. During an inpatient educational group, a client shouts out, ―This information is worthless. Nothing you have said can help me.‖ These statements indicate to the nurse leader that the client is assuming which group role? A. The group role of aggressor B. The group role of initiator C. The group role of gatekeeper D. The group role of blocker ANS: A The nurse should identify that the client is assuming the group role of the aggressor. The aggressor expresses negativism and hostility toward others in the group or to the group leader and may use sarcasm in an effort to degrade the status of others. 11. A nurse believes that the members of a parenting group are in the initial, or orientation, phase of group development. Which group behaviors would support this assumption? A. The group members manage conflict within the group. B. The group members use denial as part of the grief response. C. The group members compliment the leader and compete for the role of recorder. D. The group members initially trust one another and the leader. ANS: C The nurse should anticipate that members in the initial, or orientation, phase of group development often compliment the leader and compete for the role of recorder. Members in this phase have not yet established trust and have a fear of not being accepted. Power struggles may occur as members compete for their position in the group. 12. During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development? A. ―It‘s hard for me to tell my story when I‘m not sure about the reactions of others.‖ B. ―I think Joe‘s Antabuse suggestion is a good one and might work for me.‖ C. ―My situation is very complex, and I need professional, not peer, advice.‖ D. ―I am really upset that you expect me to solve my own problems.‖ ANS: B The nurse should determine that group members have progressed to the working phase of group development when members begin to look to each other instead of to the leader for guidance. Group members in the working phase begin to accept criticism from each other and then use it constructively to foster change.13. Which group leader activity should a nurse identify as being most important in the final, or termination, phase of group development? A. The group leader establishes the rules that will govern the group after discharge. B. The group leader encourages members to rely on each other for problem solving. C. The group leader presents and discusses the concept of group termination. D. The group leader helps the members to process feelings of loss. ANS: D The most effective intervention in the final, or termination, phase of group development would be for the group leader to help the members to process feelings of loss. The leader should encourage the members to review the goals and discuss outcomes, reminisce about what has occurred, and encourage members to provide feedback to each other about progress. 14. A nursing instructor is teaching students about self-help groups like Alcoholics Anonymous (AA). Which student statement indicates that learning has occurred? A. ―There is little research to support AA‘s effectiveness.‖ B. ―Self-help groups used to be the treatment of choice, but their popularity is waning.‖ C. ―These groups have no external regulation, so clients need to be cautious.‖ D. ―Members themselves run the group, with leadership usually rotating among the members.‖ ANS: D The student indicates an understanding of self-help groups when stating, ―Members themselves run the group, with leadership usually rotating among the members.‖ Nurses may or may not be involved in self-help groups. These groups allow members to talk about feelings and reduce feelings of isolation, while receiving support from others undergoing similar experiences. 15. The nurse should utilize which group function to help an extremely withdrawn, paranoid client increase feelings of security? A. Socialization B. Support C. Empowerment D. Governance ANS: B The nurse should identify that the group function of support would help an extremely withdrawn, paranoid client increase feelings of security. Support assists group members in gaining a feeling of security from group involvement. 16. When planning group therapy, a nurse should identify which configuration as most optimal for a therapeutic group?A. Open-ended membership; circle of chairs; group size of 5 to 10 members B. Open-ended membership; chairs around a table; group size of 10 to 15 members C. Closed membership; circle of chairs; group size of 5 to 10 members D. Closed membership; chairs around a table; group size of 10 to 15 members ANS: C The nurse should identify that the most optimal conditions for a therapeutic group are when the membership is closed and the group size is between 5 and 10 members who are arranged in a circle of chairs. The focus of therapeutic groups is on relationships within the group and the interactions among group members. 17. During the sixth week of a 10-week parenting skills group, a nurse observes as several members get into a heated dispute about spanking. As a group, they decide to create a pros-and-cons poster on the use of physical discipline. At this time, what is the role of the group leader? A. To referee the debate B. To adamantly oppose physical discipline measures C. To redirect the group to a less controversial topic D. To encourage the group to solve the problem collectively ANS: D The role of the group leader is to encourage the group to solve the problem collectively. A democratic leadership style supports members in their participation and problem-solving. Members are encouraged to cooperatively solve issues that relate to the group. 18. A 10-week, prenuptial counseling group composed of five couples is terminating. At the last group meeting, a nurse notices that the two most faithful and participative couples are absent. When considering concepts of group development, what might explain this behavior? A. They are experiencing problems with termination, leading to feelings of abandonment. B. They did not think any new material would be covered at the last session. C. They were angry with the leader for not extending the length of the group. D. They were bored with the material covered in the group. ANS: A The nurse should determine that the clients‘ absence from the final group meeting may indicate that they are experiencing problems with termination. The termination phase of group development may elicit feelings of abandonment and anger. Successful termination may help members develop skills to cope with future unrelated losses. 19. An experienced psychiatric registered nurse has taken a new position leading groups in a day treatment program. Without further education, which group is this nurse most qualified to lead? A. A psychodrama groupB. A psychotherapy group C. A parenting group D. A family therapy group ANS: C A psychiatric registered nurse is qualified to lead a parenting group. A parenting group can be classified as either a teaching group or therapeutic group. Psychodrama, psychotherapy, and family therapy are forms of group therapy that must be facilitated by qualified leaders who generally have advanced degrees in psychology, social work, nursing, or medicine. 20. A nursing instructor is teaching about psychodrama, a specialized type of therapeutic group. Which student statement indicates that further teaching is necessary? A. ―Psychodrama provides a safe setting in which to discuss painful issues.‖ B. ―In psychodrama, the client is the protagonist.‖ C. ―In psychodrama, the client observes actor interactions from the audience.‖ D. ―Psychodrama facilitates resolution of interpersonal conflicts.‖ ANS: C The nurse should educate the student that in psychodrama the client plays the role of himself or herself in a lifesituation scenario and is called the protagonist. During psychodrama, the client does not observe interactions from the audience. Other group members perform the role of the audience and discuss the situation they have observed, offer feedback, and express their feelings. Leaders of psychodrama must have specialized training to become a psychodramatist. Multiple Response 21. Which of the following observed client behaviors would lead a nurse to evaluate a member as assuming a maintenance group role? Select all that apply. A. A client decreases conflict within the group by encouraging compromise. B. A client offers recognition and acceptance of others. C. A client outlines the task at hand and proposes solutions. D. A client listens attentively to group interaction. E. A client uses the group to gain sympathy from others. ANS: A, B, D The nurse should identify clients who decrease conflict within the group, offer recognition and acceptance of others, and listen attentively to group interaction as assuming a maintenance group role. There are member roles within each group. Maintenance roles include the compromiser, the encourager, the follower, the gatekeeper, and the harmonizer.22. Which of the following behavioral skills should a nurse implement when leading a group that is functioning in the orientation phase of group development? Select all that apply. A. Encouraging members to provide feedback to each other about individual progress B. Ensuring that rules established by the group do not interfere with goal fulfillment C. Working with group members to establish rules that will govern the group D. Emphasizing the need for and importance of confidentiality within the group E. Helping the members to resolve conflicts and foster cohesiveness within the group ANS: B, C, D During the orientation phase of group development, the nurse leader should work together with members to establish rules that will effectively govern the group. The leader should ensure that group rules do not interfere with goal fulfillment and establish the need for and importance of confidentiality within the group. Members need to establish trust and cohesion to move into the working phase of group development. Chapter 12. Milieu Therapy—The Therapeutic Community Summary and Key Points ▀ In psychiatry, milieu therapy (or a therapeutic community) constitutes a manipulation of the environment in an effort to create behavioral changes and to improve the psychological health and functioning of the individual. ▀ The goal of therapeutic community is for the client to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life. ▀ The community environment itself serves as the primary tool of therapy. ▀ According to Skinner (1979), a therapeutic community is based on seven basic assumptions: ▀ The health in each individual is to be realized and encouraged to grow. ▀ Every interaction is an opportunity for therapeutic intervention. ▀ The client owns his or her own environment. ▀ Each client owns his or her behavior. ▀ Peer pressure is a useful and a powerful tool. ▀ Inappropriate behaviors are dealt with as they occur. ▀ Restrictions and punishment are to be avoided. ▀ Because the goals of milieu therapy relate to helping the client learn to generalize that which is learned to other aspects of his or her life, the conditions that promote a therapeutic community in the psychiatric setting are similar to the types of conditions that exist in real-life situations. ▀ Conditions that promote a therapeutic community include the following: ▀ The fulfillment of basic physiological needs. ▀ Physical facilities that are conducive to achievement of the goals of therapy. ▀ The existence of a democratic form of self-government. ▀ The assignment of responsibilities according to client capabilities. ▀ A structured program of social and work-related activities. ▀ The inclusion of community and family in the program of therapy in an effort to facilitate discharge from treatment.