Ch 33: Somatic Symptom and Related Disorders
a) In somatic symptom disorder, clients are not consciously aware that needs are being met through physical complaints Pg. 633 Clients with somatic symptom disorder do not intentionally cause, and have no conscious or voluntary control over, their symptoms. Lack of voluntary control is in contrast to factitious disorder and malingering. In factitious disorder, clients deliberately make up or inflict symptoms.
1. When describing the major difference between somatic symptom disorder and factitious disorders, which would the nurse include? a) In somatic symptom disorder, clients are not consciously aware that needs are being met through physical complaints b) Factitious disorders respond much more readily to psychopharmacologic treatment than does somatic symptom disorder c) In factitious disorders, clients are unaware that their symptoms are not real d) In somatic symptom disorder, clients consciously seek attention
a) Relief from emotional conflict Pg. 648 An emotional conflict precedes the development of conversion disorder; the conversion disorder relieves that specific emotional conflict. The symptoms do not result in eEmotional detachment and conversion disorder is not driven by a need for emotional support from the family. The client is not often able to directly identify his or her anxious feelings.
23. Which is the primary gain for a client with conversion disorder? a) Relief from emotional conflict b) Emotional support from family c) Identification of anxious feelings d) Emotional detachment
a) Malingering Pg. 648 Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms; it is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs. Primary gains are the direct external benefits that being sick provides. Secondary gains are the internal or personal benefits received from others because one is sick, such as attention from family members and comfort measures. Disease conviction is the preoccupation with the fear that one has a serious disease, as seen in hypochondrias.
31. Which of the following is motivated by avoiding work, evading criminal prosecution, and obtaining drugs? a) Malingering b) Secondary gain c) Primary gain d) Disease conviction
c) SSRIs Pg. SSRIs have been shown to be effective in some cases of somatoform disorders.
6. A client has been diagnosed with conversion disorder. Which medication classification has been shown to be effective in some cases of somatoform disorders? a) Antimanics b) Antibiotics c) SSRIs d) Antipsychotics
c) Illness anxiety disorder Pg. 647-648 Illness anxiety disorder is preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). It is thought that clients with this disorder misinterpret bodily sensations or functions. Conversion disorder, sometimes called conversion reaction, involves unexplained, usually sudden deficits in sensory or motor function. Pain disorder has the primary physical symptom of pain, which generally is unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance.
12. A client is seen in the primary care clinic reporting headaches. The client appears extremely distressed and insists that the client must have a brain tumor. Which mental health diagnosis is most probable for this client? a) Brain cancer b) Pain disorder c) Illness anxiety disorder d) Conversion disorder
c) Long-term psychotherapy Pg. 649-650 The overall goal of treatment for a client with factitious disorder is to replace the dysfunctional, attention-seeking behaviors with positive behaviors. To begin treatment, the client must acknowledge the deception. Because the pattern of self-injury is well established and meets overwhelming psychological needs, giving up the behaviors is difficult. The treatment is long-term psychotherapy; the client should see health care providers even when not in crisis. Short-term psychotherapy, inpatient hospitalization and group therapy are not appropriate.
8. Which of the following treatments would most likely be used for a client with a factitious disorder? a) Group therapy b) Short-term psychotherapy c) Long-term psychotherapy d) Inpatient hospitalization
c) Malingering Pg. 648 Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms; it is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs. Illness anxiety disorder is preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). Factitious disorder occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. Factitious disorder imposed on another occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a "hero" for saving the victim.
26. A middle-aged client goes to the physician reporting hip pain. The friend that brought the client to the office tells the nurse that the client's intention is to fake chronic hip pain to apply for disability benefits from the government. Which best reflects the client's potential diagnosis? a) Factitious disorder b) Factitious disorder imposed on another c) Illness anxiety disorder d) Malingering
a) The blindness is a reaction to the trauma of losing her sister and has no physiologic basis Pg. 648 With functional neurologic symptom disorder, disorder is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms. In this case, the blindness is the physical symptom manifested due to the extreme emotional stress. There is no physiologic basis for the condition. Itis an unconscious process; it will not disappear with ophthalmologic care. The symptom is unconsciously designed to reduce anxiety,
10. A client is diagnosed with functional neurologic symptom disorder after extensive evaluation. The client developed blindness after witnessing the death of her twin sister in a car accident. When teaching the client's mother about her daughter's illness, which of the following would the nurse include? a) The blindness is a reaction to the trauma of losing her sister and has no physiologic basis b) Her blindness requires a conscious effort to maintain the feigned symptom c) Her blindness results in increased anxiety and attention from family and friends d) Her blindness will gradually disappear if proper ophthalmologic care is provided
b) Relaxation techniques Pg. 642 In pain management, a single approach rarely works. Pain is a primary issue and was previously considered a separate disorder. Nursing care focuses on helping clients identify strategies to relieve pain and to examine stressors in their lives. After a careful assessment of the pain, nonpharmacologic strategies should be developed to reduce it. One nonpharmacologic strategy is the implementation of CAM with an appropriate intervention being the introduction of relaxation techniques. Daily exercise and a physical therapy referral are appropriate for back pain but are not considered CAM interventions. Modification of eating habits is appropriate for frequent gastrointestinal pain; however, this is not considered a CAM intervention.
