KM Exam 2 Practice - Group, Crisis, Personality DO

The nurse assigned to implement a critical incident stress debriefing for a group who responded to a plane crash disaster scene must correctly organize the elements of the debriefing for maximal effectiveness. Put the following elements in the order in which they should occur during CISD: A. Provide resources, summarize the meeting, and convey support and appreciation to all. B. Affirm members' responses as normal and teach other responses that can occur later. C. Ask participants to introduce themselves, then discuss the facts of the event. D. Have members talk about what was worse about the accident, what they'd like to forget. E. Have participants first share what they were thinking at the scene of the accident. F. Discus members' physical, emotional and behavioral responses to the accident.

ANS: 1. C 2. E 3. D 4. F 5. B 6. A The fact phase allows the participants to introduce themselves and tell how each was involved, including what happened from their perspective. The thought phase follows, with all participants discussing their first thoughts of the incident. First thoughts are followed by a discussion of reactions to the event: the worst thing about the incident, what participants would like to forget, and what was most painful. Symptoms are described: what cognitive, physical, emotional, or behavioral experience they encountered at the scene and after the initial experience. The normalcy of the symptoms is affirmed, and anticipatory guidance is given regarding possible future symptoms. What has been discussed is reviewed, how closure should proceed is determined, referrals and resources are provided, and the debriefing experience is summarized.

A nurse notices that although it is midsummer, a patient with borderline personality disorder has begun wearing long-sleeve shirts. The nurse investigates and discovers that the patient has cut her wrists. Place the nursing responses in the correct order, leaving out those which are inappropriate: A. Call a "Medical Assistance Code." B. Provide support and convey caring. C. Assess the severity of the injury. D. Discuss the patient's feelings. E. Remain neutral while providing first aid. F. Have the patient journal about the event. G. Place the patient under constant one-to-one observation.

ANS: 1. C 2. E 3. F 4. D First the wounds should be assessed and then cared for, both in a way that provides minimal attention and minimizes inadvertent reinforcement; calling for a code or team response would reinforce the self-mutilating behavior. During care the nurse should remain neutral and specifically should not convey caring or empathy, and should not discuss patient feelings nor any other aspect of the event at this time. The patient should then be directed to journal about events and feelings preceding the behavior, and consequences and alternatives thereafter. Only later, after the journaling has been completed, would the nurse process feelings and issues with the patient. The patient should not be placed on one-to-one supervision or in seclusion, as these increase reinforcement of the self-mutilating behavior (which produces special attention. and/or distress (e.g. being secluded).

A patient is ready to be released from leather four-point restraints (restraints on both wrists and both ankles). Place the following actions involved in releasing a patient from restraints in their correct order. A. Maintain the patient in seclusion and reassess. B. Complete the removal of the restraints. C. Continue to observe the patient closely. D. Reassess the patient for safety. E. Release one ankle from restraint. F. Remove the patient from seclusion.

ANS: 1. E 2. D 3. B 4. A 5. F 6. C The patient should be removed from restraints and reintegrated to the unit in a step-wise, progressive fashion. Restraints are removed one at a time, usually with one ankle removed first. After reassessment to assure that the patient is safe to continue the release, the restraint on the wrist opposite the free ankle is removed, and after reassessment, the remaining two restraints are removed. The patient should then remain at least briefly in seclusion for further observation and assessment, then be returned to the unit, at which time close observation should continue in case the patient's condition deteriorates again amidst the greater stimulation and reduced external controls that characterize the unit proper.

A group has two more sessions before it ends. One member who previously has been vocal and has shown much progress has grown silent. Which response by the leader would be most helpful for the quiet member and others as well? a. "The end of a group can stir up a lot of feelings, both good and bad. I'd like to hear from each of you about what the end of the group is stirring up in you." b. "Sometimes the end of a group is welcome, other times regretted. What are people feeling as we wind down and face the end of the group?" c. "I've enjoyed the group and hope it has been helpful to you all. How about if today we focus on what everyone will be doing now that group is ending." d. "The end of the group is upon us. I wish you all well and would appreciate it if everyone could take a moment to talk about what you have learned in group."

ANS: A Although during the termination phase, the leader should encourage members to set future goals and reflect on the progress each has made, the leader should also help members deal effectively with the feelings raised by the termination of the group. Asking each member to talk about what is stirred up by the end of the group both focuses on feelings and involves the quiet member as well as others (who are likely to be experiencing emotions of their own).

A new nurse is reviewing the various types of groups available on her new unit. One group adds new members as others leave. She recognizes this type of group as a(n) ________ group. a. open b. closed c. homogenous d. heterogeneous

ANS: A An open group is a group that adds members throughout the life of the group as other members leave and as more persons who would benefit from the group become available. A closed group does not add new members; the membership is established at the beginning and, except for the occasional losses as some members leave, does not change thereafter. A homogenous group includes members who are similar, and a heterogeneous group includes dissimilar members; not enough data are provided here to determine which applies in this case.

The patient tells his primary nurse "I get into trouble because I have hair-trigger responses. I shoot from the hip. Lots of times that gets me into a mess." Which response would be most therapeutic? a. "Let's look at ways to help you slow it down and think before acting." b. "It might help to explore how you came to be that way-any ideas?" c. "I'll bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness and motivation to change."

ANS: A Interventions exist to slow reactivity to at least some forms of provocation for the patient. Educating the patient about these techniques provides other coping options when faced with those same provocations in the future. Although exploring factors that contributed to the patient's current behavioral patterns can be helpful, there are effective strategies the patient can use to change behavior that are not dependent on knowing the origins of the behavior (which many times are unknown to the patient). Asking the patient about stories serves no therapeutic purpose, and maladaptive behavior can be reinforced by showing interest in them. Insight is not necessarily indicative of readiness or motivation to change.

2. A leader is planning to start a new self-esteem group. Which intervention would be most helpful for assuring mutual respect within the group? a. Describe the importance of mutual respect in the first session, and make it a group norm. b. Exclude potential members whose behavior suggests they are likely to be disrespectful. c. Give members a brochure describing the purpose, norms, and expectations of group. d. Explain that mutual respect is expected, and confront those who aren't respectful.

ANS: A It is helpful to motivate members to behave respectfully by describing how mutual respect benefits all members and is necessary for the group to be fully therapeutic. Setting a tone and expectation of mutual respect from the outset is the most helpful intervention listed. Excluding members because of how they might behave could exclude members who would have been appropriate, depriving them of the potential benefits of the group. Conveying expectations by brochure would be less effective than doing so orally, because it lacks the connection to each member a skilled leader can create to motivate members and impart the expectation of respect. Confronting inappropriate behavior is therapeutic but only addresses existing behavior rather than preventing all such undesired behavior.

Which intervention would be appropriate for a patient with a nursing diagnosis of Ineffective coping as evidenced by manipulation of others? a. Refer patient requests and questions about care to the primary nurse. b. Provide negative reinforcement for any acting-out behavior. c. Ignore rather than confront inappropriate interpersonal behavior. d. Encourage the patient to discuss feelings of fear and inferiority.

ANS: A Manipulative patients frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and prevents playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. Ignoring behavior can in some cases help extinguish the behavior, but more typically, manipulative behavior responds better to judicious use of confrontation. Antisocial patients suppress or conceal such feelings if present and would be very unlikely to admit to them, let alone discuss them.

A group is in the working phase, and one member states, "That is the stupidest thing I've ever heard. I have never been in a group like this. Everyone is just whining and telling everyone else what to do when they have no clue, and people just sit there and take it. This is a waste of time." Which response by the group leader would be most therapeutic? a. Meet privately with the member outside of group to discuss her anger. b. Advise all that hostility is inappropriate and remove her if it continues. c. Keep the focus on the hostile member so they can exhaust their anger. d. Remember that angry members feel others are weak compared to themselves.

