Chapter 23 Psych Nursing

5. An 11-year-old child talks to the school nurse about a single episode of disruptive behavior in class. The child states, ìI had a stomachache and felt like vomiting. I couldn't help it. I was just so mad at my dad.î Which would be the most appropriate response by the nurse? A) ìI can see that you're angry. Let's look at better ways to express it.î B) ìI can understand your anger, but you can't disrupt the classroom.î C) ìIf you can get rid of your anger, perhaps your stomachache will go away.î D) ìPerhaps it would be helpful if you let your dad know you're angry.î

Ans: A Feedback: A child at this age may have difficulty expressing negative or intense emotions verbally; the nurse's response helps teach the child appropriate expressions of anger.

11. The nurse is meeting with a family of a client with conduct disorder. The nurse discusses changes the parents can make to help their child change problematic behaviors. Which parenting technique would the nurse encourage the parents to use? A) Provide consistent consequences for behaviors. B) Set earlier curfews than the child's peers adhere to. C) Release the child from household responsibilities until he can demonstrate dependable behavior. D) Avoid discussing feelings and expectations with the child.

Ans: A Feedback: Parents need to replace old patterns such as yelling, hitting, or simply ignoring behavior with more effective strategies. The nurse can teach parents age-appropriate activities and expectations for clients such as reasonable curfews, household responsibilities, and acceptable behavior at home. The parents may need to learn effective limit setting with appropriate consequences. Parents often need to learn to communicate their feelings and expectations clearly and directly to these clients. Some parents may need to let clients experience the consequences of their behavior rather than rescuing them.

6. The nurse is using limit setting with a child diagnosed with conduct disorder. Which statement reflects the most effective way for the nurse to set limits with the child? A) ìThat is not allowed here. You will lose a privilege. You need to stop.î B) ìStop what you are doing. Go to your room.î C) ìI would appreciate if you would not do that.î D) ìWhy do you do these things?î

Ans: A Feedback: The nurse must set limits on unacceptable behavior at the beginning of treatment. Limit setting involves three steps: (1) informing clients of the rule or limit; (2)explaining the consequences if clients exceed the limit; and (3) stating expected behavior.

16. Which are actions of the parents of a child with conduct disorders that may contribute to the problems of the child? Select all that apply. A) The parents may not behave appropriately themselves because of a lack of knowledge. B) The parents blame the school when the child causes a disturbance in school and receives detention. C) The parents engage in yelling at, hitting, or simply ignoring the behavior of their child. D) The parents make reasonable curfews that are appropriate for the age of the client. E) The parents establish household responsibilities that are appropriate for the age of the client.

Ans: A, B, C Feedback: Parents may also need help in learning social skills, solving problems, and behaving appropriately. Often, parents have their own problems, and they have had difficulties with the client for a long time before treatment was instituted. Parents need to replace old patterns such as yelling, hitting, or simply ignoring behavior with more effective strategies. The nurse can teach parents age-appropriate activities and expectations for clients such as reasonable curfews, household responsibilities, and acceptable behavior at home. Some parents may need to let clients experience the consequences of their behavior rather than rescuing them.

3. Which are characteristics of intermittent explosive disorder (IED)? Select all that apply. A) The episode may occur with seemingly no warning. B) They usually last less than 30 minutes. C) Afterward, the person with IED will not have any remorse. D) It involves repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts. E) The intensity of the emotional outburst is usually within proportion to the stressor or situation.

Ans: A, B, D Feedback: Intermittent explosive disorder (IED) involves repeated episodes of impulsive, aggressive, violent behavior and angry verbal outbursts, usually lasting less than 30 minutes. During these episodes, there may be physical injury to others, destruction of property, and injury to the individual as well. The intensity of the emotional outburst is grossly out of proportion to the stressor or situation. The episode may occur with seemingly no warning. Afterward, the individual may be embarrassed and feel guilty or remorseful for his or her actions, but that does not prevent future impulsive, aggressive outbursts.