11. The nurse plans care for a client who experiences pain due to somatic symptom disorder (SSD). Which complementary and alternative medicine (CAM) intervention does the nurse include in the client's plan of care to address pain? a) Daily exercise b) Relaxation techniques c) Modification of eating habits d) Physical therapy referral
c) Malingering Pg. 648 Malingering occurs when an individual intentionally produces illness symptoms, motivated by another specific self-serving goal, such as being classified as disabled or avoiding work. Individuals with alexithymia have difficulty identifying and expressing their emotions. They have a preoccupation with external events and are described as concrete, externally oriented thinkers. Conversion disorder is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms. Illness anxiety disorder occurs when an individual is fearful of developing a serious illness based on a misinterpretation of body sensations.
13. Which occurs when an individual intentionally produces illness symptoms to avoid work? a) Illness anxiety disorder b) Alexithymia c) Malingering d) Conversion disorder
c) "It involves unexplained, usually sudden deficits in sensory or motor function" Pg. 648 Clients with functional neurologic symptom disorder have neurologic symptoms that include impaired coordination or balance, paralysis, aphonia (inability to produce sound), difficulty swallowing or a sensation of a lump in the throat, and urinary retention. They also may have loss of touch, vision problems, blindness, deafness, and hallucinations. In some instances, they may have seizures.
14. A family member of a client diagnosed with functional neurologic symptom disorder asks the nurse, "What is this disorder?" Which of the following is the best response by the nurse? a) "It is a preoccupation with an imagined or exaggerated defect in physical appearance" b) "It is a preoccupation with the fear that one has a serious disease" c) "It involves unexplained, usually sudden deficits in sensory or motor function" d) "It is characterized by multiple physical symptoms"
d) Functional neurologic symptom disorder is an unconscious process, while malingering disorder is a deliberate fabrication of symptoms Pg. 648 In functional neurologic symptom disorder, anxiety-provoking impulses are converted unconsciously into functional symptoms. Malingering disorder is characterized by the voluntary or intentional production of false or grossly exaggerated physical or psychological symptoms. Both produce rewards, and neither has any pathophysiological cause. Neither disorder is considered a permanent or untreatable condition.
15. Which of the following characteristics differentiates functional neurologic symptom disorder from malingering disorder? a) Functional neurologic symptom disorder has no pathophysiological cause, while malingering disorder has a neurological or endocrine basis b) Functional neurologic symptom disorder is normally permanent, while malingering disorder is transient in response to stress c) Functional neurologic symptom disorder produces reward, while malingering disorder normally results in punishment or difficulty d) Functional neurologic symptom disorder is an unconscious process, while malingering disorder is a deliberate fabrication of symptoms
d) Develop a therapeutic relationship Pg. 636 Developing a therapeutic relationship promotes trust and can minimize the client's need to search for a health care professional who believes their symptoms and suffering; therefore, this is the nurse's priority. Initiating a health history interview, conducting a physical examination, and collecting a current list of medications are all important actions but not the priority based on the client's diagnosis.
16. Which is the nurse's priority on the first meeting with a client who is diagnosed with somatic symptom disorder (SSD)? a) Collect a current list of medications b) Initiate the health history interview. c) Conduct the physical examination d) Develop a therapeutic relationship
a) "Try finding an activity you enjoy doing together to help the client feel better overall" Pg. Building a trusting relationship with the client, providing empathy and support, and being sensitive to rather than dismissive of complaints are skills that the nurse can use in any setting where clients are seeking assistance. Encouraging clients to find pleasurable activities or hobbies may help to meet their needs for attention and security. Ignoring the complaints is likely to exacerbate the situation. Providing rewards for participating does not address the root causes of this phenomenon. Telling the husband to just "understand" his wife's worries is simplistic because this does not give him any tools to address this challenging situation.
17. The spouse of a client with hypochondriasis has accompanied the client to the follow-up doctor's visit. While waiting for the doctor, the spouse expresses to the nurse frustration with the client's obsession about illness. The spouse asks the nurse, "What can I do?" What would be the best response by the nurse? a) "Try finding an activity you enjoy doing together to help the client feel better overall" b) "Try to be the client and understand that the client is worried that the client is sick" c) "Try ignoring the client's complaints, and they should subside" d) "Try to give the client some sort of reward when the client resists complaining about the client's illnesses"
d) "You must be so frustrated with this unexplained pain. Do you have other stresses in your life too?" Pg. 632 Whereas some evidence suggests that somatization is a result of abnormally high levels of physiologic response, other evidence supports the idea that somatization is the physical expression of personal problems or the internalization and expression of stress through physical symptoms. The nurse should use an approach that helps to establish trust through acknowledgment and validation. The therapeutic relationship is key. Telling the client the recommended treatment approach is supported by research may elicit a defensive reaction in the client, hindering the therapeutic relationship. Talking about culturally specific behaviors indicates the nurse is using stereotyping, a culturally incompetent approach. Encouraging the client to continue to seek multiple health care providers is ineffective and feeds into the client's beliefs about the illness. The client should be encouraged to be consistent with one, primary health care provider.