ANS: A Meeting privately with the member can convey interest and help defuse the anger so that it is less disruptive to the group. Removing the member would be a last resort and used only when the behavior is intolerably disruptive to the group process and all other interventions have failed. Decreasing the focus on the hostile member and focusing more on positive members can help soften the anger. Angry members often hide considerable vulnerability by using anger to keep others at a distance and intimidated.

A worker is characterized by her co-workers as "painfully shy" and lacking in self-confidence. Her co-workers say she stays in her cubicle all day, never coming out for breaks or lunch. One day after falling on the ice in the parking lot, she goes to the nurse's office, where she apologizes for falling and mentions that she hopes the company will not fire her for being so clumsy. With which diagnosis is this presentation most consistent? a. Avoidant b. Dependent c. Histrionic d. Paranoid

ANS: A Patients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing and expect and fear criticism. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious, hostile, and project blame.

A group is in the working phase, and one member has a history of being left alone as a 4- and 5-year-old when his parents worked or drank. His parents also belittled him and criticized him mercilessly; nothing he did was ever right or good in their eyes. Which comment would the group leader expect to be made by this member? a. "My boss is always expecting more of me than the others, but talking to him would only make it worse." b. "I'm sorry for talking all the time, but there is just so much going on, and I can't remember what I already said." c. "You could be right, maybe that would help, or at least it wouldn't hurt to give it a try next time." d. "This group is stupid; nobody here can help anybody else because we are all so messed up. It's a waste."

ANS: A People who frequently complain, yet reject help or suggestions when offered, tend to have histories of severe deprivation as children, often accompanied by neglect or abuse. The other comments reflect dynamics other than the help-rejecting complainer, such as the monopolizer who apologizes for talking too much, the person who is insightful and agrees to try a peer's suggestion, and the demoralizing member.

A woman expecting to pick her husband up at the airport has instead just been told that he has been killed in an airplane crash. Crisis counselors are present to help loved ones cope with the sad and sudden news. Which response by the counselor would be most appropriate to make next? a. State, "I will stay with you," and allow for a period of silence so she can process the news of her loss. b. Ask, "What would help you in this difficult time? Would you like to speak with a chaplain?" c. Ask, "Is there is someone who's supportive, who can take you home and spend time with you over the next few days?" d. State, "We realize this is very sudden and unexpected and very upsetting. The airline is committed to helping you in this difficult time."

ANS: A Persons facing traumatic news can experience a form of psychological shock wherein information processing can be significantly impaired. Indicating an intent to stay with the patient conveys support, helps establish a therapeutic relationship, and ensures that the patient is safe. (In some cases, survivors become suicidal at the prospect of being without their loved one or wish to rejoin their loved one in death.) Observing a period of silence allows the patient to process the news and begin to develop her initial responses. The patient needs this time to process events before facing other questions or being provided with instructions or information (which will be difficult for the patient to remember under the circumstances). Offering a chaplain could be perceived as disinterest in remaining with the patient—a form of rejection—and although connecting the woman with support resources appropriate to her particular religious and cultural preferences would be helpful later, it is premature at this very early stage of adjustment. Indicating that the airline desires to be helpful, when the airline is responsible for the crash and resulting deaths, could be perceived as self-serving and draw a very angry, nontherapeutic response from the survivors.

A nurse in the emergency room is responsible for responding to crises involving school children and has spent many days in local schools helping grieving students who have lost peers or teachers unexpectedly. She is also exposed daily to the victims of horrible accidents and other physical and emotional traumas. Which of the following would be most important for her to address in periodic clinical supervision? a. Vicarious traumatization b. Evidence-based interventions c. Research on crisis response d. Physiological response to crises

ANS: A Persons who work with survivors of trauma are indirectly—vicariously—exposed to trauma themselves and can experience the same sort of responses as those who experience trauma directly, especially as their exposure to such second-hand trauma accumulates. This phenomenon is called vicarious traumatization, and a nurse working repeatedly with traumatized students would be at risk. An emergency room nurse also experiences trauma directly in the process of caring for those who have been injured by traumatic events. Critical incident stress debriefing (CISD) is helpful and indicated for crisis counselors and others at risk for vicarious traumatization, just as it is for emergency responders at risk for posttraumatic stress disorder. Although all of the topics listed would be appropriate for discussion during supervision, focusing on the prevention of vicarious traumatization would be most important because it is essential to preserving the nurse's physical and psychological well-being.

A factory abruptly closes during hard economic times. An office worker initially tries to take it in stride, begins the job search, and networks with peers. Six weeks later, he has not received a single call-back from a prospective employer. He cannot sleep, is irritable, does not want to interact with his family or peers, paces frequently, and spends several hours most days alone in a local bar. Bills are piling up. He has given up applying for jobs. Which short-term indicator would be most important at this time? a. Patient sleeps at least 6 hours per night. b. Patient no longer goes to bars each day. c. Patient no longer paces regularly. d. Patient considering jobs to apply for.

ANS: A Resumption of normal sleep patterns suggests that depression is improving, and the increased rest should enable him to begin to cope more effectively. Reductions in pacing and going to the bar may either be a positive indicator or mean that the individual has become more immobilized. Considering jobs to apply for indicates he is moving toward more adaptive coping but not necessarily that he is making effective coping efforts

The priority assessment the nurse must make during the initial crisis intervention interview is the: a. need for external controls. b. adequacy of social supports. c. patient's perception of the precipitating event. d. patient's preferred coping mechanism.

ANS: A Safety needs of patients and others are of high priority, so assessment of potential for harm to self or others is of greater importance than the other options.

Which situation would involve the highest risk for violence? a. A nurse is about to set limits on a patient. b. Shift change and report are about to begin. c. A PRN medication is to be offered. d. The patient is a young adult male.

ANS: A Setting limits is the situation associated with the highest incidence of violent behavior. Shift change can also be a concern because there can be more confusion (as staff come and go) and fewer staff available in the milieu; however, this does not involve the degree of risk associated with limit setting. PRN medications can be offered for many reasons other than escalation and not be associated with significantly higher degrees of risk. Young adult males are statistically more prone to violence, but this does not mean that most such persons will be violent or that the risk of violence is significantly increased when the patient is a young male.

The nurse has recently set limits for a patient with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're hateful." Which phenomenon is represented by this response? a. Splitting b. Denial c. Reaction formation d. Projection

ANS: A Splitting involves an inability to recognize that an individual can have both positive and negative qualities. Instead, when a person exhibits positive qualities, the patient idealizes that person, and when the person displeases the patient, the patient denigrates that same person. In this case, the patient is switching from idealization to denigration in response to a perceived negative aspect of the nurse. Denial is a defense mechanism wherein anxiety is reduced by blocking awareness or acceptance of whatever is causing the anxiety. Reaction formation involves unconsciously doing the opposite of an anxiety-provoking impulse. Projection is a defense mechanism wherein the person denies that the anxiety-provoking urge or thought exists and instead projects it onto others, so that the patient perceives others as having the thought or urge that is really their own (but unacceptable for them to face).

A patient with antisocial personality disorder tells Nurse A, "You're a much better nurse than Nurse B said you were." The patient tells Nurse B, "Nurse A's upset with you for some reason." To Nurse C the patient states, "You'd like to think you're perfect, but I've seen three of your mistakes this morning." Which nursing intervention would be most helpful for addressing this behavior? a. Hold a weekly staff meeting to discuss feelings and conflicts related to such behavior. b. Confront the patient and advise her that if she continues this, she will lose privileges. c. Get all staff to agree that any and all inappropriate behavior will simply be ignored. d. Evaluate the patient for a medication increase or transfer to a long-term facility.