20. Which may be concerns that a nurse has when caring for clients who have conduct disorders? Select all that apply. A) Thinking that the client should be able to refrain from hostility and aggression through use of will power. B) Having conflicted feelings regarding holding clients accountable for their behaviors without having a punitive attitude. C) Discussing feelings, fears, or frustrations with colleagues. D) Having anxiety and fears for the nurse's personal safety. E) Believing that aggression is the most productive way to deal with aggression.

Ans: A, B, D Feedback: The nurse's beliefs and values about raising children affect how he or she deals with children and parents. The nurse may also have personal feelings about the disruptive and/or aggressive behaviors, such as thinking the client should be able to refrain from hostility and aggression through use of will power. It can be difficult to reconcile holding clients accountable for their behaviors, but avoiding a purely punitive attitude. Working with aggressive clients of any age may provoke anxiety and fears for personal safety in the nurse. It is important for the nurse to discuss feelings, fears, or frustrations with colleagues to keep negative emotions from interfering with the ability to provide care to clients with problems with aggression.

13. Which steps are involved in limit setting? Select all that apply. A) State expected behavior. B) Inform clients or the rule or limit. C) Threaten incarceration. D) Explain the consequences if clients exceed the limit. E) Occasionally limit enforcement.

Ans: A, B, D Feedback: Limit setting involves three steps: 1. Inform clients of the rule or limit. 2. Explain the consequences if clients exceed the limit. 3. State expected behavior. Threatening the client with incarceration is not likely effective. Providing consistent limit enforcement with no exceptions by all members of the health-care team, including parents, is essential.

12. Which are most likely included in the history of a child with conduct disorder? Select all that apply. A) Disturbed relationships with peers B) Major antisocial violations C) Aggression toward people or animals D) Destruction of property E) Serious violation of rules

Ans: A, C, D, E Feedback: Children with conduct disorder have a history of disturbed relationships with peers, aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules (e.g., truancy, running away from home, and staying out all night without permission). Major antisocial violations would be indicative of antisocial behavior.

2. A child has been displaying behaviors associated with conduct disorder. The nurse should further assess for which common risk factors seen in children with conduct disorder. Select all that apply. A) Poor family functioning B) Strict disciplinary practices C) Family history of substance abuse D) Possible child abuse E) Poverty conditions

Ans: A, C, D, E Feedback: Risk factors include poor parenting, low academic achievement, poor peer relationships, low self-esteem, poor family functioning, marital discord, family history of substance abuse and psychiatric problems, child abuse, inconsistent parental responses, exposure to violence in the media, and community socioeconomic disadvantages such as inadequate housing, crowded conditions, and poverty. Protective factors include resilience, family support, positive peer relationships, and good health.

10. A 14-year-old girl is being treated for conduct disorder. She refuses to attend class today, stating that yesterday the other nurse told her she did not have to go to class if she did not want to. Which would be the best response by the nurse? A) ìFine, but you're confined to your room.î B) ìMissing class is against the rules.î C) ìYou and I both know you're lying.î D) ìWhy do you keep fighting the system?î

Ans: B Feedback: Reinforcing rules avoids a power struggle; the nurse must set limits on the unacceptable behavior of missing class. The nurse can negotiate with a client a behavioral contract outlining expected behaviors, limits, and rewards to increase treatment compliance.

8. Which is the most commonly used treatment for oppositional defiant disorder? A) Pharmacologic treatment B) Parent training models of behavioral interventions C) Individual therapy D) ìBoot campî

Ans: B Feedback: Treatment for ODD is based on parent management training models of behavioral interventions. These programs are based on the idea that ODD problem behaviors are learned and inadvertently reinforced in the home and school. Older children may also benefit from individual therapy in addition to the behavioral program. There is little evidence that medications help ODD behaviors; however, successful pharmacologic treatment of comorbid disorders such as ADHD may also decrease the severity of ODD symptoms. Dramatic interventions, such as ìboot campî or incarceration, have not proved effective and may even worsen the situation.