18. The nurse is seeing a client who reports chronic pain that radiates to the lower back. The client reports the pain has been unresolved with analgesia, physical therapy and therapeutic massage. The client's diagnostic imaging reports are all unremarkable. Which statement by the nurse would be the most supportive response to this client? a) "The treatment that was recommended to you has worked for many clients. It is supported by research" b) "It would be best for your to see a specialist until the underlying issue is properly diagnosed" c) "Is it common in your culture to talk about psychological distress like it is physical pain?" d) "You must be so frustrated with this unexplained pain. Do you have other stresses in your life too?"
c) "You should not drive until you know if the medication makes you drowsy" Pg. 645 Common side effects of selective serotonin reuptake inhibitors (SSRIs) like fluoxetine include nausea, loss of appetite, and drowsiness. Alcohol should be avoided as it can exacerbate these side effects. Although some side effects may be unpleasant, some are mild and expected. Consultation with the prescriber should always occur before stopping an SSRI. Promoting safety, like using caution with operating a motor vehicle, is necessary until the client understands how the medication affects them individually.
19. A 24-year-old female client has been prescribed fluoxetine for treatment of a somatoform disorder. What should the nurse include in the client's teaching about this medication? a) "Limit alcohol consumption to one glass of wine per day" b) "Your appetite will increase, and you may gain weight" c) "You should not drive until you know if the medication makes you drowsy" d) "Stop taking the medication if you experience any side effects"
a) Factitious disorder Pg. 648 Persons with factitious disorders intentionally cause an illness or injury to receive the attention of health care workers. These individuals are motivated solely by the desire to become a client and develop a dependent relationship with a health care provider. Somatic symptom disorder, conversion disorder, and illness-related disorder are not disorders in which the client is motivated by the desire to become a client.
20. In which disorder is the individual motivated solely by the desire to become a health care client? a) Factitious disorder b) Conversion disorder c) Somatic symptom disorder d) Illness related disorder
a) "I seem to have more pain now that I got laid off" Pg. 633 The correlation between the client's stressors and pain suggests a somatoform disorder. The client's statements about having a "hard time," "overexerting myself" and hoping that the care team finds out what is wrong do not suggest a pathologic response to a stressor.
2. A client is seeking relief for undiagnosed pain. There is no history of significant physical illness. The history reveals that the client was laid off 4 months ago from a job. The nurses assessment is unremarkable. Which statement made by the client would most strongly suggest a somatoform disorder? a) "I seem to have more pain now that I got laid off" b) "I'm sure they will figure out what is wrong with me" c) "I probably just overexerted myself working around the house. It's hard to slow down" d) "I have been having a hard time lately. It's hard not working like I'm used to"
d) "How long have you been experiencing the GI symptoms?" Pg. 634 Encourage and allow clients who are diagnosed with SSD to discuss their physical problems before focusing on psychosocial issues. Based on this information, the priority question from the nurse is "How long have you been experiencing GI symptoms?" because this question focuses on the client's physical problems. The questions related to the client's depression and anxiety are psychosocial issues.
21. The nurse provides care to a client who is diagnosed with somatic symptom disorder (SSD) and who presents with anxiety and depression in addition to physical symptoms that affect the gastrointestinal (GI) system. Which is the priority question from the nurse when conducting the interview portion of the assessment process? a) "When did the symptoms of anxiety first start?" b) "What happens when you are anxious?" c) "How long have you been depressed?" d) "How long have you been experiencing the GI symptoms?"
a) No physiologic cause has been found for the client's symptoms Pg. 644 One of the important factors regarding the diagnosis of psychological factors affecting medical conditions is that there is no physiologic basis for these symptoms. They are often based on psychological conditions. These symptoms do not usually subside easily, clients cannot often talk about the cause of their distress, and the symptoms are always related to unconscious processes.
22. The nurse obtains a psychosocial history from a client who may have psychological factors affecting the medical condition. Which should the nurse recognize as pertinent to this diagnosis? a) No physiologic cause has been found for the client's symptoms b) The client's symptoms are related to conscious motives c) The client is able to articulate the cause of psychological distress d) The client's symptoms subside with appropriate medical treatment
d) Severe physical symptoms unexplainable by any organic or physical pathology Pg. 633 The diagnostic criteria for somatic symptom disorder were updated in the DSM-5 and include one or more symptoms that cause persistent distress or significant disruption in daily lives for at least 6 months, as well as excessive thoughts about the seriousness of the symptoms, feelings (such as anxiety about the symptoms or health) or behaviors related to the symptoms, or health concerns (such as spending excessive time and energy focusing on these symptoms or health). These symptoms cannot be explained or unexplained by medical evidence.