ANS: A Staff splitting is occurring here, wherein the patient is setting up conflict among the staff to manipulate them into focusing on each other, thus taking the focus off the patient. It is important that staff help each other recognize this dynamic and develop a plan of response that all will use consistently. A weekly meeting to discuss the behavior is beneficial. Threatening the patient with loss of privileges implies that staff will punish or reject her if she is "bad," setting up a scenario perhaps similar to others wherein relationships have been conditional; this would increase abandonment fears and increase acting out behavior. Similarly, ignoring the patient each time her behavior is inappropriate is an excessive response that will heighten abandonment issues. Instead, staff should aim for a happy medium, wherein inappropriate behavior is labeled as such and addressed but not in a punitive or other manner that inadvertently reinforces it (e.g., negative attention can also be reinforcing). A medication increase or transfer would not help the patient behave more adaptively or appropriately. Staff supporting such measures are often experiencing countertransference and acting out their own negative feelings about the patient.

Three members of the therapy group share covert glances as other members of the group bring up problems. One of them often makes a statement that subtly puts down another speaker or takes exception to a comment by the group leader. The others then nod in agreement. What explanation should the leader suspect underlies this group dynamic? a. Some members are acting as a subgroup instead of as members of the main group. b. The members in question are showing their frustration with slower members. c. Some of the members have become bored and are tuning out the rest. d. The members in question are passive aggressive in their personality style.

ANS: A Subgroups—small groups isolated within a larger group and functioning separately from it—sometimes form within therapy groups. When this occurs, subgroup members are cohesive with other subgroup members but not with the members of the larger group. Members of the subgroup may be bored or frustrated or expressing passive aggression, but the primary dynamic seen here is the splitting off of a subgroup that operates separately within the main group.

The nurse is planning a new sexuality group. Which location would best enhance the effectiveness of this group? a. A unit conference room b. The hospital's auditorium c. The unit day (living) room d. A corner of the music therapy room

ANS: A The conference room would provide a quiet, private area with few distractions, separate from other patient areas and effective for teaching and learning about a private topic. The auditorium is too large, and members' anxiety or lack of trust might lead them to spread out too far from each other, interfering with group process. The day room and the music therapy room are too busy and exposed, reducing privacy and increasing distractions.

While the nurse at the personality disorders clinic is interviewing a patient, the patient constantly scans the environment and frequently interrupts to ask what the nurse means by certain words or phrases. The nurse notes that the patient is very sensitive to the nurse's nonverbal behavior. His responses are often argumentative, sarcastic, and hostile. He suggests that he is being hospitalized "so they can exploit me." The patient's behaviors are most consistent with the clinical picture of: a. paranoid personality disorder. b. histrionic personality disorder. c. avoidant personality disorder. d. narcissistic personality disorder.

ANS: A The diagnosis of paranoid personality disorder is defined by features such as pervasive mistrust of others; perceiving the motives of others as malevolent; believing that he is being exploited or victimized; perceiving inconsequential or neutral actions as containing slights, insults, or hidden threats; and an inability to trust even those closest to him. In that these patients perceive others as aligned against them, they tend to be defensive and accusative of others. The patient with histrionic personality disorder would be flamboyant and attention seeking. Persons with avoidant personality disorder would be excessively anxious and hypersensitive to criticism. The patient with narcissistic personality disorder would be grandiose, aloof, and disparaging of others.

A factory abruptly closes; workers receive no warning and no explanation. An office worker tries to take it in stride and begins the job search, updating his resume, submitting applications, and offering support to his peers. Which assessment question would be most important to ask at this time? a. "Tell me how has this affected you, how things seem to you." b. "What do you think you will do if your plan does not work?" c. "Tell me about some other difficult times you've been through." d. "Tell me who cares about you, supports you, who you can count on."

ANS: A The initial focus in crisis situations should be on determining how the patient sees the event and his current situation and, in particular, whether psychiatric treatment or admission is needed to provide for his safety or prevent decompensation. A broad opening question that yields information on how the person interprets the event and how it has affected him so far helps to determine his perception of events and whether he requires psychiatric care. Seeking information about past crisis responses, present coping efforts, and future plans would follow.

A patient requires as-needed sedation. What would the nurse keep in mind when choosing a PRN sedative for an agitated patient? a. Intramuscular injection can be traumatic, so oral meds should be used where possible. b. Benzodiazepines are less sedating but have the advantage of no side effects. c. Lithium carbonate works well but only for those already taking regular daily dosages. d. Diazepam (Valium) is the preferred benzodiazepine because it is a short-acting sedative.

ANS: A The intramuscular route can be traumatic for patients, particularly for trauma survivors, and can itself be perceived as an aggressive or punitive intervention. Benzodiazepines in sufficient dosage can be as sedating as antipsychotics and are not free of side effects; they are central nervous system depressants and can cause paradoxical excitement or aggression in some persons. Lithium carbonate reduces aggression in select situations involving chronic aggression but is not effective or appropriate for PRN use. Diazepam is a long-acting sedative and as a result would not be appropriate for PRN use.

A patient, Mary, has talked constantly throughout the group therapy session. She has repeated the same material several times. Other members were initially attentive then became bored, inattentive, and finally sullen. Which intervention would be most effective for the nurse leader to take? a. "Most of you have become quiet. I'm wondering if it might be related to concerns you may have about how the group is progressing today." b. "Mary has been doing most of the talking. I think it would be helpful for everyone to tell Mary how that has affected your experience of the group." c. "I noticed that as the group went on, most members became quiet, then disinterested, and now seem almost angry. What is going on?" d. "Mary, you have been doing most of the talking, and others have not had much chance to speak as a result. Could you please yield to others now?"

ANS: A The most effective action the nurse leader can take will be the one that encourages the group to solve its own problem. Pointing out changes in the group and asking members to respond to them lays the foundation for a discussion of group dynamics. Asking members to respond to Mary puts Mary in an awkward position, likely increasing her anxiety as others focus on Mary herself rather than the group process; as anxiety increases, monopolizing behavior tends to increase as well, so this response would be self-defeating. Asking members what is going on is a broader opening and might lead to responses unrelated to the issue that bears addressing; narrowing the focus to the group process more directly addresses what is occurring in the group. Focusing on Mary would be less effective and involves the leader addressing the issue instead of members first attempting to do so themselves (giving them a chance to practice skills such as assertive communication).

A teacher comes to the mental health clinic saying a co-worker recently confronted her about behaviors that are annoying to other co-workers. She is now experiencing moderate to severe levels of anxiety. The co-worker told the patient that others find her very difficult because she is a perfectionist and micromanages the tasks of others on the teaching team, always demanding that things should be done according to her plans. The co-worker mentioned that the patient made everyone feel as though everything they tried was inadequate, and they feel frustrated and angry. The patient states she likes her co-workers and only wanted to help them be successful. The nurse realizes the patient's behaviors are most consistent with: a. obsessive-compulsive personality disorder. b. narcissistic personality disorder. c. histrionic personality disorder. d. schizoid personality disorder.

ANS: A The need to control at the expense of flexibility and openness, along with a preoccupation with orderliness and perfectionism, is consistent with obsessive-compulsive personality disorder. Narcissistic personality disorder involves grandiosity, the need for admiration, and lack of empathy. Histrionic personality disorder involves excessive emotionality and attention seeking. Schizoid personality disorder involves detachment from social relationships and a restricted range of expression in interpersonal settings.