▀ The program of therapy on the milieu unit is conducted by the IDT team. ▀ The team includes some, or all, of the following disciplines and may include others that are not specified here: psychiatrist, clinical psychologist, psychiatric clinical nurse specialist, psychiatric nurse, mental health technician, psychiatric social worker, occupational therapist, recreational therapist, art therapist, music therapist, psychodramatist, dietitian, and chaplain. ▀ Nurses play a crucial role in the management of a therapeutic milieu. They are involved in the assessment, diagnosis, outcome identification, planning, implementation, and evaluation of all treatment programs. ▀ Nurses have significant input into the IDT plans, which are developed for all clients. They are responsible for ensuring that clients' basic needs are fulfilled; assessing physical and psychosocial status; administering medication; helping the client develop trusting relationships; setting limits on unacceptable behaviors; educating clients; and ultimately, helping clients, within the limits of their capability, to become productive members of society. Multiple Choice 1. An angry client on an inpatient unit approaches a nurse, stating, ―Someone took my lunch! People need to respect others, and you need to do something about this now!‖ The nurse‘s response should be guided by which basic assumption of milieu therapy? A. Conflict should be avoided at all costs on inpatient psychiatric units. B. Conflict should be resolved by the nursing staff. C. Every interaction is an opportunity for therapeutic intervention. D. Conflict resolution should be addressed only during group therapy. ANS: C The nurse‘s response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning. 2. A client on an inpatient unit angrily states to a nurse, ―Peter is not cleaning up after himself in the community bathroom. You need to address this problem.‖ Which is the appropriate nursing response? A. ―I‘ll talk to Peter and present your concerns.‖ B. ―Why are you overreacting to this issue?‖ C. ―You should bring this to the attention of your treatment team.‖ D. ―I can see that you are angry. Let‘s discuss ways to approach Peter with your concerns.‖ ANS: D The most appropriate nursing response involves restating the client‘s feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills. 3. A newly admitted client asks, ―Why do we need a unit schedule? I‘m not going to these groups. I‘m here to get some rest.‖ Which is the most appropriate nursing reply?A. ―Group therapy provides the opportunity to learn and practice new coping skills.‖ B. ―Group therapy is mandatory. All clients must attend.‖ C. ―Group therapy is optional. You can go if you find the topic helpful and interesting.‖ D. ―Group therapy is an economical way of providing therapy to many clients concurrently.‖ ANS: A The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. A basic assumption of milieu therapy is that every interaction, including group therapy, is an opportunity for therapeutic intervention. 4. A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment? A. Peer pressure B. Structured programming C. Visitor restrictions D. Mandated activities ANS: B The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. In the milieu, time is also devoted to personal problems and focus groups. 5. To promote self-reliance, how should a psychiatric nurse best conduct medication administration? A. Encourage clients to request their medications at the appropriate times. B. Refuse to administer medications unless clients request them at the appropriate times. C. Allow the clients to determine appropriate medication times. D. Take medications to the clients‘ bedside at the appropriate times. ANS: A The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem. 6. A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic? A. Dream analysisB. Creative cooking C. Paint by number D. Stress management ANS: D The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client‘s learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication compliance. 7. What is the best rationale for including the client‘s family in therapy within the inpatient milieu? A. To structure a program of social and work-related activities B. To facilitate discharge from the hospital C. To provide a concrete demonstration of caring D. To encourage the family to model positive behaviors ANS: B The nurse should include the client‘s family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment. 8. How does a democratic form of self-government in the milieu contribute to client therapy? A. By setting punishments for clients who violate the community rules B. By dealing with inappropriate behaviors as they occur C. By setting community expectations wherein all clients are treated on an equal basis D. By interacting with professional staff members to learn about therapeutic interventions ANS: C A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input. 9. A client has undergone psychological testing. With which member of the interdisciplinary team should a nurse collaborate to review these results? A. The psychiatrist B. The psychiatric social workerC. The clinical psychologist D. The clinical nurse specialist ANS: C The nurse should consult with the clinical psychologist to review psychological testing results for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process. 10. In the role of milieu manager, which activity should the nurse prioritize? A. Setting the schedule for the daily unit activities B. Evaluating clients for medication effectiveness C. Conducting therapeutic group sessions D. Searching newly admitted clients for hazardous objects ANS: D The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the client‘s safety and physiological needs are met within the milieu. Multiple Response 11. A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? Select all that apply. A. Respiratory therapist B. Occupational therapist C. Recreational therapist D. Social worker E. Mental health technician ANS: B, C, D, E The typical interdisciplinary treatment team in a psychiatric inpatient setting consists of a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, dietician, psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. Other disciplines may be included on the basis of resources available in a particular hospital setting and individual patient needs. 12. Which of the following are accurate descriptors of a therapeutic community? Select all that apply. A. The unit schedule includes unlimited free time for personal reflection. B. Unit responsibilities are assigned according to client capabilities. C. A flexible schedule is determined by client needs.D. The individual is the sole focus of therapy. E. A democratic form of government exists. ANS: B, E In a therapeutic community the unit responsibilities are assigned according to client capability, and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills. Chapter 18. Behavior Therapy Summary and Key Points ▀ The basic assumption of behavior therapy is that problematic behaviors occur when there has been inadequate learning and, therefore, can be corrected through the provision of appropriate learning experiences. ▀ The antecedents of today's principles of behavior therapy are largely the products of laboratory efforts by Pavlov and Skinner. ▀ Pavlov introduced a process that came to be known as classical conditioning. ▀ Pavlov demonstrated in his trials with laboratory animals that a neutral stimulus could acquire the ability to elicit a conditioned response through pairing with an unconditioned stimulus. He considered the conditioned response to be a new, learned response. ▀ Skinner, in his model of operant conditioning, gave additional attention to the consequences of the response as an approach to learning new behaviors. ▀ Skinner believed that the connection between a stimulus and a response is strengthened or weakened by the consequences of the response. ▀ Various techniques for modifying client behavior include the following: ▀ Shaping: a technique in which reinforcements are given for increasingly closer approximations to the desired response. ▀ Modeling: refers to the learning of new behaviors by imitating the behavior of others. ▀ Premack principle: this technique states that a frequently occurring response can serve as a positive reinforcement for a response that occurs less frequently. ▀ Extinction: the gradual decrease in frequency or disappearance of a response when the positive reinforcement is withheld. ▀ Contingency contracting: a contract is drawn up specifying a specific behavior change and the reinforcers to be given for performing the desired behaviors. ▀ Token economy: a type of contingency contracting in which the reinforcers for desired behaviors are presented in the form of tokens. ▀ Time-out: an aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is being exhibited.▀ Reciprocal inhibition: a technique that decreases or eliminates a behavior by introducing a more adaptive behavior, but one that is incompatible with the unacceptable behavior. ▀ Overt sensitization: a type of aversion therapy that produces unpleasant consequences for undesirable behavior. ▀ Covert sensitization: relies on an individual's imagination to produce unpleasant consequences for undesirable behaviors. ▀ Systematic desensitization: a technique for overcoming phobias in which there is a hierarchy of anxiety-producing events through which the individual progresses. ▀ Flooding (also called implosion therapy): desensitizes individuals to phobic stimuli by ―flooding‖ them with a continuous presentation (through mental imagery) of the phobic stimulus until it no longer elicits anxiety. ▀ Nurses can implement behavior therapy techniques to help clients modify maladaptive behavior patterns. ▀ The nursing process is a systematic method of directing care for clients who require this type of assistance. Multiple Choice 1. A kindergarten rule states that if unacceptable behavior occurs, a child‘s personalized fish will be moved to the sea grass. Children who behave keep their fish out of the sea grass. The school nurse should identify this intervention as based on which principle of behavior therapy? A. Classical conditioning B. Conditioned response C. Positive reinforcement D. Negative reinforcement ANS: D Negative reinforcement is increasing the probability that behavior (appropriate classroom behavior) will recur by removal of an undesirable reinforcing stimulus (personalized fish in sea grass). 2. An adolescent comes from a dysfunctional family where physical and verbal abuse prevails. At school this adolescent bullies and fights with classmates. According to principles of behavior therapy, what is the probable source of this behavior? A. Shaping B. Modeling C. Premack principle D. Reciprocal inhibition ANS: B Modeling is the learning of new behaviors by imitating the behaviors of others. This adolescent, witnessing physical and verbal abuse in the home, models this behavior in school.3. A third-grader feigns illness in order to avoid doing homework. The teacher recommends an educational program that uses a token economy. How should a school nurse explain a token economy to this child‘s parent? A. ―Your child will receive green tokens for completing homework that can be cashed in for desired rewards.‖ B. ―Your child will receive red tokens when homework is incomplete and this will result in school suspension.‖ C. ―Your child will receive a time out for each homework assignment not completed.‖ D. ―Your child, with your assistance, will envision receiving rewards for completed homework.‖ ANS: A In a token economy, tokens are a form of contingency contracting in that tokens immediately reinforce appropriate behavior (completed homework) and are exchanged later for a desired reward. 4. A client is diagnosed with an anxiety disorder. The nurse counselor recommends intervention with the behavioral technique of reciprocal inhibition. The client asks, ―What‘s that?‖ Which is the most appropriate nursing reply? A. ―At the beginning of this intervention, a contract will be drawn up explicitly stating the behavior change agreed upon.‖ B. ―By introducing an adaptive behavior that is mutually exclusive to your maladaptive behavior, we will expect subsequent behavior to improve.