24. Somatic symptom disorder is characterized by what? a) Self-inflicted injuries b) Physical symptoms coupled with extreme focus on emotional state c) Self-induced disease states or faked symptoms to garner attention d) Severe physical symptoms unexplainable by any organic or physical pathology
d) The client will identify the occurrence of physical symptoms when stressed Pg. 650 Teaching about the relationship between stress and physical symptoms is a useful way to help clients begin to see the mind-body relationship. This involves the expression of emotions, but the primary purposes is identifying a link between the two phenomena. Journaling is not suggested as a means for the nurse to control the client's stressors or to assess symptoms; the client is the focus of the exercise.
25. The client has severe headaches that are debilitating. The nurse has encouraged the client with a somatic symptom illness to keep a journal. Which treatment outcomes might be met by journaling? a) The client will express emotions privately b) The nurse will control external stressors that trigger the client's physical symptoms c) The nurse will assess the onset of physical symptoms d) The client will identify the occurrence of physical symptoms when stressed
d) Illness anxiety disorder Pg. 647-648 When individuals are fearful of developing a serious illness based on their misinterpretation of body sensations, the classification of illness anxiety disorder can be used to describe this preoccupation. The fear of having an illness continues despite medical reassurance, and this interferes with psychosocial functioning. The individual spends time and money on repeated examinations looking for feared illnesses. With factitious disorder, the illness or injury is intentionally caused to gain attention of health care workers. Functional neurologic symptom disorder or conversion disorder is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms.
27. A client who has been having difficulty functioning in daily life comes to the nurse and states, "I'm really afraid. I've had these funny feelings in my stomach. I'm scared that I might have cancer." The client has been seen by numerous health care professionals and no evidence of cancer has been demonstrated. The nurse suspects what? a) Conversion disorder b) Functional neurologic symptom disorder c) Factitious disorder d) Illness anxiety disorder
c) Underlying pathology should be ruled out Pg. The nurse must investigate physical health status thoroughly to ensure that there is no underlying organic pathology requiring treatment. When a client has been diagnosed with a somatic symptom illness, it is important not to dismiss all future complaints because at any time the client could develop a physical condition that would require medical attention. Financial factors do not drive the nurse's plan for assessments and it would be inappropriate to perform assessment for the sole purpose of easing the client's mind. Psychological, not physical, problems underlie somatic disorders.
28. The client presented to the emergency department with a report of chest pain. The nurse performs a thorough physical examination for this client, who has a history of a somatic symptom illness. Which is the best rationale for the physical exam? a) Ease the client's mind that the nurse is looking for physical illness b) Physical exams are reimbursed by third-party payers c) Underlying pathology should be ruled out d) Physical disorders underlie somatic disorders
c) The CAGE questionnaire Pg. Some studies have reported that men who present with multiple somatic symptoms may also be suffering from substance abuse disorders and with the recent epidemic of opioid overdoses, this risk factor needs to be considered. The CAGE questionnaire screens for alcohol abuse. The Mini Mental Status and St. Louis University Mental Status examinations are used for the assessment of cognition to identify signs of dementia. Although the Hamilton Rating Scale for Depression may be useful with this client, the use of substances needs to be ruled out as this poses an imminent safety risk to the client.
29. The nurse is seeing a male client who reports multiple somatic symptoms including back pain, nausea, and headache. The client has reported the same symptoms on multiple visits and a detailed physical examination including lab values and diagnostic imaging tests have been unremarkable. Which assessment tool should the nurse include in this visit with the client? a) The Mini Mental Status Examination b) The St. Louis University Mental Status assessment c) The CAGE questionnaire d) The Hamilton Rating Scale for Depression
d) Manifestation of physical symptoms from psychological distress Pg. 633 The concept of somatization acknowledges and respects that bodily sensations and functional changes are expressions of health and illness, and even though they may be unexplained, they are not imaginary or "all in the head." Somatization (from soma, meaning body) is the manifestation of psychological distress as physical symptoms, which may result in functional changes, somatic descriptions, or both. The terms hysteria and hysterical were used to describe physical or emotional symptoms that could not be substantiated by physicians.
3. Which best describes the concept of somatization? a) Symptoms that cannot be substantiated by physicians b) Physical symptoms that are all in one's head c) Psychological origin of illness that is not real d) Manifestation of physical symptoms from psychological distress
d) Munchausen's syndrome Pg. 648 In 1951, the term Munchausen's syndrome was used to describe the most severe form of factitious disorder, which was characterized by fabricating a physical illness, having recurrent hospitalizations, and going from one medical provider to another. Malingering occurs when an individual intentionally produces illness symptoms that are motivated by another specific self-serving goal, such as being classified as disabled or avoiding work. Alexithymia and hypochondriasis are not factitious disorders.