4. During group therapy, John states, "When I first started in this group, Betty wasn't able to make a decision. Now she can. She has made a lot of progress. I am beginning to think that maybe I can conquer my fears too." According to Yalom, this statement reflects: a. hope. b. altruism. c. catharsis. d. cohesiveness.

ANS: A The patient's profession that he may be able to learn to cope more effectively reflects hope. Groups can instill hope in individuals who are demoralized or pessimistic. Altruism refers to doing good for others, which can result in positive feelings about oneself. Catharsis refers to venting of strong emotions. Cohesion refers to coming together and developing a connection with other group members.

A patient, aged 16 years, comes to the crisis clinic and tells the nurse that an uncle tried to rape her yesterday. The patient had told her mother of the uncle's behavior, but the mother accused the daughter of lying and, contrary to the patient's hopes, indicated she would still allow the uncle to visit the family. The patient describes feeling "all confused" and shows minor lacerations on her forearms to the nurse, which she indicates she did out of desperation rather than a wish to die. Which nursing diagnosis would be most appropriate as her primary diagnosis? a. Powerlessness b. Disturbed thought processes c. Rape-trauma syndrome d. Interrupted family process

ANS: A The patient, a teenager, has relatively little control over her circumstances compared to her parents. However, when she approached her parent seeking support and protection, she was instead rebuffed and identified as the perpetrator rather than the victim. The patient made an effort to exert the power available to her by reporting the attempted assault, only to be accused herself and have the protection she desired withheld. Of the diagnoses listed, the most applicable would be powerlessness. There are no data to support an alteration in thought processes or interruption in family process. Rape-trauma syndrome involves posttraumatic stress disorder-like symptoms that include flashbacks and intrusive thoughts, none of which are documented here.

"It doesn't really matter what we do, I'm just here because they make me attend." a. Playboy b. Energizer c. Organizer d. Gatekeeper e. Follower

ANS: A The playboy is disinterested, or feigns disinterest, in the group. A gatekeeper monitors the participation of all members to keep communication open.

A nurse deciding whether or not to place an agitated patient in seclusion or restraints would need to keep in mind that: a. the goal in using either seclusion or restraint is always to maintain the safety of the patient or others. b. restraints are designed to discourage inappropriate behavior by serving as negative reinforcements. c. seclusion and restraint are used in place of de-escalation when staff judge that de-escalation would be ineffective. d. once implemented, restraints should not be terminated until the patient has remained calm for at least 6 hours.

ANS: A The reason for using seclusion or restraints must always be to maintain the safety of the patient and/or others. All feasible alternative interventions must have been tried and proven unsuccessful before measures as restrictive as seclusion or restraints are used. They are never to be used as punishment or negative reinforcers and should be replaced with less-restrictive alternatives as soon as the patient is able to follow directions and remain safe.

An elderly patient with multi-infarct dementia is striking out with her arms and kicking at people who walk past in the hall. The nurse determines that the patient believes she is at home and that the other patients have broken into her home. The clinical nurse specialist suggests that staff use validation. Which of the following responses reflect this intervention? a. "I'm a nurse who has come to check on you. Tell me about your home." b. "You are in a nursing home. The others here are patients, just like you are." c. "I wish you could be home, but you have been sick and are in a nursing home." d. "You are not at home. This is a nursing home. It is September 10th, 2010."

ANS: A Validation involves reducing distress by validating the essence of the patient's experience. By explaining her purpose for being with the patient, the nurse reduces the patient's tendency to see her as one of the home invaders. Asking the patient to talk about her home is the beginning of the validation process; subsequently the nurse will acknowledge the patient's desire to be home, gently guide the patient to reconsider whether her present location is her home, and whether the others might in fact belong there. The other choices are all variations on reorienting the patient to reality and are less likely to be effective (or may even be counterproductive in some patients).

The emergency department nurse realizes that the husband of a patient appears increasingly irritable as he waits alone in the waiting room. Which intervention would best prevent further escalation? a. Periodically update the husband about his wife and what is being done for her. b. Explain that waiting is necessary because patients are treated in order of need. c. Reassure him that everything possible is being done and suggest ways to relax. d. Suggest that he return home and await an update from the physician in 3 hours.

ANS: A Waiting without information about what is occurring, especially for one already worried about an ill spouse, is very anxiety provoking. Some persons would interpret this waiting as neglect, a sign that staff do not care, leading to increasing frustration and anger. Providing periodic updates on the patient's condition and what is being done to help her keeps the spouse involved and reduces misperceptions. The other options fail to address specifically the dynamic underlying the spouse's escalating frustration, because they do not fill in the unknowns with specific information. Asking him to wait 3 hours at home would only compound his anxiety. Suggesting that he relax could be perceived as implying that his response is unreasonable, which would likely be perceived as criticism, frustrating him further and likely increasing his anger.

A patient presents in crisis. She tells the nurse, "I cannot take it anymore! It has to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend." The nurse can make the assessment that crisis intervention is successful when the patient: a. resolves her grief regarding the actual and potential losses in her life. b. permits others to make decisions for her until her anxiety is reduced. c. develops a higher degree of resilience to use when facing future crises. d. learns to respond more calmly and logically in crisis situations.

ANS: A When a person's crisis centers on actual or potential losses, the patient is dealing with actual or anticipatory grief. Although the actual or threatened losses increase anxiety as well, successful resolution of the crisis depends on resolving the grief she is experiencing. Permitting others to assume decision making increases dependency and is rarely a strategy in crisis intervention. Enhancing resilience is always desirable but is not required to resolve the present crisis. Learning to respond more calmly when under stress would seem helpful but is not fundamental to resolving a crisis situation.

Place the steps for limit setting in the most desirable order. a. Implement consequences when undesired behaviors present. b. Identify undesirable behavior and discuss concerns with patient. c. Jointly establish consequences for future inappropriate behavior. d. Jointly determine what behaviors would be preferred instead.

ANS: A, B, C, D The limit-setting process basically involves identifying the problem (undesired behavior), exploring acceptable alternatives, determining consequences for the undesired behavior, and consistent, fair implementation of consequences when the undesired behaviors occur thereafter.

An aggressive patient was placed in four-point restraints and given an intramuscular dosage of anxiolytic medication. Nursing care of the restrained patient should include: (Select all that apply.) a. assessment of vital signs and hydration. b. constant direct observation until release. c. provision of fluids and finger foods. d. opportunities for elimination at least hourly. e. regular reassessment of mental status. f. range-of-motion and comfort needs.

ANS: A, B, C, D, E, F Patients in restraints are entirely dependent on others for their basic safety and all of their physiological needs. They are also at risk of injury from poor positioning that interferes with their circulation or airway. Therefore all restrained patients must be constantly observed to ensure they are safe and secure. They also are to be provided with adequate nutrition (straws for fluids and finger foods for solids ease intake), regular opportunities for elimination, repositioning or other interventions to provide for periodic range-of-motion exercise, regular assessment of mental status, and attention to other hygiene and comfort needs.