15. The nurse understands that when working with a child with a disruptive behavior disorder, the family must be included in the care. Which is one of the best ways the nurse can advocate for the child? A) Support transferring the child to a healthy living environment. B) Teach the parents age-appropriate expectations of the child. C) Reinforce the parents' expectations of the child's behavior. D) Interpret the child's thoughts and feelings to the parent.

Ans: B Feedback: Working with parents is a crucial aspect of dealing with children with these disorders. Parents often have the most influence on how these children learn to cope with their disorders. The nurse can teach parents age-appropriate activities and expectations for clients.

21. Which are important points for the nurse to consider when working with clients with disruptive behavior disorders and their families? Select all that apply. A) Most behavior disorders are caused by being raised by parents who had behavior disorders in their own childhoods. B) Remember to focus on the client's strengths and assets, as well as their problems. C) Transient conduct disorders are common in all children. D) Avoid a ìblamingî attitude toward clients and/or families. E) Focus on positive actions to improve situations and/or behaviors.

Ans: B, D, E Feedback: Points to consider when working with clients with disruptive behavior disorders and their families include the following: ï Remember to focus on the client's strengths and assets, as well as their problems. ï Avoid a blaming attitude toward clients and/or families; rather focus on positive actions to improve situations and/or behaviors. There is a familial tendency for behavior disorders, but that is not the only cause for behavior disorders. Conduct disorders are not common in all children, but it can be difficult to distinguish normal child behavior from conduct disorders at times.

17. When presenting information about conduct disorders to a community group, the nurse is asked, ìwhich is the best setting for care of a client with conduct disorders when parents cannot provide safe, structured environments and adequate supervision for the client?î Which would be the most appropriate reply by the nurse? A) The acute care setting B) School C) Residential treatment settings D) Jail-diversion program

Ans: C Feedback: Group homes, halfway houses, and residential treatment settings are designed to provide safe, structured environments and adequate supervision if that cannot be provided at home. Clients with conduct disorder are seen in acute care settings only when their behavior is severe and only for short periods of stabilization. Clients with legal issues may be placed in detention facilities, jails, or jail-diversion programs.

22. Which is the most important reason for the nurse who cares for children with conduct disorders to discuss feelings, fears, or frustrations with colleagues? A) To make the nurse feel better and avoid burnout. B) To encourage camaraderie between colleagues. C) To keep negative emotions from interfering with the ability to provide care to clients with problems with aggression. D) To ensure that all caregivers have the same attitudes and beliefs about children with conduct disorders.

Ans: C Feedback: It is important for the nurse to discuss feelings, fears, or frustrations with colleagues to keep negative emotions from interfering with the ability to provide care to clients with problems with aggression. It may also make the nurse feel better and avoid burnout, but that is not the most important reason to do so. It may encourage camaraderie between colleagues, but that is not the most important reason for the nurse to do so. It will not be possible to ensure that all caregivers have the same attitudes and beliefs about children with conduct disorders, but they must be consistent with limit setting, irrespective of their own attitudes and beliefs.

18. Which is an effective way for parents to deal with problem behaviors in children and to prevent later development of conduct disorders? A) Administering medications B) Avoiding setting limits C) Group-based parenting classes D) Being overprotective of the child

Ans: C Feedback: Parental behavior profoundly influences children's behavior. Group-based parenting classes are effective to deal with problem behaviors in children and prevent later development of conduct disorders.

19. The nurse has been working with the family of a small child with oppositional defiant disorder. The nurse is feeling very frustrated because the parents refuse to implement effective parenting skills that the nurse has taught. What is the best nursing action at this time? A) Review effective disciplinary practices with the parents again. B) Refer the parents to a family therapist. C) Try to remember that the parents are trying to the best of their ability to carry out the suggestions. D) Explore alternative living arrangements for the child

Ans: C Feedback: The nurse's beliefs and values about raising children affect how he or she deals with children and parents. The nurse must not be overly critical about how parents handle their children's problems until the situation is fully understood: Caring for a child as a nurse is very different from being responsible around the clock. The parents likely have other obstacles in carrying out effective discipline. Teaching again is not likely to effect change. It is premature to refer to family therapy or remove the child from the home. Emotional barriers to effective parenting should be explored first.