30. The most severe form of factitious disorder includes which of the following? a) Hypochondriasis b) Alexithymia c) Malingering d) Munchausen's syndrome
a) Childhood sexual abuse, which is related to somatization, happens more frequently to girls c) Women seek medical treatment more often than men, and it is more socially acceptable for them to do so c) Women more often receive treatment for psychiatric disorders with strong somatic components such as depression e) Boys in the United States are taught to be stoic and to "take it like a man," causing them to offer fewer physical complaints as adults Pg. 641 Somatization is associated most often with women, as evidenced by the old term hysteria (Greek for "wandering uterus";). Ancient theorists believed that unexplained female pains resulted from migration of the uterus throughout the woman's body. Psychosocial theorists posit that increased incidence of somatization in women may be related to various factors: Boys in the United States are taught to be stoic and to "take it like a man,"causing them to offer fewer physical complaints as adults.\ Women seek medical treatment more often than men, and it is more socially acceptable for them to do so. Childhood sexual abuse, which is related to somatization, happens more frequently to girls. Women more often receive treatment for psychiatric disorders with strong somatic components such as depression.
32. A nurse is preparing a presentation for a local community group about somatic symptom disorder. When describing the factors associated with the increased incidence of somatization in women, which belief would the nurse most likely include? Select all that apply. a) Childhood sexual abuse, which is related to somatization, happens more frequently to girls b) Unexplained female pains result from migration of the uterus throughout the woman's body c) Women seek medical treatment more often than men, and it is more socially acceptable for them to do so c) Women more often receive treatment for psychiatric disorders with strong somatic components such as depression e) Boys in the United States are taught to be stoic and to "take it like a man," causing them to offer fewer physical complaints as adults
c) Somatization Pg. 635 Somatization is a term used to describe the conversion of unexpressed emotions into physical symptoms. The la belle indifference is a seeming lack of concern or distress for deficits seen in conversion disorder. Hysteria refers to multiple physical complaints with no organic basis. The term psychosomatic is used to convey the connection between the mind and the body in states of health and illness.
33. Which term describes the conversion of unexpressed emotions into physical symptoms? a) Hysteria b) La belle indifference c) Somatization d) Psychosomatic
d) Recognizing the symptoms but not providing the client the opportunity to dwell on them Pg. 648 Conversion disorder is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms. The symptoms, different from those with an organic basis, do not follow a neurologic course but rather follow the person's own perceived conceptualization of the problem. It is important to understand that the symptoms are real for the client and should never be ignored. In approaching the client, rather than using distraction, the nurse treats conversion symptoms as real symptoms that may have distressing psychological aspects. Acknowledging the symptoms, even when the diagnostic tests fail to confirm them physically, helps the client deal with them.
34. A client disagnosed with a conversion disorder repeatedly reports abdominal symptoms to the nursing staff. What response provided by the nurse managing the client's care will best meet the client's needs therapuetically? a) Reminding the client that the tests were all negative and that the symptoms are just imaginary b) Ignoring the reports but documenting the symptoms c) Distracting the client with offers to include the client in group activities d) Recognizing the symptoms but not providing the client the opportunity to dwell on them
a) Mother Pg. 650 A rare but dramatic disorder, factitious disorder imposed on another (previously factitious disorder by proxy or Münchausen's by proxy), involves a person who inflicts injury on another person. It is commonly a mother who inflicts injuries on her child to gain the attention of a health care provider through her child's injuries. These actions include inducing seizures, poisoning, or smothering. This most severe form of child abuse is usually identified in the emergency department. The mother rarely admits injuring the child and thus is not amenable to treatment; the child is removed from the mother's care.
35. Factitious disorder imposed on another is commonly inflicted by which family member upon a child? a) Mother b) Sibling c) Father d) Grandparent
d) Pseudologia fantastica Pg. 648 With factitious disorder, clients are extremely creative in simulating illnesses, and they tell fascinating but false stories of personal triumph. These tales are referred to as pseudologia fantastica and are a core symptom of the disorder. Pseudologia fantastica are stories that are not entirely improbable and often contain a matrix of truth and falsehood. Malingering involves an individual who intentionally produces illness symptoms but is motivated by as self-serving goal such as being classified as disabled or avoiding work. Individuals with alexithymia have difficulty identifying and expressing their emotions. They have a preoccupation with external events and are described as concrete externally oriented thinkers. Hypochondriasis is seen in individuals who are fearful of developing a serious illness based on their misinterpretation of body sensations.