During his first interview at the crisis center, a patient who is having difficulty coping with divorce proceedings tells the nurse he has usually been able to talk over problems with his sister. He also states he finds playing the guitar relaxing, but it was loud, and he had given it up when he became an apartment dweller. He mentions that he is an alcoholic but has been in recovery for the past 4 years, though he is afraid the stress might cause him to relapse. Which of the following options would be appropriate for the nurse to recommend to enhance the patient's coping? Select all that apply. a. Visiting his sister to talk about his feelings and situation b. Finding a place to play guitar that won't disturb others c. Returning to the clinic for daily sessions during the coming week d. Attending AA meetings more frequently until the crisis passes e. Taking a drug similar to diazepam but which has fewer side effects f. Learning assertiveness skills to protect his rights during the proceedings

ANS: A, B, D, F His sister has been an effective source of support in the past, and it is realistic that he can reconnect with her for this purpose. Playing guitar has also been stress-reducing, and he can overcome the noise obstacle to playing by finding a more secluded or soundproof area to play in. Attending AA meetings can provide support from persons who share his addiction history and are likely to be empathetic; this is especially helpful for persons under stress and vulnerable to relapse. Assertiveness skills could increase his confidence and reduce his sense of powerlessness over the divorce proceedings. However, daily counseling sessions are not clinically indicated unless other coping options are inadequate, and that does not appear to be the case here. Benzodiazepines are similar in action and effects to alcohol and could increase the chance of relapse or be abused themselves.

A new head nurse discovers her mental health unit has an unusually high incidence of critical incidents involving aggression. Which milieu interventions or modifications would be likely to help reduce the frequency of such events? Select all that apply. a. Make sure staffing is adequate for the needs of the patient group. b. Train staff to provide humane, person-centered, strengths-based care. c. Reward more effective staff with better schedules or pay increases. d. Increase or decrease the amount of stimulation to match patient needs. e. Structure patient schedules so patients are kept consistently busy. f. Monitor the milieu closely, and promptly address stressors or triggers.

ANS: A, B, D, F The key task for the manager and all staff is to design, monitor, and adjust the physical and social milieu so that, as much as possible, it is therapeutic. Staffing should be adequate in number and skills and should be adjusted as needed at least each shift. Care must be humane, effective, patient-centered, and strengths-based. The amount of stimulation is of special importance and should be adjusted upward or downward for each patient and for the group at large as their needs change. Monitoring the milieu for stressors and triggers is key to preventing undesired incidents. However, as professionals, staff should aspire to provide highly effective care without expectation of special rewards. Patients recovering from psychiatric disorders need breaks, periods where stimulation and demands upon them are reduced, to adequately process and respond to internal and external experiences.

A patient with personality disorder seemed intelligent to the nurse. He said all the right things to please the nurse but often failed to follow through. One evening he was brought back late from a pass, acutely intoxicated. The nurse seemed dismayed and remarked, "I thought he was making such good progress." Which phenomena are likely illustrated in the nurse's response? Select all that apply. a. Successful manipulation by the patient b. Naiveté on the part of the nurse herself c. Guilt for having supported the patient's pass d. Failure by the nurse to remain objective e. An incompletely formed therapeutic relationship f. Honest disappointment that the patient regressed

ANS: A, B, D, F This patient may have successfully convinced the nurse that he had made more progress than was actually the case. Patients may manipulate staff in this way to get increased privileges or achieve discharge. Inexperienced nurses often have high expectations for the progress of personality disorder patients and fail to appreciate how enduring the patient's behavior patterns have become, and as a result, how likely it is that progress can be incomplete or subject to regression. The nurse may have allowed positive but superficial behaviors or traits in the patient to lead her to overestimate his progress (i.e., she lost objectivity). The nurse might also have been genuinely disappointed; the initial reaction to relapse or continuing acting-out behaviors is often disappointment. The scenario does not provide data supporting a role for guilt or a defective relationship in the nurse's response.

The next-to-last meeting of an interpersonal therapy group is taking place. One would expect the leader to take which action(s)? Select all that apply. a. Encourage members to reflect on their progress and that of the group itself. b. Facilitate discussion and resolution of feelings about the end of the group. c. Support appropriate expression of disagreement by the group's members. d. Remind members of the group's norms and rules, emphasizing confidentiality. e. Help members identify goals they would like to accomplish after the group ends. f. Promote the identification and development of new options for solving problems.

ANS: A, B, E The goals for the termination phase of groups are to prepare the group for separation, resolve related feelings, and prepare each member for the future. Contributions and accomplishments of members are elicited, postgroup goals are identified, and feelings about the group's ending are discussed. Group norms are the focus of the orientation phase, and conflict and problem solving are emphasized in the working phase.

A new nurse overhears the clinical specialist talking about trauma-informed care and asks for more information about it. What information would the clinical nurse specialist provide? Select all that apply. a. Patients who are disruptive or aggressive often have been severely traumatized. b. It is critical that our interventions do not themselves add to the patient's trauma. c. Trauma is ever present in modern life, and patients cannot heal unless sheltered from it. d. Trauma survivors self-sooth excessively, leading to narcissism and demanding behavior. e. Trauma survivors are further traumatized by restraint and other coercive interventions. f. The role of trauma in one's current life should be a focus in assessment and treatment.

ANS: A, B, E, F Trauma-informed care operates on several key principles. First, many people who act out have significant trauma histories, and such trauma histories may be hidden or underappreciated. Second, the experience of trauma makes the trauma survivor more susceptible to future trauma. Third, to be therapeutic, our interventions must themselves not be traumatizing to the trauma survivor. Fourth, a number of our interventions are in fact traumatizing, particularly those that are coercive or restrictive (e.g., restraints, involuntary intramuscular medications). However, although life is stressful, it is neither possible nor desirable to attempt to shield survivors of trauma from all the demands and trauma that might occur in life; such experiences can also lead to growth. Trauma survivors tend to have difficulty self-soothing when under stress and as a result are more likely to cope via maladaptive means.

Which of the following interventions would be appropriate when working with a woman whose nursing diagnosis is Ineffective coping related to impaired impulse control as evidenced by impulsive self-injurious behavior? (Select all that apply.) a. Assist the patient to develop a list of effective coping options to carry for future use. b. Encourage her to use negative reinforcers (e.g., pain) to discourage undesired behavior. c. Guide the patient to examine the advantages and costs of her present coping strategies. d. Help her to practice the desired responses in role plays and later in real-life situations. e. Teach the patient to "cue" herself to stop and think before taking undesired actions. f. Consult with her psychiatrist about antianxiety medication to help reduce impulsiveness.

ANS: A, C, D, E Persons who are impulsive may have difficulty identifying better alternatives in the heat of the moment. A list of more adaptive, preferred alternative responses—created ahead of time and carried with her—can be consulted when in crisis, compensating for the patient's difficulty with identifying better alternatives when under stress. Guiding the patient to identify advantages and disadvantages of available options can help her learn to make more adaptive choices when considering which actions to take in the future. Practice via role plays allows opportunity to refine one's plans and builds confidence in one's ability to enact the adaptive strategies identified. Later practice in real life also builds confidence and further hones skills. Interrupting the "impulse-action" pattern by cuing oneself to stop and consider before acting is very important to reducing impulsive behaviors. Rather than using negative reinforcers when "doing something wrong," positive reinforcers (such as rewarding oneself with a treat) are used to reinforce desired actions instead. Anxiety is not the main issue driving impulsive behavior, and antianxiety medications can be abused and in some cases can be disinhibiting, decreasing the patient's ability to control impulses rather than helping it.

A head nurse is concerned about the frequency of patient violence on her unit. Which of the following actions would be likely to reduce such incidents? Select all that apply. a. Encourage staff to have numerous, brief, nondirective interactions with all patients starting at admission. b. Increase the percentage of males working on the unit so that the male presence will inhibit violent behavior. c. Make sure a thorough assessment of risk for violence is completed on all patients at admission. d. Train staff to implement seclusion and restraint promptly when a patient shows signs of escalating aggression. e. In supervision, facilitate self-awareness regarding staff's feelings about violence and any possible nontherapeutic responses that might result from these feelings. f. In cases where several or more patients on the unit are prone to violence, set stricter rules and limits on the unit to maintain a high degree of staff control.