‖ C. ―Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety.‖ D. ―In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.‖ ANS: B Reciprocal inhibition decreases or eliminates an undesired behavior by introducing a more adaptive behavior that is incompatible with the undesired behavior. 5. A client reports, ―My friend panicked at the site of spiders. Her therapist used gradual exposure to spiders that initially made her increasingly more anxious.‖ Which technique was the friend‘s therapist most likely using? A. Extinction B. Covert sensitization C. Systematic desensitization D. Reciprocal inhibition ANS: C Systematic desensitization is a treatment for phobias in which a phobic individual is gradually exposed to increasing amounts of the phobic stimulus while practicing relaxation techniques. Eventually, the phobic stimulus causes little or no anxiety. 6. A 2-year-old engages in frequent temper tantrums that usually result in the parents giving in to demands. During family therapy, how should a nurse counsel the parents?A. ―You are shaping your child‘s behavior.‖ B. ―Your child has modeled your behavior.‖ C. ―You are positively reinforcing your child‘s behavior.‖ D. ―You are negatively reinforcing your child‘s behavior.‖ ANS: C 7. A child always chooses to ask mother over father when seeking special privileges. The father is more apt to disagree than agree with the child‘s requests, whereas the mother usually consents. The child‘s choice is the result of which component of operant conditioning? A. Conditioned stimuli B. Unconditioned stimuli C. Aversive stimuli D. Discriminative stimuli ANS: D This child is able to discriminate between stimuli. This child can predict with assurance that asking mother (not father) will result in a desired response. 8. Parents decide to try the nurse practitioner‘s suggestion of time out when their child misbehaves. What teaching should the nurse practitioner provide the parents? A. ―Correct your child‘s behavior by spanking for a specified time period.‖ B. ―Ignore the child‘s negative behavior.‖ C. ―Add positive reinforcement for acceptable behavior.‖ D. ―Temporarily move your child to an area where behavior is not being reinforced.‖ ANS: D A time out is an aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is occurring. Usually during a time out, the person is temporarily isolated so there is no reinforcing attention. This discourages a reoccurrence of the undesired behavior. 9. Parents of a 3-year-old have noticed an improvement in behavior because of using a ―time out‖ behavioral approach. What aspect of ―time out‖ therapy may be responsible for this child‘s improved behavior? A. ―Negative reinforcement discourages maladaptive behavior.‖ B. ―Positive reinforcement is removed.‖ C. ―Covert sensitization is being applied.‖ D. ―Reciprocal inhibition is eliminated.‖ANS: B In a ―time out,‖ the positive reinforcement of attention is removed from the child during inappropriate behavior. 10. A client is in therapy with a nurse practitioner for the treatment of arachnophobia. The nurse practitioner decides to use the technique of ―flooding.‖ Which intervention best exemplifies this technique? A. Giving rewards for demonstrating a decrease in fear of spiders B. Encouraging the client to sit through the movie ―Spiderman‖ C. Accompanying the client to a 1-hour visit to the local zoo‘s spider room D. Offering a computer program that progressively presents anxiety-producing spider scenarios ANS: C Visiting the spider room would flood the client with the phobic stimuli of real spiders. This would continue until the stimulus no longer creates anxiety. 11. During a smoking cessation group, the community health nurse explains that in their effort to quit smoking, a reciprocal inhibition approach will be used. The nurse should give the group which example of this technique? A. ―Before you can smoke, you must first take a half-hour walk.‖ B. ―When you have the urge to smoke, imagine being short of breath.‖ C. ―You‘ll receive $1 for each cigarette not smoked and forfeit $2 for each cigarette smoked.‖ D. ―When you have the urge to smoke, hold your breath and then rhythmically breathe.‖ ANS: D These breathing exercises cannot be done while the client smokes. Therefore, they decrease or eliminate the undesired behavior (smoking) that is incompatible with the desired behavior (smoking cessation). This is an example of the behavior therapy of reciprocal inhibition. 12. A mother states, ―You are old enough to clean your own bedroom.‖ Later inspection finds the floor clear, but with everything stacked in a chair. The mother praises the child for clearing the floor. This is consistent with which technique of behavior modification? A. Shaping B. Extinction C. Stimulus generalization D. Reciprocal inhibition ANS: A In shaping, behavior is molded in a desired direction by reinforcing each small step toward the desired behavior. The child is praised for clearing the floor, the first step toward cleaning the room.13. During hospitalization, an attention-seeking client has repeatedly cut herself. After threatening to cut herself again, the nurse states, ―Here are some Band-Aids so you won‘t bleed on the sheets.‖ Which is the underlying reason for this nurse‘s response? A. The nurse is using an aversive stimulus in response to the client‘s manipulative cutting behavior. B. The nurse is using negative reinforcement in response to the client‘s behavior. C. The nurse is minimizing reinforcement of the client‘s manipulative behavior with the goal of extinction. D. The nurse lacks empathy for the client‘s recurring self-injurious behavior. ANS: C Extinction is the gradual decrease in frequency or disappearance of a response when a positive reinforcement is withheld. The nurse is withholding attention to the client who is exhibiting manipulative, attention-seeking behavior. The lack of positive response (attention) should cause extinction of the undesired behavior. 14. A nursing instructor is teaching about the behavior technique of modeling. When asked to give an example of this behavioral intervention, which student statement meets the learning objective? A. ―A child is first rewarded for using a spoon to eat and then rewarded for using a fork, and finally rewarded for cutting food with a knife.‖ B. ―An adolescent imitates Dad by using and caring for tools appropriately.‖ C. ―A client and therapist agree to conditions of therapy, stating explicitly in writing the behavior change that is desired.‖ D. ―A mother tells her child that television can be watched only after homework is completed.‖ ANS: B Modeling refers to the learning of new behaviors by imitating the behavior of others. 15. A mother tells her teenager that in order for college tuition to be paid, the teenager must quit smoking. They develop a written agreement stipulating time frames and consequences. This is an example of which technique of behavior modification? A. Shaping B. Modeling C. Contracting D. Premack principle ANS: C Contracting occurs when the mother and teenager together develop a written agreement related to desired behavior (smoking cessation) and positive reinforcement (paid college tuition). 16. When asked to identify principles that define the term ―maladaptive behavior,‖ which nursing student statement indicates that further teaching is needed?A. ―Behavior is maladaptive when it is age inappropriate.‖ B. ―Behavior is maladaptive when it interferes with adaptive functioning.‖ C. ―Behavior is maladaptive when it is identified as inappropriate in the context of one‘s culture.‖ D. ―Behavior is maladaptive when it results in change within an otherwise stable subsystem.‖ ANS: D Behaviors that result in change within a subsystem, even when it is stable, could be either adaptive or maladaptive behaviors. This statement, therefore, is incorrect. 17. Which assumption is most reflective of a behavioral theory model? A. Mental illness is characterized by structural and biochemical alterations. B. Thought processes influence behaviors. C. All personality development has a social context. D. There is a basic relationship between stimulus and response. ANS: D That there is a basic relationship between stimulus and response is an assumption of a behavioral theory model. The connection between a stimulus and a response is strengthened or weakened by the consequences of the response. 18. A nurse should recognize which intervention as most appropriate within a behavioral therapy program? A. A child is given a Popsicle for staying dry and clean. B. A child is put in time-out after soiling his or her undergarments. C. A child is allowed to remain in soiled undergarments. D. A child is taught the advantages of staying dry and clean. ANS: A A stimulus that follows a behavior or response is called a reinforcing stimulus or reinforcer. The reward of a Popsicle is a reinforcer for the child staying dry and clean. This is an example of operant conditioning, a form of behavioral therapy. 19. An adolescent client was recently admitted to the psychiatric unit because of impulsivity and acting-out behavior at school. The nurse should initially implement which nursing action? A. Redirect the client to activities to decrease stress. B. Explain the unit rules and consequences of breaking the rules. C. Place the client on close observation to insure a trusting relationship. D. Administer an anti-anxiety medication.ANS: B It is important for the nurse to initially explain the unit rules and consequences of breaking the rules. It is imperative that consequences of rule infractions are explained early in treatment to avoid misunderstanding and manipulation. 20. According to behavioral theory, the treatment of phobic symptoms should involve which action? A. The manipulation of the environment B. The use of desensitization C. The use of family therapy D. The uncovering of past events ANS: B Systematic desensitization is a technique for assisting individuals to overcome their fear of a phobic stimulus. It is ―systematic‖ in that there is a hierarchy of anxiety-producing events through which the individual progresses during therapy. Chapter 19. Cognitive Therapy Summary and Key Points ▀ Cognitive therapy is founded on the premise that how people think significantly influences their feelings and behavior. ▀ The concept was initiated in the 1960s by Aaron Beck in his work with depressed clients. Since that time, it has been expanded for use with a number of emotional illnesses. ▀ Cognitive therapy is short-term, highly structured, and goal-oriented therapy that consists of three major components: didactic, or educational, aspects; cognitive techniques; and behavioral interventions. ▀ The therapist teaches the client about the relationship between his or her illness and the distorted thinking patterns. Explanation about cognitive therapy and how it works is provided. ▀ The therapist helps the client to recognize his or her negative automatic thoughts (sometimes called cognitive errors). ▀ Once these automatic thoughts have been identified, various cognitive and behavioral techniques are used to assist the client to modify the dysfunctional thinking patterns. ▀ Independent homework assignments are an important part of the cognitive therapist's strategy. ▀ Many of the cognitive therapy techniques are within the scope of nursing practice. ▀ As the role of the psychiatric nurse continues to expand, the knowledge and skills associated with a variety of therapies will need to be broadened. Cognitive therapy is likely to be one in which nurses will become more involved. Multiple Choice1. A nursing instructor is teaching about the didactic aspects of cognitive therapy. Which student statement indicates a deficit in meeting the learning objectives of this content? A. ―The therapist provides information about the process of cognitive therapy.‖ B. ―The therapist uses guided imagery in an effort to elicit automatic thoughts.‖ C. ―The therapist provides information about how cognitive therapy works.‖ D. ―The therapist uses reading assignments to reinforce learning.‖ ANS: B Cognitive therapy prepares the client to become his or her own cognitive therapist. The didactic portion of the therapy provides educational material to reinforce learning about the therapy and how it affects psychiatric disorders. 2. A psychiatric nurse is counseling a client who has thought patterns consisting of rapid responses to a situation without rational analysis. What assessment data will the nurse document on this client? A. ―Thought patterns are triggered by specific stressful stimuli.‖ B. ―Thought patterns contain the client‘s fundamental beliefs and assumptions.‖ C. ―Thought patterns are flexible and based on personal experience.‖ D. ―Thought patterns include a predominance of automatic thoughts.‖ ANS: D According to Beck, automatic thoughts consist of rapid responses to a situation without rational analysis. These thoughts are often negative and based on erroneous logic. 3. A successful business executive continually thinks that job accomplishments are not adequate. A nurse recognizes that the client‘s thinking is reflective of which cognitive error? A. Minimization B. Dichotomous thinking C. Arbitrary inference D. Personalization ANS: A Minimization is the cognitive error that undervalues positive events and experiences. The client cannot give credit for personal strengths. 4. A nursing student states, ―The instructor gave me a failing grade on my research paper. I know it‘s because the instructor doesn‘t like me.‖ Which cognitive error does a nurse recognize in this student‘s statement? A. Dichotomous thinking B. Catastrophic thinkingC. Magnification D. Overgeneralization ANS: C In magnification, negative events are exaggerated. It is irrational to assume that there is a relationship between failing a paper and being personally disliked by the instructor. 5. An advanced practice nurse recommends that a client participate in cognitive therapy. The client asks, ―What‘s cognitive therapy and how can it help me?‖ Which is the nurse‘s most appropriate reply? A. ―It is a system of techniques in which you use positive thinking to improve your mood.‖ B. ―It is a long-term interpersonal approach that emphasizes the role of early childhood experiences.‖ C. ―It is an interpersonal treatment approach that specifically targets magical thinking.‖ D. ―It is a type of psychotherapy that focuses treatment on the modification of distorted thinking and maladaptive behaviors.‖ ANS: D Cognitive therapy is meant to be a time-limited intervention in which the therapist works in collaboration with the client to modify thinking to eliminate cognitive errors that reinforce emotional disturbances. 6. A welder has been selected as employee of the year. The welder wants to ask for a promotion but is hampered by poor self-esteem. The employee health nurse provides assistance. Which technique should the nurse use to help the employee request the promotion? A. Socratic questioning B. Activity scheduling C. Distraction D. Cognitive rehearsal ANS: D Cognitive rehearsal allows the employee to uncover potential automatic thoughts in advance of his or her meeting to request a promotion. This allows the employee to develop strategies to modify any dysfunctional thinking. 7. An advanced practice nurse is counseling a client diagnosed with generalized anxiety disorder. The nurse plans to use activity scheduling to address this client‘s concerns. What is the purpose of this nursing intervention? A. To identify important areas needing concentration during therapy B. To increase self-esteem and decrease feelings of helplessness C. To modify maladaptive behaviors by the use of role-play D. To divert away from intrusive thoughts and depressive ruminationsANS: A In activity scheduling, the client is asked to keep a daily log of activities and rate them for mastery and pleasure in order to identify recurring daily patterns that may need to be addressed in therapy. 8. When a client‘s husband comes home late from work, the wife immediately fears infidelity. The advanced practice nurse therapist encourages the wife to consider other explanations for her husband‘s tardiness. What technique is the nurse using? A. Examination of the evidence B. Decatastrophizing C. Generating alternatives D. Reattribution ANS: C Using the technique of generating alternatives will assist the client to recognize a wider range of possible explanations for her husband‘s behavior. 9. A nursing student evaluates her group project partner as irresponsible because of minimal participation in planning. When told of this situation, the nursing instructor plans to use the cognitive technique of ―examining the evidence.‖ Which response exemplifies this technique? A. ―Let‘s look at the potential reasons why your partner has not participated.‖ B. ―How would you define irresponsibility?‖ C. ―Has it occurred to you that your partner may be working on the project at home?‖ D. ―Are you telling me that you feel totally responsible for this project?‖ ANS: A When using the technique of examining the evidence, the student and nurse review automatic thoughts and study the evidence to support or counter the belief. 10. A nursing assistant has failed a prerequisite course toward admission to nursing school and states, ―I will always be only a nursing assistant and never an RN.‖ Her nursing advisor understands this is an example of which automatic thought? A. Arbitrary inference B. Overgeneralization C. Dichotomous thinking D. Personalization ANS: BOvergeneralization occurs when sweeping conclusions are made on the basis of one incident. Because the student failed a prerequisite nursing course, the student overgeneralizes that the goal of being an RN will never be attained. 11. A high school basketball player sustains a serious knee injury and states to the school nurse, ―I will never get to college if I don‘t receive a basketball scholarship.‖ Which nursing reply would assist the student to see a broader range of possibilities? A. ―Let‘s look at the alternatives for funding your college education.‖ B. ―I know you are feeling helpless now, but you are looking at this from only one perspective.‖ C. ―Can your family afford knee surgery?‖ D. ―You now need to prioritize your academics and not focus on basketball.‖ ANS: A When the nurse helps the student to see a broader range of possibilities, the nurse is using the cognitive technique of generating alternatives. 12. A labor and delivery nurse listens to a new mother relate thoughts regarding her healthy, 8-pound baby girl. Which statement by the mother indicates to the nurse the use of the cognitive error, selective abstraction? A. ―My baby is refusing to nurse, and I know it‘s because she hates me.‖ B. ―My baby needs to be under the ‗bilirubin lights,‘ but I resent her time away from me.‖ C. ―My baby is wonderful, but I‘m depressed because I wanted twins.‖ D. ―My baby has an elevated bilirubin, and I know it will get worse and she will die.‖ ANS: C In selective abstraction the individual focuses attention on evidence that is viewed as a failure (not having twins) rather than any successes (a healthy baby) that have occurred. 13. A client admitted to a Veterans Administration (VA) hospital with a diagnosis of major depressive disorder tells the nurse, ―I failed my battalion by giving the wrong order. Fortunately, no one was injured.‖ Which nursing diagnosis should the nurse assign to this client? A. Chronic low self-esteem B. Risk for self-directed violence C. Powerlessness D. Situational low self-esteem ANS: D Emotional responses are largely dependent on cognitive appraisals of the significance of environmental cues. The nursing diagnosis of situational low self-esteem is used for individuals who have a negative perception of self-worth in response to a current situation. This client‘s cognitive appraisal of the situation has led to the diagnosis of major depressive disorder and low self-esteem.14. The director of nursing (DON) sets up a meeting with the newly appointed nurse manager, who, to this point, has done an excellent job. The nurse manager anticipates job termination. What is the best description of the cognitive error being employed by the nurse manager? A. Thinking from an ―all-or-nothing‖ perspective B. Always thinking the worst will occur without considering positive outcomes C. Viewing only selected negative evidence while editing out positive aspects D. Undervaluing the positive significance of an event ANS: B Catastrophic thinking involves always thinking that the worst will occur without considering the possibility of more likely positive outcomes. The nurse manager has quickly jumped to the conclusion that the meeting will result in job termination. 15. A nursing instructor is teaching about dichotomous thinking. Which student statement indicates that learning has occurred? A. ―Dichotomous thinking is when an individual views situations as being ‗good or bad‘ or ‗black or white.‘‖ B. ―Dichotomous thinking is when an individual takes complete responsibility for situations without considering other circumstances.‖ C. ―Dichotomous thinking is when an individual exaggerates the negative significance of an event.‖ D. ―Dichotomous thinking is when an individual undervalues the positive significance of an event.‖ ANS: A An individual who is using dichotomous thinking views situations in terms of ―all or nothing,‖ ―good or bad,‖ or ―black or white.‖ 16. A client states, ―I keep having horrible nightmares about the car accident that killed my daughter. I shouldn‘t have taken her with me to the store.‖ Using a cognitive approach, which nursing reply would be most therapeutic? A. ―Are other issues from your past affecting your ability to move on?‖ B. ―Describe your current feelings about your loss.‖ C. ―Let‘s talk about something that will help you move on.‖ D. ―Can anyone predict when a car accident will happen?‖ ANS: D When the nurse attempts to encourage the client to reframe thoughts, the nurse is using a cognitive approach. 17. Which client statement would exemplify the level of cognitive function that you would expect to see in mild anxiety? A. ―Right now I feel as sharp as a tack.‖B. ―I‘m having a tough time focusing.‖ C. ―Sometimes I feel like I‘m having an out-of-body experience.‖ D. ―All I seem to focus on is my anger.‖ ANS: A Cognitive ability will be enhanced with mild anxiety. Mild anxiety prepares the individual for heightened responses to environmental stimuli. 18. When using a cognitive approach, a nurse would include which point in teaching a client about panic disorder? A. ―You might want to stay in the house when you notice the symptoms beginning.‖ B. ―Medications such as lorazepam (Ativan) should be taken when symptoms start.‖ C. ―Remind yourself that symptoms of a panic attack are time limited and will end.‖ D. ―Keep a journal in order to note feelings surrounding the panic attacks.‖ ANS: C When a nurse reminds a client that symptoms of a panic attack are time limited and will end, the nurse is using the cognitive approach of presenting rational thinking. 19. Using a cognitive approach, a nurse would choose which intervention for assisting clients to manage their anger without the use of violence? A. Assist the client to identify thoughts that trigger anger and substitute reality-based thinking. B. Provide consequences, such as removal from group therapy, in response to angry outbursts. C. Administer antipsychotic medications and use limit-setting such as a room restriction. D. Administer anti-anxiety medication and encourage participation in a group on medication actions. ANS: A By assisting the client to identify thoughts that trigger anger and encourage the substitution of more reality-based thinking, the nurse can help the client to alter dysfunctional beliefs that predispose the client to distort experiences. 20. A client recovering from alcohol toxicity is using minimization. Which statement reflects this cognitive distortion? A. ―I can‘t give up alcohol right now because I just gave up smoking.