36. A client diagnosed with factitious disorder tells the nurse about how he overcame a tremendous disability. Based on the client's history, the nurse knows that the story is not all true. The client is exhibiting which of the following? a) Malingering b) Alexithymia c) Hypochondriasis d) Pseudologia fantastica
c) Client progress is expected to be very slow Pg. 643 Clients who cope through physical symptoms can be frustrating for the nurse. Initially, they are unwilling to consider that anything other than major physical illness is the root of all their problems. The client's progress is slow and painstaking, if any change happens at all. The nurse should be realistic about the small successes that can be achieved in any given period. To enhance the ongoing relationship, the nurse must be able to accept the client and his or her continued complaints and criticisms while remaining nonjudgmental. Psychological factors are the root of the illness. The nurse can never know if he or she has done all that can be done for the client and the nurse should not "write off" the client as untreatable.
37. The client has a somatic symptom illness. During individual therapy, the client yells at the nurse, "You are all quacks! Can't you see I am sick?" Which knowledge statement would help the nurse to work most effectively with this client? a) The client will never be free of somatic symptoms b) Physical illness is the root of the client's problems c) Client progress is expected to be very slow d) The nurse has done everything possible to treat the client
c) Provide nursing care in a supportive but matter-of-fact manner Pg. 648 Conversion disorder, sometimes called conversion reaction, involves unexplained, usually sudden deficits in sensory or motor function (e.g., blindness, paralysis). These deficits suggest a neurologic disorder but are associated with psychological factors. There is usually significant functional impairment. Interacting in a supportive but matter-of-fact way reduces the potential for any secondary reward on the part of the client. The client is not feigning illness, so is not a malinger. An appointment with an eye doctor is not needed since the source of the blindness is not physical. The client is not permanently blind, so occupational therapy at this point is not a priority.
38. A client experiencing the sudden onset of blindness is diagnosed with a conversion disorder. Which nursing intervention would be most appropriate? a) Provide an occupational therapy consult to address the needs of a blind person b) Assist the client in making an appointment with an endocrinologist c) Provide nursing care in a supportive but matter-of-fact manner d) Suggest to the client that this is possible malingering
a) Laboratory and diagnostic test results are usually negative Pg. 648 Functional neurologic symptom disorder (or conversion disorder) is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms (APA, 2013). Clients with conversion disorder have neurologic symptoms that include impaired coordination or balance, paralysis, aphonia (inability to produce sound), difficulty swallowing, a sensation of a lump in the throat, and urinary retention. They also may have loss of touch, vision problems, blindness, deafness, and hallucinations. In some instances, they may have seizures (Nielsen, Stone, & Edwards, 2013). However, laboratory, electroencephalographic, and neurologic test results are typically negative. The symptoms, different than those with an organic basis, do not follow a neurologic course but rather follow the person's own perceived conceptualization of the problem.
39. A nurse is conducting an inservice presentation for a group of newly hired mental health nurses. Which would the nurse most likely include when describing conversion disorder (functional neurologic symptom disorder)? a) Laboratory and diagnostic test results are usually negative b) The symptoms follow a typical neurologic pattern c) The client's complaints are not real d) Symptoms expressed reflect a neurologic illness
a) Develop a sound, positive nurse-client relationship Pg. 642 Although administering prescribed pharmacotherapy, counseling, and assisting in developing a daily routine are important, the most crucial part of the plan of care is developing a sound, positive nurse-client relationship. Without the relationship, the nurse is just one more provider who fails to meet the client's expectations.
4. Which would be most important for a nurse to do when caring for a client with somatic symptom disorder? a) Develop a sound, positive nurse-client relationship b) Ensure adherence to counseling c) Administer prescribed pharmacotherapy d) Assist in developing a daily routine
c) Malingering Pg. 648 Malingering refers to the situation in which an individual intentionally produces illness symptoms because the motivation is another specific self-serving goal, such as being classified as disabled or avoiding work. Clients with factitious disorder injure themselves covertly. The illnesses are produced in such a manner that the health care provider is tricked into believing that a true physical or psychiatric disorder is present. Factitious disorder imposed on another involves a person who inflicts injury on another person. It is commonly a mother, who inflicts injuries on her child to gain the attention of the health care provider through her child's injuries. Functional neurologic symptom disorder is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms.
40. Assessment reveals that a client has been intentionally injuring the self so that the client can receive long-term disability and not have to work. The nurse interprets this behavior as suggesting which condition? a) Factitious disorder b) Functional neurologic symptom disorder c) Malingering d) Factitious disorder imposed on another
a) A female of African descent who works two minimum wage jobs Pg. 634 Epidemiologic studies have reported that SSD occurs primarily in nonwhite, less educated women, particularly those with a lower socioeconomic status and high emotional distress. Men are less likely to be diagnosed with SSD, partly because of stereotypic male traits, such as a disinclination to admit discomfort or seek help for their symptoms. Based on this information, the client who is at greatest risk for SSD is the female of African descent who works two minimum wage jobs because there are three risk factors (ethnicity, gender, and low socioeconomic status). The white male, the white female, and the male client of African descent each have one risk factor for SSD.