ANS: A, C, E Frequent neutral or positive interactions build trust in staff, which in turn increases staff effectiveness in de-escalation situations, reducing violence. Thorough risk assessments are essential to identifying and responding quickly and therapeutically to patients who are at high risk of violence. Staff self-awareness about their feelings and responses to aggression and violence is essential to assuring that nursing interventions will be prompt and therapeutic. An increased presence of male staff does not necessarily reduce patient violence; both male and female staff should be equally highly skilled in violence prevention and de-escalation. De-escalation techniques should be used before restrictive responses such as restraint or seclusion are considered; relying on restrictive responses can intensify rather than reduce patient violence. Research suggests that a reduced sense of control over one's circumstances can contribute to increased violence.

After an incident in which staff intervention was required to control a patient's aggressive behavior, a critical incident debriefing will take place. Which topics should be covered during the debriefing group? Select all that apply. a. What, if anything, could have been done to prevent the patient's aggression? b. Which staff members could most improve their response and by what means? c. What feelings do staff have about the patient, and do they affect staff's effectiveness? d. Why was a dangerous patient admitted, and how can this be prevented in the future? e. Was anyone traumatized emotionally, and if so, how best can this be addressed? f. What changes could be made in future such situations to achieve a better outcome?

ANS: A, C, E, F The purpose of debriefing after a critical incident is to assure that the event and its effects on all involved are understood, that interventions are critiqued and improved in the future (both for preventing incidents and responding to them), and that arrangements for support and education are made when needed. It is important that such sessions not result in assigning blame in a public setting; if an individual performed poorly or inappropriately, the matter should be addressed in one-to-one clinical supervision instead of during the debriefing. Expecting that potentially dangerous persons not be admitted is unrealistic; persons who may become dangerous also require care, and staff and the admitting institution are responsible for being adequately prepared and capable of providing the needed care safely.

A nurse takes a dinner tray to a patient who has been pacing and preoccupied. The patient suddenly places his butter knife against his throat and demands that everyone stay back. Which of the following considerations should be kept in mind in responding to this situation? Select all that apply. a. Maintaining and conveying a sense of calm confidence helps calm the patient. b. The patient will require restraint because he has presented a danger to self. c. In that the patient is not in control, the nurse should control what happens. d. Determine what the patient considers to be his need, to be important to him. e. Ask the patient for ideas about what he thinks would help resolve the crisis. f. Tell the patient that your goal is that everyone remains safe while you talk.

ANS: A, D, E, F To de-escalate a situation such as this, a number of principles should be kept in mind. One is that staff should act as they intend for the patient to act, that is, they should remain calm and convey a sense of confidence that the situation will be resolved safely. Involving the patient in identifying the triggers or stressors underlying the crisis and in identifying possible solutions is much more likely to lead to a positive resolution. The alternative, wherein staff act on their assumptions about the causes of the event are and determine solutions unilaterally, is less likely to be effective and may even provoke the patient to escalate further if the precipitating event entailed the patient feeling he did not have control over what was happening to him. Stating staff's goal of safety for all is also important and should be added to the patient's goals; defining the safety of all as the priority also conveys that staff care about the patient. Although some staff feel that highly restrictive measures are required any time a person has endangered himself or others, in point of fact this decision should be made on a case-by-case basis. The prospect of seclusion or restraint can prolong and intensify a crisis and/or lead to further crises.

A factory abruptly closes. An office worker initially tries to take it in stride, begins the job search, and networks with peers. Five weeks later, he has not received a single call-back from a prospective employer. He cannot sleep, is irritable, does not want to interact with his family or peers, paces, and spends several hours most days alone in a local bar. He has given up applying for jobs. Which three nursing diagnoses would be the highest priority at this time? Select all that apply. a. Risk for self-injury b. Risk for compromised resilience c. Ineffective denial d. Ineffective coping e. Chronic low self-esteem f. Social isolation

ANS: A, D, F The fact that the person is no longer making adaptive efforts to cope suggests hopelessness. Withdrawal, irritability, and impaired sleep suggest possible depression. The depression, hopelessness, alcohol abuse, and isolation are risk factors for suicide, so Risk for self-injury is the highest-priority diagnosis. The root cause of his current status is that his systems for coping have been overwhelmed, making Ineffective coping the second priority after safety. Risk for compromised resiliency is not a priority relative to other concerns, and the data do not support Ineffective denial or Chronic low self-esteem. Social isolation is clearly a concern because of his withdrawal and lack of access to supports, so it is also a top-three priority.

A patient with borderline personality disorder has cut her wrists. The physician orders daily dressing changes for the lacerations. The nurse performing this care should: a. encourage the patient to vent anger and aggression. b. provide care in a matter-of-fact manner. c. be kindly, sympathetic, and concerned. d. offer to listen to the patient's feelings about cutting.

ANS: B A matter-of-fact approach does not provide the patient with inadvertent positive reinforcement for self-injurious behavior. The goal of providing emotional consistency is supported by this approach. All other options provide positive reinforcement of the behavior. Discussion of feelings should occur apart from episodes of self-mutilating behavior and related nursing care. Sympathy is not therapeutic in general; overtures of kindness and concern can evoke fears of abandonment, and even when this is not a concern, can reinforce self-injurious behavior if they are provided during response to self-mutilating behavior.

An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. Which intervention would be safest and most appropriate? a. Enter the day room and say, "Would you like to come to your room and take some medication that your doctor has ordered for you?" b. Take three staff members as backup and say, "Please come to your room so I can give you some medication that will help you feel more comfortable." c. Take two male aides with you and tell the patient, "You can come to your room willingly so I can give you this medicine, or we will have to take you there." d. Four staff should clear the room of patients, restrain the target patient, then administer the PRN medication and continue to hold him until he calms.

ANS: B A patient gains feelings of security if he or she sees others are present to help ensure everyone's safety. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach conveys to the patient that he can act responsibly and maintain control, increasing the chances that he will act in the manner indicated. Asking the patient if he would like to take the medication implies incorrectly that he has a choice in this instance; if the decision has been made that the medication is to be given, offering him a choice and then retracting it if he declines will violate trust with staff and possibly increase his distress and agitation. All staff, regardless of gender, should have the training and skills necessary to de-escalate patients and assist in crises, including physically if needed. Physical control measures should be used only as a last resort; they can be perceived as assaultive or punitive and increase the risk of injury to the patient and/or staff.

The patient on the mental health unit who should be assessed as being at highest risk for directing violent behavior toward others is the patient who has: a. obsessive-compulsive disorder and performs many rituals. b. paranoid delusions of being followed by the Mafia. c. severe depression with feelings of worthlessness and self-loathing. d. completed alcohol withdrawal and is now in a rehabilitation program.

ANS: B A patient who has paranoid ideation or delusions may feel threatened and respond violently toward those believed to represent a danger. Impaired reality testing also reduces the person's ability to accurately perceive the world around him and can impair judgment. The other situations are not usually associated with a higher risk of violence.

Which health care worker should be referred to critical incident stress debriefing? a. A nurse who worked 8 hours answering visitor queries at the intensive care unit information desk after a bus crash led to multiple admissions b. The emergency medical technician who treated victims of a car bomb attack on a large department store c. A nurse who works at an oncology clinic with patients receiving chemotherapy, many of whom are terminally ill d. A case manager working day in, day out, with low-functioning severely mentally ill persons in group homes

ANS: B Although each of the individuals mentioned experiences job-related stress on a daily basis, the person most in need of critical incident stress debriefing is the emergency medical technician who experienced an adventitious crisis event by responding to a bomb attack and providing care to trauma victims.