7. A client with conduct disorder starts yelling at another client and calling the client insulting names. Which is the most appropriate response by the nurse? A) ìHow would you feel if someone yelled at you like that?î B) ìWhat's the matter with you? Don't you know any better?î C) ìYelling at others is unacceptable. You need to let staff know you're upset.î D) ìYou're still having problems controlling your anger.î

Ans: C Feedback: The nurse must show acceptance of clients as worthwhile persons even if their behavior is unacceptable. This means that the nurse must be matter of fact about setting limits and must not make judgmental statements about clients. He or she must focus only on the behavior.

1. A child is expelled from school for repeated fighting and vandalizing school property. The school nurse and counselor meet with the parents to explain that the child may benefit from counseling as the child is experiencing signs of which disorder? A) Oppositional defiant disorder B) Asperger's syndrome C) Attention deficit hyperactivity disorder D) Conduct disorder

Ans: D Feedback: Conduct disorder is characterized by persistent antisocial behavior in children and adolescents that significantly impairs their ability to function in social, academic, or occupational areas. Behavioral symptoms include physical fights, destruction of property, vandalism, and serious violation of rules among others. ODD consists of an enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures without major antisocial violations. Asperger's disorder is a pervasive developmental disorder characterized by the same impairments of social interaction and restricted stereotyped behaviors seen in autistic disorder, but there are no language or cognitive delays. Attention deficit hyperactivity disorder (ADHD) is characterized by inattentiveness, overactivity, and impulsiveness.

9. Which is likely to be most effective for adolescents with conduct disorder? A) Involvement with the legal system B) Focusing on the parenting education C) Incarceration D) Early intervention

Ans: D Feedback: Many treatments have been used for conduct disorder with only modest effectiveness. Early intervention is more effective, and prevention is more effective than treatment. Dramatic interventions, such as ìboot campî or incarceration, have not proved effective and may even worsen the situation. Treatment must be geared toward the client's developmental age. For school-aged children with conduct disorder, the child, family, and school environment are the focus of treatment. Adolescents rely less on their parents and more on peers, so treatment for this age group includes individual therapy. Many adolescent clients have some involvement with the legal system as a result of criminal behavior, but this is a consequence of and not a treatment for conduct disorder.

14. Which is true of the time-out strategy that may be used for persons with conduct disorder? A) It is a punishment. B) It should only be used as a last resort. C) Eventually, the goal is for the client to avoid time-out. D) Time-out is retreat to a neutral place, so clients can regain self-control.

Ans: D Feedback: Time-out is retreat to a neutral place, so clients can regain self-control. It is not a punishment. When a client's behavior begins to escalate, such as when he or she yells at or threatens someone, a time-out may prevent aggression or acting out. Staff may need to institute a time-out for clients if they are unwilling or unable to do so. Eventually, the goal for clients is to recognize signs of increasing agitation and take a self-instituted time-out to control emotions and outbursts.

4. Which disorder is exemplified by vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity? A) Intermittent explosive disorder B) Mild conduct disorder C) Oppositional defiance Disorder D) Moderate conduct disorder

Ans: D Feedback: Examples of moderate conduct disorder include vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity. Intermittent explosive disorder (IED) involves repeated episodes of impulsive, aggressive, violent behavior and angry verbal outbursts, usually lasting less than 30 minutes. In mild conduct disorder, the child has some conduct problems that cause relatively minor harm to others. Examples include repeated lying, truancy, minor shoplifting, and staying out late without permission. Oppositional defiant disorder (ODD) consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations.