Foundations and Modes of Care

The parents of an infant born with a unilateral cleft lip and palate ask, "What caused our baby to be born deformed?" Which response is the most therapeutic?

"It sounds like you're concerned that you did something wrong." Rationale: A universal reaction to the birth of an imperfect child is guilt; encouraging the parents to discuss such feelings, without actually asking whether they feel guilty, provides an opportunity to express such thoughts. "You're feeling guilty" makes assumptions about the parents' feelings. "I'm glad" shifts the focus to the nurse, rather than actual concerns of the parents. "Don't worry" minimizes the parents' concerns and blocks the expression of feelings.

Which side effects would the client expect after undergoing electroconvulsive therapy? Select all that apply. One, some, or all responses may be correct.

- Headache - Confusion - Memory Loss Rationale: The electrical energy passing through the cerebral cortex during electroconvulsive therapy (ECT) results in a headache after treatment, a temporary state of confusion, and temporary memory loss. Loss of appetite and postural hypotension are not usual or expected side effects.

According to Kübler-Ross' theory of death and dying, which stage is a terminally ill client displaying by gradually moving towards resolution of feelings about impending death?

Acceptance stage When acceptance is reached, the individual is beginning to withdraw from life; communication is simple, concise, and most often nonverbal. Kübler-Ross' research has shown that at this stage, verbal communication is typically less important, and touch and presence are most important. The client has moved past the anger, denial, and bargaining stages

Which definition describes the defense mechanism of sublimation?

Channeling unacceptable impulses into socially acceptable behavior. Rationale: The individual using sublimation attempts to fulfill desires by selecting a socially appropriate activity rather than one that is socially unacceptable. Returning to an earlier, less mature stage of development is regression. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling. Repression is excluding psychologically disturbing thoughts from the consciousness.

When a client complains about the nursing care, the nurse replies, "We're doing the best we can; others need attention too." Which type of behavior is the nurse displaying?

Defensive behavior Rationale: The nurse's response is not therapeutic because it does not recognize the client's needs but instead tries to make the client feel guilty for being demanding. Impulse control refers to a sudden driving force being constrained or held back. The nurse is not using reality reinforcement or setting limits.

Which type of therapy will be best for a preschool-aged child with a history of physical and sexual abuse?

Play Rationale: When children play out feelings, they can learn to face them by controlling, accepting, or abandoning the feelings. Music therapy could be used in conjunction with play therapy to establish a therapeutic environment. Family and psychodrama therapies are not child-specific and are generally better suited to adolescents, young adults, and adults.

A woman is afraid of the water, and she insists her teenage son doesn't want to go swimming or boating with his friends. Which defense mechanism is she displaying?

Projection Rationale: The woman with a fear of water is projecting her own fears on to her son. Dissociation is the disconnection of thoughts or feelings that are associated with a memory; for example, a child has a near drowning but later in life is unable to connect the childhood trauma with fear of the water. In introjection, a person internalizes and incorporates the traits of another; for example, the son adopts his mother's fear of water. In reaction formation, expressed feelings are opposite of the experienced feelings. For example, a woman with a fear of water often talks about the benefit of water sports

A client in the mental health unit is walking swiftly around the room and rubbing his hands together. Which term describes the behavior?

Psychomotor agitation Rationale: Psychomotor agitation is constant motion such as pacing, hand wringing, nail biting, and other types of energetic body movements. Tardive dyskinesia is a syndrome of involuntary movements (e.g., oral, buccal, lingual, masticatory) that occur as a result of prolonged treatment with neuroleptic medications that block dopamine type 2 receptors. Withdrawal syndrome includes the signs and symptoms caused by the abrupt cessation of a substance that the client has become dependent on as a result of prolonged use. Psychophysiological insomnia refers to difficulty attaining or maintaining sleep; it is not related to agitated behavior.

Which intervention is most helpful for a depressed client whose husband has recently died?

Talk with the client about her husband and the details of his death. Rationale: Talking about the husband and his death will help the client work through the grief process. Depressed clients usually do not have much physical or emotional energy for activities or for interacting with others. The client must cope with the past and present before addressing the future.

The nurse receives a telephone call from an adolescent who expresses suicidal ideations. Which client response indicates that the nurse can safely terminate the call?

The adolescent formulates an action plan to control self-harm behaviors. Rationale: The client should be able to state specific behaviors that can be used to decrease self-destructive thoughts and actions. Terminating the conversation is ineffective because the client may end the conversation and remain suicidal. Risk assessment is the first step of the nursing process, but the dialogue should continue until a contract has been set or self-destructive behaviors have diminished. Repeating the same information that has already been discussed indicates the client has not reached catharsis and needs to continue talking to the nurse

Which rationale supports the use of family therapy when a child has a terminal illness?

The entire family is involved because what happens to one member affects them all. Rationale: Family therapy views the whole (gestalt) within the context in which the emotional problems are occurring. Efficiency is not an adequate rationale for choosing this therapeutic approach. Promotion of truthfulness is a secondary gain achieved with this mode of therapy. An astute nurse can control manipulation and alliance within any group, but this is not the primary reason for selecting family therapy.

According to Peplau's model of the nurse-client relationship, in which phase will most of the client's problem solving occur?

Working phase Rationale: During the working phase, goals are met, problems are resolved, and changes in behavior occur. In the preorientation phase, the nurse prepares for the orientation phase. During the orientation phase, trust is the primary focus, goals and contracts are set, and problems are identified. During the termination phase, the nurse and client review accomplishments, reinforce the use of new behaviors, and close the relationship.

Which statement indicates the adolescent client is having a situational crisis?

"My dad kicked me out of the house after we had a fight." Rationale: An adolescent who abruptly loses parental support is facing a situational crisis. The other adolescents are trying or considering various roles, which is an adolescent developmental task.

An older adult who lives alone says, "I really don't need anyone to talk to. The TV is my best friend." Which defense mechanism is the client using?

Denial Rationale: The client's statement is an example of the use of denial, a defense that blocks problems by unconsciously refusing to admit that they exist. Projection is a defense that is used to deny unacceptable feelings and emotions and attribute them to others. Sublimation is a defense in which socially acceptable behavior is substituted for unacceptable instincts. Displacement is a defense that is used to allow the shifting of feeling from an emotionally charged person or object to a safe substitute person or object

A married woman reports intermittent episodes of being beaten by her husband. Which behavior is typical of the honeymoon stage in the cycle of domestic violence?

Husband brings flowers and shows kindness Rationale: After an abusive episode, there is often a "honeymoon" period because the tensions of the abuser have been released. The abuser is kind and expresses remorse. During the tension-building phase, abusers may try to reduce tension by using alcohol or drugs, whereas the victim will try to please the abuser. The wife may unconsciously be trying to provoke an incident by staying at work. Some experts believe that this is the victim's way of releasing tension, so that the honeymoon phase can begin.

Which age group is in Freud's phallic stage of psychosexual development and Erikson's psychosocial phase of initiative versus guilt?

3 to 5 years Rationale: Ages 3 to 5 years are Freud's phallic stage and Erikson's stage of initiative versus guilt. Birth to 1 year is Freud's oral stage and Erikson's stage of trust versus mistrust. Ages 6 to 12 years are Freud's latency stage and Erikson's stage of industry versus inferiority. Adolescence is Freud's genital stage and Erikson's stage of identity versus role confusion. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

A 70-year-old man with a history of depression has few interests since retirement. He says, "I feel useless and unneeded." Based on Erikson's psychosocial stages of development, which outcome is occurring?

Despair Rationale: Integrity versus despair is the task of the older adult; the client has difficulty accepting what life is and was, resulting in feelings of despair and disgust. Initiative versus guilt is the task of the preschool-aged child. Intimacy versus isolation is the task of the young adult. Identity versus role confusion is the task of the adolescent.

Which speech pattern is a disturbed client displaying when she or he starts to repeat phrases that others have just said?

Echolalia Rationale: Echolalia is repetition of another person's remarks, words, or statements. It occurs when individuals are fearful of saying their own words and echo the words of others. Alogia is limited speech. Neologism is when new words are coined or old words take on private symbolic meanings. Symbolic speech is use of symbols to replace direct communication.

Which characteristic is most essential for the nurse to have in caring for clients with mental health disorders?

Empathy Rationale: Empathy—understanding and, to some extent, sharing the emotions of another—encourages the expression of feelings. Sympathy, or feeling sorry for someone, may further decrease the client's feelings of self-worth. Although organization may help the client accept limits and organize activities, it is not as important as empathy. An authoritarian approach will emphasize the client's weak ego and lack of self-esteem.

Which characteristic usually results in a behavior being viewed and accepted as normal?

Fits within standards accepted by one's society Rationale: An accepted practice in some parts of the world may well be considered abnormal behavior in others. Coping skills and expressions of feelings may be viewed as normal or abnormal, depending on their cultural context. Behavior that is aggressive or destructive, even if it helps the client reach a goal, cannot be considered normal.

For a newly admitted client, which aspect of the therapeutic contract is the most important?

Helping a client define treatment goals and expectations Rationale: Helping the client define treatment goals and expectations gives direction to the relationship and provides a blueprint for future evaluation of progress. The time, place, frequency, and duration of meetings and explaining the professional responsibilities of the nurse provide structure to help the client meet goals.

Which intervention is most important to assist a couple to cope with their feelings about the husband's terminal illness?

Helping the couple express to each other their feelings about his terminal illness Rationale: It is important for the couple to discuss their feelings to maintain open communication and support each other. Referring the husband to the psychotherapist for help in dealing with his anger will not meet the needs of this couple. A couples' therapy group that addresses terminal illness may be useful in the future, but this couple need to work through their own feelings first. Encouraging the wife to verbalize her feelings during individual sessions will not directly improve communication between the husband and wife; this is the primary goal.STUDY TIP: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow, they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.

The parents have severe long-term marital problems; the 14-year-old son is failing school and the 16-year-old daughter is withdrawn and refuses to talk to her parents. Which concern is the priority for this family?

How the couple's marital problems are affecting their children Rationale: The parents' ongoing marital problems appear to have interfered with their parental roles, resulting in their children's behavioral problems. The children need support, not limits. The son's and daughter's behaviors are linked to the parents' behavior. Once the parents are able to resume their parental roles, assessment and assistance can be offered as necessary if the children continue to demonstrate behavioral problems.

Based on Erikson's psychosocial stages of development, which task must a 30-year-old client work through?

Intimacy v Isolation Rationale: The major task of the young adult is to develop close, sharing relationships that may include a sexual partnership; the person develops a sense of belonging and avoids isolation (intimacy versus isolation). During the integrity-versus-despair stage, the adjusted older adult can look back with satisfaction and acceptance of life and resolve the inevitability of death; failure at these tasks results in despair. The middle school-aged child gains a sense of competence and self-assurance as social interactions and academic pursuits are mastered; failure in these tasks leads to feelings of inferiority. During adolescence the individual develops a sense of self, self-esteem, and emotional stability; failure to establish self-identity results in a lack of self-confidence and difficulty with occupational choices.STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.