A patient with severe orthopedic injuries after an automobile accident is irritable, angry, and belittles the nurses who provide his care. While the nurse is changing the dressing over a deep laceration, the patient screams, "Don't touch me! You are so stupid; you're only making it worse!" Which intervention would be most therapeutic? a. Wordlessly leave the room and ask to switch assignments with another nurse who may be more acceptable to the patient. b. Apologize, explain that the dressing change is necessary to prevent infection, and jointly explore ways to decrease the discomfort involved. c. State: "Since you believe we nurses aren't able to change your dressing, perhaps you would like to change it yourself." d. State: "This is frustrating for both of us, but there is no choice because your doctor has ordered this dressing change."

ANS: B Apologizing, explaining the need for the intervention, and jointly exploring options to reduce its discomfort make use of both validation and problem solving. Involving the patient in problem solving increases his sense of control over his circumstances. Loss of control over one's circumstances typically increases anxiety and often accompanies serious medical illnesses or trauma. If the nurse were unable to maintain a professional demeanor because of countertransference, leaving and switching assignments would be appropriate, but that situation is not indicated here. Suggesting the patient change his own dressing is a hostile response by the nurse designed to "put him in his place"; it may serve to vent the nurse's own frustration, but it is obviously not addressing the underlying causes of the patient's hostile acting out. Acknowledging that it is frustrating could be a helpful adjunctive intervention if accompanied by another response that addresses the root cause of the patient's acting out.

During a multifamily support group, a patient who has schizophrenia says, "Sometimes I feel very sad that I will never have a good job like my brother, who is an executive. Then I dwell on it, and maybe I should not." The nurse leader can best facilitate discussion of this issue by responding: a. "Grieving for what is lost is a normal part of having a mental disorder." b. "How have others in the group handled painful feelings like these?" c. "It is often better to focus on our successes rather than our failures." d. "I wonder if you might also experience feelings of anger and helplessness."

ANS: B Asking for others to share their experiences will facilitate discussion of an issue. Giving information may serve to close off discussion of the issue because it sounds final. Suggesting a focus on the positives implies a discussion of the issue is not appropriate. Suggesting other possible feelings is inappropriate at this point, considering the patient has identified feelings of sadness and seems to have a desire to explore this feeling. Focusing on other feelings will derail discussion of the patient's grief for his perceived lost potential.

A patient being interviewed on his first visit to the crisis center says he is there because he needs help, but then he falters and cannot continue his explanation. Which question would be of value in helping him relate his perception of the precipitating event? a. "It will be hard to help you if we cannot get more information." b. "Tell me about what happened that led you to come in today." c. "Who is available to help and support you with your problem?" d. "What things do you usually do to get through difficult times?"

ANS: B Asking the patient to talk about what led him to visit to the clinic will help the patient identify the precipitating event. The precipitating event must be identified before planning, goal setting, and intervention can take place. Pointing out that his reticence interferes with treatment does not address any of the reasons he is having difficulty speaking; instead, it adds to the pressure he is already experiencing. Focusing on supports and coping skills is part of the assessment but does not address the precipitating event.

A newly admitted patient required seclusion immediately on entering the inpatient unit. His assessment was incomplete, and no medical orders had been written. Immediately after secluding the patient, the priority action of the nurse should be to: a. provide a chance for the patient to use the bathroom. b. notify the physician and obtain an order for seclusion. c. complete necessary forms and notify the unit manager. d. debrief the staff and any witnesses to the incident.

ANS: B Emergency seclusion can be initiated by a credentialed nurse but must be followed by securing a medical order supporting the use of seclusion within a period of time specified by the state and the agency (often 1 hour). The other options may be important but are not required by law.

A patient with borderline personality disorder has been making steady progress but one day gets a phone call from her boyfriend, who breaks off their relationship. Although she has not self-injured in over 2 months, she makes repeated lacerations on her forearm. Which statement about this and most maladaptive behaviors seen in personality disorders is most accurate? a. People with personality disorders rarely achieve lasting improvement. b. However dysfunctional, most behavior is the person's best effort to cope. c. People with personality disorders are at the mercy of others' actions. d. What appears to be improvement can be manipulation instead.

ANS: B Even when a behavior is maladaptive or ineffective, it usually represents our best effort to cope, given the coping skills and resources available to us at that time. For people with personality disorders, coping overall is usually less effective and more rigid than for other persons, but it too represents each person's best efforts to cope with the circumstances at that moment. Recovery from many medical and psychiatric disorders, including personality disorders, can be slow and involve periods of relapse or regression. However, that does not mean that personality disorders do not improve or that these patients are at the mercy of others' actions. Like everyone else, they can learn to cope and be resilient under stress. What looks like improvement is not necessarily manipulation instead.

A patient with borderline personality disorder cut her wrists while out on a pass. For future planning, staff should consider that the reason for the self-mutilation is probably related to: a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. fear of abandonment associated with relationships or increasing autonomy. c. use of projective identification and splitting to bring anxiety to manageable levels. d. a constitutional inability to regulate affect, predisposing to psychic disorganization.

ANS: B Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when the patients experience success or growth or begin to develop relationships with others, because these changes increase anxiety and renew fears of abandonment. Research does not indicate that self-injurious behavior is genetic, nor that difficulty regulating affect is constitutional (integral to the person and unchanging) in nature. Although splitting is a frequently demonstrated defense mechanism in borderline personality disorder, projective identification is less common; neither is related to self-injurious behavior.

An elderly patient with multi-infarct dementia is striking out with her arms and kicking at people who walk past in the hall. Intervention by the nurse should begin by: a. gently touching the patient's arm. b. saying the patient's name to gain contact. c. asking the patient what she needs. d. approaching from behind to reassure her.

ANS: B Getting the patient's attention is fundamental to intervention. The nurse should make eye contact and smile while repeating the patient's name until the patient focuses on the nurse. Once the nurse has the patient's attention, gently touching the patient in a reassuring manner could be appropriate. Striking out usually signals fear or that the patient perceives the environment to be out of control; approaching from behind would startle the patient and increase her fearfulness, increasing the risk of acting out violently.

The crisis that occurs as an individual moves from young adulthood to middle age and becomes concerned with loss of his youthful appearance would be assessed by the nurse as a(n) ____ crisis. a. situational b. maturational c. reactive d. adventitious

ANS: B Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. No classification called reactive crisis exists. Adventitious crises occur when disasters such as natural disasters (e.g., floods, hurricanes), war, or violent crimes disrupt coping.

Which characteristics of the unit milieu are most likely to result in a low incidence of violent behavior? a. A milieu that emphasizes maintaining control and structure b. A unit that is adequately staffed and not overcrowded c. A unit that has a high percentage of newer, fresher staff d. A milieu that focuses on privileges to reward or punish behavior

ANS: B Overcrowding and inadequate staffing are the factors associated with greater numbers of violent episodes. Structure is desirable so long as it is accompanied by a degree of flexibility rather than emphasizing control. Units with higher numbers of new staff tend to have more incidents, owing to limited experience and self-awareness. Privileges can help motivate behavior, but interventions emphasizing punishment are not likely to be therapeutic and more likely to create conflict and evoke hostile responses.

Which statement about aggression would accurately serve as a basis for care planning? a. Brain injury or disorders are often blamed for, but rarely contribute to, violence. b. Some people are biologically predisposed to become irritated or angry more easily. c. Aggression is an innate behavior rather than a learned response to frustration. d. Mature persons with patterns of effective coping almost never behave violently.