‖ B. ―I just read that red wine has health benefits.‖ C. ―I may have a minor problem, but I can handle it.‖ D. ―I don‘t drink as much as my wife, and nobody thinks she has a problem.‖ ANS: CThe statement ―I may have a minor problem, but I can handle it‖ is an example of the use of the cognitive distortion of minimization. Minimization is the undervaluing of the positive significance of an event. 21. A client is experiencing auditory hallucinations. Using a cognitive strategy, the nurse would encourage the client to do which of these? A. ―Try singing Happy Birthday until the voices are gone.‖ B. ―Document what the voices are saying, to note cause and effect.‖ C. ―Try listening to music using headphones for distraction.‖ D. ―Remind yourself that the voices are symptoms of your disease.‖ ANS: D The focus of cognitive therapy is on the modification of distorted cognitions and maladaptive behaviors. 22. A client diagnosed with borderline personality disorder states, ―Get out of here. No one cares about me or my situation!‖ Which nursing reply is an example of a cognitive intervention? A. ―You have an anti-anxiety medication ordered. It may make you feel better.‖ B. ―It sounds like you are feeling really frustrated.‖ C. ―Can you explain further your thinking about your situation?‖ D. ―No one cares about you?‖ ANS: C When a nurse asks for an explanation about a client‘s thinking, the nurse is using a cognitive approach to assessment. The focus of cognitive interventions is on the modification of distorted cognitions and maladaptive behaviors. Multiple Response 23. A nursing instructor is lecturing about cognitive therapy. Which of the following are objectives when implementing this therapy? Select all that apply. A. To modify automatic thoughts to promote minimization of negative cognitions B. To apply a variety of methods to create change in an individual‘s thinking C. To apply cognitive principles in order to change an individual‘s basic schema D. To modify belief systems in an effort to bring about emotional change E. To modify belief systems in an effort to bring about behavioral change ANS: B, D, E In cognitive therapy, the therapist‘s objective is to use a variety of methods to create change in a client‘s thinking and belief system, in an effort to bring about lasting emotional and behavioral change.24. A nurse practitioner uses cognitive therapy with depressed clients. The nurse asks clients to keep a daily record of dysfunctional thoughts. Which of the following are appropriate nursing replies to a client questioning the purpose of this exercise? Select all that apply. A. ―The purpose of this exercise is to identify automatic thoughts.‖ B. ―The purpose of this exercise is to identify rational alternatives.‖ C. ―The purpose of this exercise is to modify cognitive errors.‖ D. ―The purpose of this exercise is to eliminate irrational beliefs.‖ E. ―The purpose of this exercise is to monitor thoughts related to self-esteem.‖ ANS: A, B, C In a daily record of dysfunctional thoughts, clients (1) identify automatic thoughts and (2) generate a more rational response. In this way, the tool serves to help them (3) modify or make changes in their thinking. A daily record of dysfunctional thoughts does not eliminate the occurrence of irrational beliefs or monitor thoughts solely related to selfesteem. 25. Which of the following client statements would indicate that teaching about benzodiazepines has been successful? Select all that apply. A. ―I can‘t drink alcohol when taking lorazepam (Ativan).‖ B. ―If I abruptly stop taking buspirone (BuSpar), I may have a seizure.‖ C. ―Valium can make me drowsy, so I shouldn‘t drive for awhile.‖ D. ―My new diet cannot include aged cheese or pickled herring.‖ E. ―When the fluoxetine (Prozac) begins working, I can stop the alprazolam (Xanax).‖ ANS: A, C When a nurse teaches about medications, he or she is using a cognitive approach. A core concept of cognitive theory relates to the mental process of thinking and reasoning. Chapter 20. Electroconvulsive Therapy Summary and Key Points ▀ Electroconvulsive therapy (ECT) is the induction of a grand mal seizure through the application of electrical current to the brain. ▀ ECT is a safe and effective treatment alternative for individuals with depression, mania, or schizoaffective disorder who do not respond to other forms of therapy. ▀ ECT is contraindicated for individuals with increased intracranial pressure. ▀ Individuals with cardiovascular problems are at high risk for complications from ECT.▀ Other factors that place clients at risk include severe osteoporosis, acute and chronic pulmonary disorders, and high-risk or complicated pregnancy. ▀ The exact mechanism of action of ECT is unknown, but it is thought that the electrical stimulation results in significant increases in the circulating levels of the neurotransmitters serotonin, norepinephrine, and dopamine. Modulation of white matter microstructure in pathways connecting frontal and limbic areas of the brain may also be involved. ▀ The most common side effects with ECT are temporary memory loss and confusion. ▀ Although it is rare, death must be considered a risk associated with ECT. When it does occur, the most common cause is cardiovascular complications. ▀ There may be a risk for some degree of permanent long-term memory loss, and some opponents suggest that a risk for brain damage also exists (although there is little or no substantiating evidence). ▀ The nurse assists with ECT using the steps of the nursing process before, during, and after treatment. ▀ Important nursing interventions include ensuring client safety, managing client anxiety, and providing adequate client education. ▀ Nursing input into the ongoing evaluation of client behavior is an important factor in determining the therapeutic effectiveness of ECT. Multiple Choice 1. A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurse‘s rationale for this procedure? A. To prevent increased intracranial pressure resulting from anoxia B. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation C. To prevent anoxia due to medication-induced paralysis of respiratory muscles D. To prevent blocked airway resulting from seizure activity ANS: C The nurse administers 100% oxygen during and after electroconvulsive therapy to prevent anoxia due to medicationinduced paralysis of respiratory muscles. Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain. 2. Immediately after electroconvulsive therapy, in which position should a nurse place the client? A. On his or her side to prevent aspiration B. In semi-Fowler‘s position to promote oxygenation C. In Trendelenburg‘s position to promote blood flow to vital organs D. In prone position to prevent airway blockage ANS: AThe nurse should place a client who has received electroconvulsive therapy on his or her side to prevent aspiration. After the treatment, most clients will awaken within 10 to 15 minutes and will be confused and disoriented. Some clients will sleep for 1 to 2 hours. All clients require close observation following treatment. 3. A nursing instructor is teaching about electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred? A. ―During ECT a state of euphoria is induced.‖ B. ―ECT induces a grand mal seizure.‖ C. ―During ECT a state of catatonia is induced.‖ D. ―ECT induces a petit mal seizure.‖ ANS: B Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain for the purpose of decreasing depression. 4. A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for electroconvulsive therapy (ECT). During the course of ECT, a nurse should recognize the continued need for which critical intervention? A. Suicide assessment must continue throughout the ECT course. B. Antidepressant medications are contraindicated throughout the ECT course. C. Discourage expressions of hopelessness throughout the ECT course. D. Encourage a high-caloric diet throughout the ECT course. ANS: A ECT is an intervention for major depression that often includes suicidal ideations as a symptom. Continued suicide assessment is needed because mood improvement due to ECT may cause the client to act on suicidal ideations. 5. After undergoing two of nine electroconvulsive therapy (ECT) procedures, a client states, ―I can‘t even remember eating breakfast, so I want to stop the ECT.‖ Which is the most appropriate nursing reply? A. ―After you begin the course of treatments, you must complete all of them.‖ B. ―You‘ll need to talk with your doctor about what you‘re thinking.‖ C. ―It is within your right to discontinue the treatments, but let‘s talk about your concerns.‖ D. ―Memory loss is a rare side effect of the treatment. I don‘t think it should be a concern.‖ ANS: C The client has the right to terminate treatment. This nursing reply acknowledges this right but focuses on the client‘s concerns so that the nurse can provide needed information.6. Immediately after an initial electroconvulsive therapy (ECT) procedure, a client states, ―I‘m not hungry and just want to stay in bed and sleep.‖ On the basis of this information, which is the most appropriate nursing intervention? A. Allow the client to remain in bed. B. Encourage the client to join the milieu to promote socialization. C. Obtain a physician‘s order for parenteral nutrition. D. Involve the client in physical activities to stimulate circulation. ANS: A Immediately after electroconvulsive therapy a nurse should monitor pulse, respirations, and blood pressure every 15 minutes for the first hour, during which time the client should remain in bed. 7. A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a client‘s electroconvulsive therapy (ECT) procedure. What is the rationale for administering this medication? A. Robinul decreases anxiety during the ECT procedure. B. Robinul induces an unconscious state to prevent pain during the ECT procedure. C. Robinul prevents severe muscle contractions during the ECT procedure. D. Robinul decreases secretions to prevent aspiration during the ECT procedure. ANS: D Glycopyrrolate (Robinul) is the standard preoperative medication given prior to ECT procedures to decrease secretions and prevent aspiration. 8. A nursing instructor is teaching about the medications given prior to and during electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred? A. ―Atropine (Atro-Pen) is administered to paralyze skeletal muscles during ECT.‖ B. ―Succinylcholine chloride (Anectine) decreases secretions to prevent aspiration.‖ C. ―Thiopental sodium (Pentothal) is a short-acting anesthesia to render the client unconscious.‖ D. ―Glycopyrrolate (Robinul) is given to prevent severe muscle contractions during seizure.‖ ANS: C In order to render a client unconscious during the ECT procedure, an anesthesiologist administers intravenously a short-acting anesthetic such as thiopental sodium (Pentothal). 9. A client scheduled for electroconvulsive therapy (ECT) at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. On the basis of this observation, which is the most appropriate nursing action? A. The nurse notifies the client‘s physician of the situation and cancels the ECT. B. The nurse removes the breakfast tray and assists the client to the ECT procedure room.C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m. D. The nurse increases the client‘s fluid intake to facilitate the digestive process. ANS: A A client who is scheduled for ECT procedures is given nothing by mouth (NPO) for a minimum of 6 to 8 hours before treatment. 10. A client who is learning about electroconvulsive therapy (ECT) asks a nurse, ―Isn‘t this treatment dangerous?‖ Which is the most appropriate nursing reply? A. ―No, this treatment is side-effect free.‖ B. ―There can be temporary paralysis, but full functioning returns within 3 hours of treatment.‖ C. ―There are some risks, but a thorough examination will determine your candidacy for ECT.‖ D. ―Transient ischemic attacks (TIAs) can occur but are rare.‖ ANS: C Clients are given medical clearance for ECT. This decreases the risk of injury from the treatment. 