41. Which client does the nurse identity as having the greatest risk for developing somatic symptom disorder (SSD)? a) A female of African descent who works two minimum wage jobs b) A white male who works two minimum wage jobs c) A white female with a college degree who works in advertising d) A male of African descent with an associate degree in nursing
c) Evaluate the client's risk for suicide Pg. 636 In this scenario, the nurse must fully investigate any negative thoughts, feelings, or behaviors that place the client at risk of suicide. The statement, "I won't need them anyway," could indicate that the client has suicidal ideations and has decided that using the limbs is unnecessary since they will be deceased. Journaling and talk therapy that addresses the bullying incident are all important nursing care plan items but come below safety and security in order of priority. Clients with conversion disorder have difficulty understanding that their symptoms are part of a coping/disease process and often take on the attitude of "la belle indifférence."
42. The nurse plans to care for a teenage male client experiencing conversion disorder after a bullying incident. The client has stated, "It does not matter if my legs do not work. I will not need them anyway." What is the priority nursing action for this client? a) Ask the client to describe the bullying incident b) Remind the client that disturbed body image is a normal symptom of their conversion disorder c) Evaluate the client's risk for suicide d) Have the client journal feelings about enjoyable activities they will miss if they do not use their legs
a) Frequency of generalized somatic complaints Pg. 650 Somatic symptom illness is characterized by multiple physical symptoms. The frequency of generalized somatic complaints will give the nurse information about the current status of the disorder. Conversion disorder involves unexplained, usually sudden deficits in sensory or neurologic motor function and might be manifested by sensory deficits being experienced by the client. Pain disorder has the primary physical symptom of pain and would be reassessed with the description of the character of any pain reported by the client. If the nurse would reassess for signs of possible neurologic disorders, it may serve to reinforce to the client that there might be something wrong.
43. The nurse is planning care for a client with somatic symptom illness disorder. Which should the nurse plan to reassess on a daily basis? a) Frequency of generalized somatic complaints b) Sensory deficits experienced by the client c) Signs of possible neurologic disorders d) Character of pain reported by the client
c) SSRIs Pg. 644-645 Clients with anxiety are treated pharmacologically, similar to those with depression. The first line of treatment for all anxiety disorders is with a selective serotonin reuptake inhibitor (SSRI). Doses for SSD are usually higher than those prescribed for depression to relieve and manage the symptoms of the anxiety disorders, including panic, social phobia, generalized anxiety, OCD, and posttraumatic stress disorder. Any additional signs and symptoms of the disorder, such as headache, should be treated with medication that has the least potential for dependence or abuse. Therefore, an NSAID would be a favorable choice over narcotic analgesics.
44. A client with somatic symptom disorder (SSD) which involves chronic headaches is prescribed medication therapy. Which medication would the nurse expect to be prescribed? a) Antipsychotics b) Antimanics c) SSRIs d) Monoamine oxidase inhibitors (MAOIs)
d) Ruling out a physical cause of pain Pg. 639 Pain disorder has the primary physical symptom of pain, which generally is unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance. Initially the presence of a physical cause of the pain must be ruled out. The assessment of the client's understanding of the disorder or recording the feelings regarding the trauma are not priorities until a diagnosis of pain disorder is made.
45. A client reports severe pain during intercourse since being sexually assaulted three years ago. Which is the first step in confirming the diagnosis of a pain disorder? a) Assessing the client for posttraumatic stress disorder b) Asking the client to keep a journal of her feelings regarding the assault c) Evaluating the client's understanding of a pain disorder d) Ruling out a physical cause of pain
c) "Even though my body hurts, I have made a goal to exercise four times per week" Pg. 648 Clients with a somatoform disorder need ongoing support, care, and validation of their feelings. Clients that minimize their disorder by stating it will "Go away" or "It's not real" limit their ability to practice effective coping techniques and understand their mind-body relationship. Asking for additional testing indicates that the client is not yet able to obtain relief in a non-chemical, non-medical way. Incorporating routines such as exercise and relaxation can help the client increase their mental and physical well-being and diminish their reliance on psychosomatic symptoms to cope with stress.
46. A nurse is caring for a young adult female client with a somatoform disorder. Which statement by the client would indicate effective coping? a) "Once I am done with the stresses of school, I will feel better" b) "When I feel sick or in pain, I tell myself, 'It is not real; get over it'" c) "Even though my body hurts, I have made a goal to exercise four times per week" d) "I saw online that I should consider getting a Magnetic Resonance Imaging (MRI) test"
b) Illness anxiety disorder Pg. 647-648 When individuals are fearful of developing a serious illness based on their misinterpretation of body sensation, the diagnosis of illness anxiety disorder can be used to describe the preoccupation. Individuals with alexithymia have difficulty identifying and expressing their emotions. Conversion disorder is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms. Persons with factitious disorders intentionally cause an illness or injury to receive the attention of health care workers. These individuals are motivated solely by the desire to become a client and develop a dependent relationship with a health care provider.
47. During a client interview, the nurse determines that the client has a fear of developing a serious illness based on a misinterpretation of body sensation. The nurse identifies this as being characteristic of what? a) Factitious disorder b) Illness anxiety disorder c) Alexithymia d) Conversion disorder
c) Women of lower socioeconomic status e) Black women Pg. 634 Epidemiological studies have reported that SSD occurs primarily in non-white, less educated women, particularly those with a lower socioeconomic status and high emotional distress. Men are less likely to be diagnosed with SSD, partly because of stereotypic male traits, such as a disinclination to admit discomfort or seek help for their symptoms.
48. A nurse is preparing a presentation for a staff meeting about somatic symptom disorder (SSD). When describing the epidemiology associated with SSD, the nurse would identify which groups as likely to develop this condition? Select all that apply. a) White women b) Non-white men c) Women of lower socioeconomic status d) Men experiencing high emotional distress e) Black women
a) Ineffective coping related to unresolved psychological issues as evidenced by inability to express feelings verbally Pg. 633 Nursing diagnoses for clients with somatic system disorders focus on identifying the causes of dysfunctional coping and issues related to the family and psychosocial interaction.
49. The nurse has concluded the assessment of a client recently diagnosed with somatic symptom disorder. The client states the client's most significant source of stress is that "No one believes how sick I am." The client's physical complaints include fatigue, loss of appetite, and frequent urination. Based on these data, the most appropriate nursing diagnosis is what? a) Ineffective coping related to unresolved psychological issues as evidenced by inability to express feelings verbally b) Hopelessness related to chronicity of symptoms as evidenced by dependency c) Chronic low self-esteem related to physical symptoms that inhibit the client's daily functioning d) Risk for spiritual distress related to feelings of isolation
c) The client usually thinks anxiety is behind the symptoms Pg. 633 Individuals with somatic symptom disorder perceive themselves as being "sicker than the sick" and report all aspects of their health as poor. Many eventually become disabled and cannot work. They typically visit health care providers multiple times per month and quickly become frustrated because their primary health care providers do not appreciate their level of suffering and are unable to validate that a particular problem accounts for their extreme discomfort. Clients do not have insight to identify anxiety as a problem.
5. After teaching a group of nursing students about somatic symptom disorder, the instructor determines that additional education is needed when the students identify which as true? a) The client believes he/she has a serious illness b) The client embraces the "sick role" c) The client usually thinks anxiety is behind the symptoms d) The client believes that his/her condition is catastrophic and disabling
a) Set limits with the client about the complaints Pg. 648 If a client with the diagnosis of hypochondriasis has been told that the client has no life-threatening or severe illnesses, but the client continues to verbalize clinical symptoms, limit-setting is used. A "false" assessment is unethical, and repeating diagnostic testing reinforces the client's behavior. Having diagnostic results presented by another member of the care team is unlikely to eliminate the client's concerns.
50. Following a long history of multiple visits to community clinics and emergency departments, a client has been diagnosed with hypochondriasis. During this current visit to the emergency department, the client has just been informed that diagnostic testing and assessment reveal no severe illness. Despite this, the client persists in verbalizing physical complaints. How should the nurse respond to this? a) Set limits with the client about the complaints b) Facilitate a repeat of the previous diagnostic testing in order to appease the client c) Have a different member of the care team present the test and assessment results to the client d) Feign an assessment of the client in order to calm the client's anxiety
d) "How many episodes of diarrhea do you have each week?" Pg. 633 Somatic symptom disorder (SSD) is one of the most difficult disorders to manage because its symptoms tend to change, are diffuse and complex, and vary and move from one body system to another. Although all these assessment questions focus on SSD symptoms, it is only the question "How many episodes of diarrhea do you have each week?" that addresses GI symptoms. Headache is a neurologic symptom, aching legs is a musculoskeletal symptom, and pain with intercourse is a sexual issue.
7. The nurse suspects that a client is experiencing somatic symptom disorder (SSD). Which question should the nurse include in the assessment process to determine specific gastrointestinal (GI) symptoms? a) "When did you first notice your legs aching?" b) "When did you first notice pain with intercourse?" c) "How often do you experience headaches?" d) "How many episodes of diarrhea do you have each week?"
a) Factitious disorder imposed on another Pg. 650 Factitious disorder imposed on another (previously factitious disorder by proxy or Münchausen's by proxy), involves a person who inflicts injury on another person. It is commonly a mother, who inflicts injuries on her child to gain the attention of the health care provider through her child's injuries. Conversion disorder or functional neurologic symptom disorder is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms.
9. Assessment of a client reveals that the client has been inflicting illness on her daughter to gain the attention of medical personnel. The nurse identifies this as which of the following? a) Factitious disorder imposed on another b) Functional neurologic symptom disorder c) Factitious disorder d) Conversion disorder