11. A client experienced bradycardia during electroconvulsive therapy (ECT). A nurse assigns a nursing diagnosis of decreased cardiac output R/T vagal stimulation occurring during ECT. Which outcome would the nurse expect the client to achieve? A. The client will verbalize an understanding of the need for moving slowly after treatment. B. The client will maintain an oxygen saturation level of 88% 1 hour after treatment. C. The client will continue adequate tissue perfusion 1 hour after treatment. D. The client will verbalize an understanding of common side effects of ECT. ANS: C Vagal stimulation induced by ECT may cause a client to experience bradycardia. Adequate tissue perfusion would be a realistic expectation when normal cardiac output is restored. 12. A nursing student is observing an electroconvulsive therapy (ECT) procedure. The student notices a blood pressure cuff on the client‘s lower leg. The student questions the instructor about the cuff placement. Which is the most accurate instructor reply? A. ―The cuff has to be placed on the leg because both arms are used for intravenous fluids.‖ B. ―The cuff functions to prevent succinylcholine from reaching the foot.‖ C. ―The cuff position gives a more accurate blood pressure reading during the treatment.‖ D. ―The cuff is placed on the leg so that arms can easily be restrained during seizure.‖ ANS: BA blood pressure cuff is placed on the lower leg and inflated above systolic pressure before injection of succinylcholine. This is to ensure that seizure activity can be observed and timed in this one limb that is unaffected by the paralytic agent. 13. A client states, ―My doctor has told me I am a candidate for electroconvulsive therapy (ECT). Where will the treatment take place, and how much time would this entail?‖ Which is the most accurate nursing reply? A. ―Clients typically receive ECT in their hospital room, daily for 1 month.‖ B. ―Clients typically undergo 6 to 12 ECT procedures, three times a week in an outpatient setting.‖ C. ―Clients typically receive an unlimited number of treatments, in the hospital procedure room.‖ D. ―Clients typically receive two to three treatments, in either an outpatient or inpatient setting.‖ ANS: B Most clients require an average of 6 to 12 ECT procedures, but some may require up to 20 procedures. Treatments are usually administered every other day, three times per week. Treatments are performed on either an inpatient or outpatient basis, depending on the need for client monitoring. 14. A client is scheduled for an initial electroconvulsive therapy (ECT) procedure. Which information should a nurse include when teaching about the potential side effects of this procedure? A. ―You may experience transient tangential thinking.‖ B. ―You may experience some memory deficit surrounding the ECT.‖ C. ―You may experience avolution for the remainder of the day.‖ D. ―You may experience a higher risk for subsequent seizures.‖ ANS: B The most common side effect of ECT is temporary amnesia following the ECT procedure. 15. When scheduling electroconvulsive therapy (ECT), which client should the nurse prioritize? A. A client in bed in a fetal position who is experiencing active suicidal ideations B. A client with an irritable mood and exhibiting angry outbursts C. A client experiencing command hallucinations and delusions of reference D. A client experiencing manic episodes of bipolar disorder ANS: A A client who is experiencing suicidal ideations is in need of an immediate intervention to prevent self-harm and must be prioritized when the nurse schedules ECT. 16. A client with cognitive deficits is extremely suicidal. The client has not responded to antidepressants and the treatment team is considering electroconvulsive therapy (ECT). What client information would impact the feasibility of this treatment option?A. Because the client is extremely suicidal, ECT is an appropriate option. B. Because antidepressant medications have been ineffective, ECT is a good alternative. C. Because informed consent is required for ECT, cognitive deficits could preclude this option. D. Because of the client‘s cognitive deficits, a signed consent is waived. ANS: C A client who is experiencing cognitive deficits cannot give informed consent, which is required prior to ECT. A court proceeding could determine the client‘s level of competency and, if necessary, the judge would appoint a guardian. Multiple Response 17. A nurse should recognize that electroconvulsive therapy (ECT) would potentially improve the symptoms of clients with which of the following diagnoses? Select all that apply. A. Major depressive disorder B. Bipolar I disorder: manic episode C. Schizoaffective disorder D. Obsessive-compulsive disorder E. Body dysmorphic disorder ANS: A, B, C ECT has been shown to be effective in the treatment of severe depression, acute mania, and acute schizophrenia, particularly if it is accompanied by catatonic or affective (depression or mania) symptomatology. ECT has also been tried with other disorders, such as obsessive-compulsive disorder (OCD) and anxiety disorders, but little evidence exists to support its efficacy in the treatment of these conditions. 18. Which assessment results should a nurse evaluate and report in the process of clearing a client for electroconvulsive therapy (ECT)? Select all that apply. A. Electrocardiographic records B. Pulmonary function study results C. Electroencephalogram analysis D. Complete blood count values E. Urinalysis results ANS: A, B, D, E A nurse should evaluate electrocardiographic records, pulmonary function study results, complete blood count, and urinalysis results and report any abnormalities to the client‘s physician. The client must be medically cleared prior to ECT.19. During a course of 12 electroconvulsive therapy (ECT) procedures, an anxious client diagnosed with major depression refuses to bathe or attend group therapy. He reports some memory problems and says he has trouble figuring out what time of day it is. At this time, which of the following nursing diagnoses should be assigned to this client? Select all that apply. A. Anxiety R/T post-ECT confusion and memory loss B. Risk for injury R/T post-ECT confusion and memory loss C. Risk for activity intolerance R/T post-ECT confusion and memory loss D. Altered sensory perception R/T post-ECT confusion and memory loss E. Social isolation R/T post-ECT confusion and memory loss ANS: A, B, C, E Because of the post-ECT thought alterations of confusion and memory loss, the client is anxious, is accident prone, and has socially isolated self. Altered sensory perception is related to psychotic thoughts of a sensory nature such as hallucinations, and because this client is diagnosed with major depression, not schizophrenia, altered sensory perception would not be anticipated. 20. Which of the following conditions would place a client at risk for injury during electroconvulsive therapy (ECT)? Select all that apply. A. Severe osteoporosis B. Acute and chronic pulmonary disorders C. Hypothyroidism D. Recent cardiovascular accident E. Prostatic hypertrophy ANS: A, B, D Severe osteoporosis, acute and chronic pulmonary disorders, and a recent history of cardiovascular accident (CVA) can render clients at high risk for injury during electroconvulsive therapy. Chapter 29. Somatic Symptom and Dissociative Disorders Summary and Key Points ▀ Somatic symptom disorders and dissociative disorders are associated with anxiety that occurs at the severe level. The anxiety is repressed and manifested in the form of symptoms and behaviors associated with these disorders. ▀ Somatic symptom disorders, known historically as hysteria, affect about 5 to 7 percent of the general population. Types of somatic symptom disorders include somatic symptom disorder, illness anxiety disorder, conversion disorder, psychological factors affecting other medical conditions, factitious disorder, and other specified or unspecified somatic symptom disorders. ▀ Somatic symptom disorder is manifested by physical symptoms that may be vague, dramatized, or exaggerated in their presentation. No evidence of organic pathology can be identified.▀ Illness anxiety disorder is an unrealistic preoccupation with fear of having a serious illness. This disorder may follow a personal experience, or the experience of a close family member, with serious or life-threatening illness. ▀ The individual with conversion disorder experiences a loss of or alteration in bodily functioning, unsubstantiated by medical or pathophysiological explanation. Psychological factors may be evident by the primary or secondary gains the individual achieves from experiencing the physiological manifestation. ▀ With the diagnosis of psychological factors affecting other medical conditions, psychological or behavioral factors have been implicated in the development, exacerbation, or delayed recovery from a medical condition. ▀ In factitious disorder, the individual falsifies physical or psychological signs or symptoms, or induces injury, on the self or another person in order to receive attention from medical personnel. ▀ A dissociative response has been described as a defense mechanism to protect the ego in the face of overwhelming anxiety. ▀ Dissociative responses result in an alteration in the normally integrative functions of identity, memory, or consciousness. ▀ Classification of dissociative disorders includes dissociative amnesia, dissociative identity disorder (DID), depersonalization-derealization disorder, and other specified or unspecified dissociative disorders. ▀ The individual with dissociative amnesia is unable to recall important personal information that is too extensive to be explained by ordinary forgetfulness. ▀ The prominent feature of DID is the existence of two or more personalities within a single individual. An individual may have many personalities, each of which serves a purpose for that individual of enduring painful stimuli that the original personality is too weak to face. ▀ Depersonalization-derealization disorder is characterized by an alteration in the perception of oneself and/or the environment. Depersonalization is described as a feeling of unreality or detachment from one's body. Derealization is an experience of unreality or detachment with respect to one's surroundings. ▀ Individuals with somatic symptom and dissociative disorders often receive health care initially in areas other than psychiatry. ▀ Nurses can assist clients with these disorders by helping them to understand their problem and identify and establish new, more adaptive behavior patterns. Multiple Choice 1. A client diagnosed with somatic symptom disorder is most likely to exhibit which personality disorder characteristics? A. Uses ―splitting‖ and manipulation in relationships B. Is socially irresponsible, exploitative, and guiltless and disregards rights of others C. Expresses heightened emotionality, seductiveness, and strong dependency needs D. Uncomfortable in social situations; perceived as timid, withdrawn, cold, and strange ANS: CIt has been suggested that in somatic symptom disorder, there may be some overlapping of personality characteristics and features associated with histrionic personality disorder. These features include heightened emotionality, impressionistic thought and speech, seductiveness, strong dependency needs, and a preoccupation with symptoms and oneself. Somatic symptom disorder is characterized by the expression of multiple somatic complaints associated with psychosocial distress and without medical basis. 2. A nurse is working with a client diagnosed with somatic symptom disorder. What predominant symptoms should a nurse expect to assess? A. Disproportionate and persistent thoughts about the seriousness of one‘s symptoms B. Amnestic episodes in which the client is pain free C. Excessive time spent discussing psychosocial stressors D. Lack of physical symptoms ANS: A The primary focus in somatic symptom disorder is on physical symptoms that suggest medical disease but which have no basis in organic pathology. Although the symptoms are associated with psychosocial distress, the individual focuses on the seriousness of the physical symptoms rather than the underlying psychosocial issues. 3. Which would be considered an appropriate outcome when planning care for an inpatient client diagnosed with somatic symptom disorder? A. The client will admit to fabricating physical symptoms to gain benefits by day 3. B. The client will list three potential adaptive coping strategies to deal with stress by day 2. C. The client will comply with medical treatments for physical symptoms by day 3. D. The client will openly discuss physical symptoms with staff by day 4. ANS: B The nurse should determine that an appropriate outcome for a client diagnosed with somatic symptom disorder would be for the client to list three potential adaptive coping strategies to deal with stress by day 2. Because the symptoms of somatic symptom disorder are associated with psychosocial distress, increasing coping skills may help the client reduce symptoms. 4. Carly has been diagnosed with somatic symptom disorder. As the nurse is talking with Carly and her family, which of the following statements suggest primary or secondary gains that the physical symptoms are providing for the client? A. The family agrees that Carly began having physical symptoms after she lost her job. B. Carly states that even though medical tests have not found anything wrong, she is convinced her headaches are indicative of a brain tumor. C. Carly‘s mother reports that someone from the family stays with Carly each night because the physical symptoms are incapacitating. D. Carly states she noticed feeling hotter than usual the last time she had a headache.ANS: C It is important for the nurse to identify gains that the symptoms might be providing for the client, since these can reinforce illness behavior. Having family attend to the patient when she is symptomatic could reinforce increased dependency and attention needs. 5. A nursing instructor is teaching about the etiology of dissociative disorders from a psychoanalytical perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred? A. ―Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness.‖ B. ―When their physical symptoms relieve them from stressful situations, their amnesia is reinforced. C. ―People with dissociative disorders typically have strong egos.‖ D. ―There is clear and convincing evidence of a familial predisposition to this disorder.‖ ANS: A The nurse should understand that from a psychoanalytical perspective, dissociation occurs because of repression of painful information or experiences. 6. An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority? A. Encourage exploration of sexual abuse B. Encourage guided imagery C. Establish trust and rapport D. Administer antianxiety medications ANS: C The nurse should prioritize establishing trust and rapport when beginning to work with a client diagnosed with dissociative identity disorder. DID was formerly called multiple personality disorder. Each personality views itself as a separate entity and must be treated as such to establish rapport. Trust is the basis of every therapeutic relationship. 7. A client diagnosed with dissociative identity disorder (DID) switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function? A. It is a means to attain secondary gain. B. It is a means to explore feelings of excessive and inappropriate guilt. C. It serves to isolate painful events so that the primary self is protected. D. It serves to establish personality boundaries and limit inappropriate impulses. ANS: CThe nurse should anticipate that a client who switches personalities when confronted with destructive behavior is dissociating in order to isolate painful events so that the primary self is protected. The transition between personalities is usually sudden, dramatic, and precipitated by stress. 8. A client is diagnosed with dissociative identity disorder (DID). What is the primary goal of therapy for this client? A. To recover memories and improve thinking patterns B. To prevent social isolation C. To decrease anxiety and need for secondary gain D. To collaborate among subpersonalities to improve functioning ANS: D The nurse should anticipate that the primary therapeutic goal for a client diagnosed with DID is to collaborate among subpersonalities to improve functioning. Some clients choose to pursue a lengthy therapeutic regimen to achieve integration, a blending of all the personalities into one. The goal is to optimize the client‘s ability to function appropriately and achieve optimal personal potential. 9. Which of the following statements accurately describes dissociative fugue? A. Dissociative fugue is not precipitated by stressful events. B. Dissociative fugue is characterized by sudden, unexpected travel or bewildered wandering with inability to recall some or all of one‘s past. C. Dissociative amnesia and dissociative fugue are completely different types of disorders. D. Dissociative fugue is characterized by a sense of observing oneself from outside the body. ANS: B Dissociative fugue is characterized by unexpected travel or bewildered wandering, and amnesia for all or part of one‘s past. Dissociative fugue is a subtype of dissociative amnesia. 10. Which should the nurse recognize as an example of localized amnesia? A. A client cannot relate any lifetime memories, including personal identity. B. A client can relate family memories but has no recollection of a particular brother. C. A client cannot remember events surrounding a fatal car accident. D. A client whose home was destroyed by a tornado only remembers waking up in the hospital. ANS: C An individual with localized amnesia is unable to recall all incidents associated with a stressful event. 11. Neurological tests have ruled out pathology in a client‘s sudden lower-extremity paralysis. Which nursing care should be included for this client?A. Deal with physical symptoms in a detached manner. B. Challenge the validity of physical symptoms. C. Meet dependency needs until the physical limitations subside. D. Encourage a discussion of feelings about the lower-extremity problem. ANS: A The nurse should assist the client in dealing with physical symptoms in a detached manner to avoid reinforcing the symptoms by providing secondary gains. This is an example of a conversion disorder in which symptoms affect voluntary motor or sensory functioning. Examples include paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, and hallucinations. 12. The family of a client diagnosed with conversion disorder asks the nurse, ―Will his paralysis ever go away?‖ Which of these responses by the nurse is evidence-based? A. ―Most symptoms of conversion disorder resolve within a few weeks.‖ B. ―Typically people who have conversion disorder symptoms that include paralysis will be paralyzed for the rest of their lives.‖ C. ―The only people who recover are those that develop conversion disorder symptoms without a precipitating stressful event.‖ D. ―Technically, he could walk now since he is intentionally feigning paralysis.‖ ANS: A The evidence supports that most conversion disorder symptoms resolve within a few weeks, and about 20% will have a relapse within 1 year. Multiple Response 13. A client is diagnosed with illness anxiety disorder. Which of the following symptoms is the client most likely to exhibit? Select all that apply. A. Obsessive-compulsive traits B. Pseudocyesis C. Disabling fear of having a serious illness D. Multiple pronounced physical symptoms E. Depression ANS: A, C, E Illness anxiety disorder involves a preoccupation with and fear of having or acquiring a serious disease. Somatic symptoms are either absent or mild in intensity.14. A client is exhibiting symptoms of generalized amnesia. Which of the following questions should the nurse ask to confirm this diagnosis? Select all that apply. A. ―Can you tell me your name and where you live?‖ B. ―Have you ever traveled suddenly or unexpectedly away from home?‖ C. ―Have you recently experienced any traumatic event?‖ D. ―Have you ever felt detached from your environment?‖ E. ―Have you had any history of memory problems?‖ ANS: A, C, E An individual who has generalized amnesia has amnesia for his or her identity and total life history. The first question assesses orientation to identity. Items C and D assess for awareness of current issues and historical issues, respectively. Affirmative descriptions of either of these issues would rule out generalized amnesia. 15. Which of the following somatic symptom and dissociative disorders are identified with known effective pharmacological treatments for that disorder? Select all that apply. A. Antidepressants have been used effectively in treating pain associated with somatic symptom disorder. B. Lithium has been effective in treating illness anxiety disorder. C. Muscle relaxants have been effective in resolving conversion disorder symptoms. D. The antidepressant clomipramine (Anafranil) has shown promise in treating depersonalization-derealization disorder. ANS: A, D The nurse should recognize that psychological therapies are central treatment modalities for these disorders, although evidence exists that for specific issues (as those identified in items A and C), psychopharmacological agents have demonstrated effectiveness. Chapter 37. The Bereaved Individual Summary and Key Points ▀ Loss is the experience of separation from something of personal importance. ▀ Loss is anything that is perceived as such by the individual. ▀ Loss of any concept of value to an individual can trigger the grief response. ▀ Elisabeth Kübler-Ross identified five stages that individuals pass through on their way to resolution of a loss. These include denial, anger, bargaining, depression, and acceptance. ▀ John Bowlby described similar stages that he identified in the following manner: stage I, numbness or protest; stage II, disequilibrium; stage III, disorganization and despair; and stage IV, reorganization.▀ George Engel's stages include shock and disbelief, developing awareness, restitution, resolution of the loss, and recovery. ▀ J. William Worden, a more contemporary clinician, has proposed that bereaved individuals must accomplish a set of tasks in order to complete the grief process. These four tasks include accepting the reality of the loss, processing the pain of grief, adjusting to a world without the lost entity, and finding an enduring connection with the lost entity in the midst of embarking on a new life. ▀ The length of the grief process is highly individual, and it can last for a number of years without being maladaptive. ▀ The acute stage of the grief process typically lasts a couple of months, but resolution usually takes much longer. ▀ Kübler-Ross suggested that a calendar year of experiencing significant events and anniversaries without the lost entity may be required. ▀ Anticipatory grieving is the experiencing of the feelings and emotions associated with the normal grief process in response to anticipation of the loss. ▀ Anticipatory grieving is thought to facilitate the grief process when the actual loss occurs. ▀ Three types of pathological grief reactions have been described. These include the following: ▀ Delayed or inhibited grief in which there is absence of evidence of grief when it ordinarily would be expected. ▀ Distorted or exaggerated grief response in which the individual remains fixed in the anger stage of the grief process and all of the symptoms associated with normal grieving are exaggerated. ▀ Chronic or prolonged grieving in which the individual is unable to let go of grieving behaviors after an extended period of time and in which behaviors are evident that indicate the bereaved individual is not accepting that the loss has occurred. ▀ Several authors have identified one crucial difference between normal and maladaptive grieving: the loss of selfesteem. ▀ Feelings of worthlessness are indicative of depression rather than uncomplicated bereavement. ▀ Very young children do not understand death, but often react to the emotions of adults by becoming more irritable and crying more. They often believe death is reversible. ▀ School-age children understand the finality of death. Grief behaviors may reflect regression or aggression, school phobias, or sometimes a withdrawal into the self. ▀ Adolescents are usually able to view death on an adult level. Grieving behaviors may include withdrawal or acting out. Although they understand that their own death is inevitable, the concept is so far-reaching as to be imperceptible. ▀ By the time a person reaches the 60s or 70s, he or she has experienced numerous losses. Because grief is cumulative, this can result in bereavement overload. Depression is a common response. ▀ Nurses must be aware of the death rituals and grief behaviors common to various cultures. Some of these rituals associated with African Americans, Asian Americans, Filipino Americans, Jewish Americans, Mexican Americans, and Native Americans were presented in this chapter. ▀ Hospice is a program that provides palliative and supportive care to meet the special needs of people who are dying and their families.▀ The term advance directive refers to either a living will or a durable power of attorney for health care. Advance directives allow clients to be in control of decisions at the end of life and spare family and loved ones the burden of making choices without knowing what is most important to the person who is dying. Multiple Choice 1. A client is diagnosed with terminal cancer. Which situation would the nurse assess as reflecting Kübler-Ross‘s grief stage of ―anger‖? A. The client registers for an iron-man marathon to be held in 9 months. B. The client is a devoted Catholic but refuses to attend church and states that his faith has failed him. C. The client promises God to give up smoking if allowed to live long enough to witness a grandchild‘s birth. D. The client gathers family in order to plan a funeral and make last wishes known. ANS: B The nurse should assess that the client is in the ―anger‖ stage of grieving when the client refuses to attend church and states that his faith has failed him. Anger is the second stage of Kübler-Ross‘s grief process, in which the reality of the situation is realized and the individual has feelings of sadness, guilt, shame, helplessness, and hopelessness. 2. A nurse is caring for an Irish client who has recently lost a spouse. The client states to the nurse, ―I‘m planning an elaborate wake and funeral.‖ According to George Engel, what purpose would these rituals serve? A. To delay the recovery process initiated by the loss of the client‘s spouse B. To facilitate the acceptance of the loss of the client‘s spouse C. To avoid dealing with grief associated with the loss of the client‘s spouse D. To eliminate emotional pain related to the loss of the client‘s spouse ANS: B The nurse should anticipate that the purpose of these rituals is to facilitate the acceptance of the loss of the client‘s spouse. Resolution of the loss is the fourth stage in Engel‘s grief process, in which the bereaved experiences a preoccupation with the loss, which gradually decreases over time. 3. A woman returns home after delivering a stillborn infant to find that neighbors have dismantled the nursery that she and her husband planned. According to Worden, how should a nurse expect the neighbor‘s action to affect the woman‘s grieving task completion? A. This action may hamper the woman from accepting the reality of the loss. B. This action would help the woman forget the sorrow and move on with life. C. This action communicates full support from her neighbors. D. This action would motivate the woman to look to the future and not the past. ANS: AThe nurse should anticipate that this action could hinder the woman from accepting the reality of the loss. The first task in Worden‘s grief process is to accept the reality of the loss. It is common for individuals to refuse to believe that the loss has occurred. Behaviors may include misidentifying an individual in the environment as their loved one, retaining possessions of the lost loved one, and removing all reminders of the loved one so as not to have to face reality. The bereaved person is considered an active participant in the grief process and the above-mentioned behaviors are part of that process. 4. A teenager has recently lost a parent. Which grieving behavior should a school nurse expect when assessing this client? A. Denial of personal mortality B. Preoccupation with the loss C. Clinging behaviors and personal insecurity D. Acting-out behaviors, exhibited in aggression and defiance ANS: D The school nurse should anticipate that this teenager would exhibit aggression and acting-out behaviors. Adolescents have the ability to understand death on an adult level yet have difficulty tolerating the intense feelings associated with the death of a loved one. It is often easier for adolescents to express sorrow by acting out rather than typical emotional expressions of the grieving process. 5. What term should a nurse use when describing a response to grieving that includes a sudden physical collapse and paralysis, and which cultural group would be associated with this behavior? A. ―Falling out‖ in the African American culture B. ―Body rocking‖ in the Vietnamese American culture C. ―Conversion disorder‖ in the Jewish American culture D. ―Spirit possession‖ in the Native American culture ANS: A The nurse should use the term ―falling out‖ to describe a sudden physical collapse and paralysis. This behavior is associated with the African American culture. The individuals may also experience an inability to see or speak yet maintain hearing and understanding. 6. Which grieving behaviors should a nurse anticipate when caring for a Southwest Navajo Indian client? A. Celebrating the life of a deceased person with festivities and revelry B. Not expressing grief openly and reluctance to touch a dead body C. Holding a prayerful vigil for a week following the person‘s death D. Expressing grief openly and publicly and erecting an altar in the home to honor the dead ANS: BThe nurse should identify that a Navajo client would not express grief openly and would be reluctant to touch a dead body. Navajo Indians do not bury the body of a deceased person for 4 days after death, and they conduct a cleaning ceremony prior to burial. The dead are buried with their shoes on the wrong feet and rings on their index fingers. 7. A nursing instructor is teaching about the typical grieving behaviors of Chinese Americans. Which student statement would indicate that more instruction is needed? A. ―In this culture, the color red is associated with death and is considered bad luck.‖ B. ―In this culture, there is an innate fear of death.‖ C. ―In this culture, emotions are not expressed openly.‖ D. ―In this culture, death and bereavement are centered on ancestor worship.‖ ANS: A The nursing instructor should evaluate that more instruction is needed if a student states that the color red is associated with death and bad luck. Chinese Americans consider the color white as associated with death and both the colors black and white are considered bad luck. Red is the ultimate color of luck in this culture. Chinese Americans also avoid purchasing insurance because of the fear that they may be inviting death. 8. The nurse assesses a client as experiencing maladaptive grieving. Which of the following factors confirms the nurse‘s assessment? A. The client‘s spouse died 12 months ago. B. The client still cries when recalling memories of the deceased. C. The client reports feelings of worthlessness. D. The client reports intermittent anxiety. ANS: C Several authors identify loss of self-esteem as the differentiating factor between normal and maladaptive grieving. The length of time needed to grieve is variable, so it is difficult to establish a time frame as indicative of maladaptive grief. 9. A nurse assesses a woman whose husband died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless and aimless. According to Bowlby, this widow is in which stage of the grieving process? A. Stage I: Numbness or protest B. Stage II: Disequilibrium C. Stage III: Disorganization and despair D. Stage IV: Reorganization ANS: C The nurse should identify that this client is in the third stage of Bowlby‘s grief process, called disorganization and despair. This stage is characterized by feelings of despair in response to the realization that the loss has occurred.The individual experiences helplessness, fear, and hopelessness. Perceptions of visualizing or being in the presence of the lost individual may occur. 10. Which is the most accurate description of the nursing diagnosis of spiritual distress? A. The client reports no church affiliations. B. The client struggles to identify meaning and purpose in life. C. The client reports seeing the spirit of his deceased wife. D. The client reports that meditation helps him feel connected spiritually. ANS: B One common nursing diagnosis in relation to complicated grief (and some authors would argue that all grief is complicated) is the risk for spiritual distress, which addresses the person‘s sense of meaning, purpose, and outlook for the future. Multiple Response 11. A nurse is leading a bereavement group. Which of the following group members should the nurse identify as being at high risk for having difficulty grieving? Select all that apply. A. A widower who has recently experienced the death of two good friends B. A man whose wife died suddenly after a cerebrovascular accident C. A widow who, after a year, allowed removal of life support from her terminally ill husband D. A woman who had a competitive relationship with her recently deceased brother E. A young couple whose child recently died of a genetic disorder ANS: A, B, D, E Several factors have been identified that may make the grief response more difficult: grieving when the bereaved person was strongly dependent on the lost entity, the relationship with the lost entity was highly ambivalent, the individual experienced a number of recent losses, the loss is that of a young person, the individual‘s physical or psychological health is unstable, and the bereaved person perceived responsibility for the loss. A widow who has experienced the process of loss for an extended period of time is more likely in the stage of acceptance and resolution of grief. 12. An instructor is teaching nursing students about Worden‘s grief process. According to Worden, which of the following client behaviors would delay or prolong the grieving process? Select all that apply. A. Refusing to allow self to think painful thoughts B. Indulging in the pain of loss C. Using alcohol and drugs D. Idealizing the object of lossE. Recognizing that time will heal ANS: A, C, D The nurse should identify that refusing to allow self to think painful thoughts, using alcohol and drugs, and idealizing the object of loss will delay or prolong the grieving process. Task II of Worden‘s grief process is working through the pain or grief. Pain must be acknowledged and resolved in order to move on. 13. Which of the following types of care should the interdisciplinary team of hospice provide? Select all that apply. A. Physical care available on a 24/7 basis B. Counseling on the addictive properties of pain-management medications C. Discussions related to death and dying D. Explorations of new, aggressive treatments E. Assistance with obtaining spiritual support and guidance ANS: A, C, E The nurse should identify that the interdisciplinary team of hospice provides physical care available on a 24/7 basis, discussions related to death and dying, and assistance with obtaining spiritual support and guidance. Hospice is a program that provides palliative and supportive care to meet the needs of people who are dying. Support is also provided to client families. [Show More]

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