ANS: B Research suggests that a number of abnormalities in brain and neurotransmitter function can contribute to increased likelihood of violent behavior; some persons do seem to be biologically predisposed to tolerate frustration less well and respond more readily with anger or rage responses. Brain injury or disorders such as cerebrovascular accidents, dementia, temporal lobe epilepsy, and tumors can lead to increased violent behavior as well. Research also supports a role for aggression as a learned response, whether from observing violent role models within one's family or community or through exposure to violence in the media. Persons who have otherwise not shown a pattern of violence can nonetheless behave violently when their normal coping abilities have been overwhelmed.

A newly admitted patient required seclusion immediately on entering the inpatient unit. What criteria would the nurse use to decide when to discontinue the use of seclusion? a. Seclusion can be discontinued when the patient seems calm. b. Discontinuation is based on outcomes developed for each patient. c. Seclusion continues until the patient has been calm for at least 4 hours. d. Seclusion lasts until the physician orders its discontinuation.

ANS: B Restraint and seclusion are treatments requiring a physician's order. As with any other treatment, they should be discontinued as soon as they have achieved their purpose. Since the reason for their use varies with each patient, the criteria for discontinuation should be based on improvement in the behavior that led to seclusion for that particularly patient. Typically this includes at least the patient's ability to follow direction and maintain safe behavior. Patient calmness can be misleading but should be a factor considered along with others. There is no minimum time that patients must be calm before being released. In most locales, an order to discontinue seclusion or restraint is not needed.

A patient presents in crisis. She tells the nurse, "I cannot take it anymore! It has to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend." After making the assessment that the patient's nuclear family is unable to provide the patient with sufficient support, which intervention would be most appropriate? a. Suggest that the patient seek admission to the inpatient crisis stabilization unit. b. Explore other possible sources of support among her extended family and friends. c. Allow her to vent, and explore her concerns about the daughter's plan to leave. d. Foster insight by relating the present situation to earlier situations involving loss.

ANS: B The assessment of supports should continue; even though the patient's nuclear family may not be supportive, other supportive family or peers may be available. An inpatient or crisis center admission would be an option for a patient at risk for self-harm or decompensating emotionally, but typically this would not be sought otherwise, unless outpatient interventions were proving inadequate to stabilizing her. Allowing her to vent, exploring concerns, and building insight are therapeutic responses but are of lower priority than establishing a system of support outside of the counseling relationship.

We aren't getting much done; let's speed things up and make our decision." a. Playboy b. Energizer c. Organizer d. Gatekeeper e. Follower

ANS: B The energizer expedites the group progress and keeps the group moving.

Which of the following indicators best demonstrates that crisis intervention has been successful? a. Patient reports that he is no longer distressed. b. Patient reports that his life is back to normal. c. Patient reports sleeping 6 hours or more per night. d. Patient has returned to previous work schedule.

ANS: B The focus of crisis intervention is on returning the patient to at least his pre-crisis level of functioning, as suggested by "life is back to normal." The other indicators suggest progress but are not as definitive in showing that the main goal of crisis intervention has been achieved.

The nurse in the emergency department tells the daughter of a patient that her 86-year-old mother has had a stroke. The daughter tearfully asks the nurse, "Who will take care of me now?" When the nurse explores this query, the daughter mentions that her mother always tells her what job to take, what clothes to buy and wear, and what to have for lunch. The daughter states that she needs someone to direct her and reassure her when she gets anxious. With which personality disorder is this presentation most consistent? a. Histrionic b. Dependent c. Narcissistic d. Borderline

ANS: B The main characteristic of dependent personality disorder is a pervasive need to be taken care of that leads to submissive behaviors and fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting.

The assumption that will be most useful to the nurse planning crisis intervention for any patient who is experiencing a crisis is that the patient: a. is experiencing a type of mental illness. b. is experiencing a state of disequilibrium. c. has high potential for self-injury. d. poses a threat of violence to others.

ANS: B The only answer universally true for all patients in crisis is that they are experiencing a period of disequilibrium, when their capacity and resources for coping have been overwhelmed, upsetting the previous balance in their lives. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness, and although some traumatic events may result in risk to self or others, this does not occur in most cases.

A factory abruptly closes; workers receive no warning and no explanation. An office worker tells the factory nurse, who is standing by to assist overwhelmed employees: "I do not know what to do. How will I get another job? Who will pay the bills? How will I get money to feed my kids? What will we do?" Which nursing diagnosis best fits this presentation? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Disturbed thought processes

ANS: B The patient describes feelings of lack of control over events in his life. No direct mention is made indicating hopelessness or chronic low self-esteem, and the patient's thought processes are not shown to be altered at this point.

A woman goes to the airport to pick up her husband, returning from one of many business trips. Persons awaiting his flight are directed to a conference room where airline counselors explain that the flight crashed into the ocean, and it is believed that there are no survivors. The woman tells a counselor that it is too soon to be sure, he might still be alive, clinging to wreckage and waiting to be found. The patient is demonstrating: a. trial-and-error problem solving. b. adaptive denial. c. ineffective denial. d. acute confusion.

ANS: B The patient is denying the very likely death of her husband. Denial reduces anxiety, and it is adaptive when it serves to help the patient cope until more adaptive coping strategies and resources can be brought to bear. It would be ineffective denial if it failed to help her anxiety or was not replaced with more effective coping mechanisms. There is no indication that the patient is confused about the circumstances facing her. Trial-and-error problem solving is not in evidence, since it would involve a series of random responses, each tried in turn after the pervious effort failed.

A worker is characterized by her co-workers as "painfully shy" and lacking in self-confidence. Her co-workers say she stays in her cubicle all day, never coming out for breaks or lunch. One day after falling on the ice in the parking lot, she goes to the nurse's office, where she apologizes for falling and mentions that she hopes the company will not fire her for being so clumsy. Which nursing approach or response would be most therapeutic? a. Remain professional and a bit detached so as not to arouse suspiciousness on her part. b. Reassure her that many others have fallen at work and not ever been criticized or fired. c. Acknowledge her concerns in a matter-of-fact manner and provide first aid as needed. d. Explain that an incident report about her fall will go to a manager who will contact her.

ANS: B The patient manages anxiety by keeping a low profile at work, avoiding situations where others might have any reason to criticize her (or even be aware of her). The fall has interfered with this coping strategy. It is likely she will be highly anxious about the prospect of being criticized and fear that a disciplinary action will follow. Therefore, interventions which reduce her anxiety and help her reframe her fears so they are more realistic are desirable. The best example here is sharing that others have fallen and never been criticized or fired. This patient's presentation does not suggest an inclination to be suspicious of others, and support would be more helpful for her anxiety than detachment or behaving in a matter-of-fact manner that focuses on her physical injuries rather than her emotional concerns. Telling her about the incident report going to a manager who will respond at some unknown point in the future is likely to greatly heighten and extend her anxiety and distress.

A patient being treated in the burn injury unit has demonstrated good coping skills for several weeks. Today, a new nurse is assigned to care for him and has proven to be poorly organized. The patient's usual schedule has not been followed, and by midafternoon, he is angry and raises his voice to complain to the nurse clinician. Which course of action for the nurse clinician would be best? a. Explain the reasons for the problem, and take over his care for the rest of the shift. b. Validate his distress, review the options, and ask what he would like to happen. c. Apologize and ask that he be patient with the situation for the rest of the shift. d. Ask him to control his anger, and ask him if he too wasn't once new at something.

ANS: B When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should problem solve with the patient by acknowledging and validating the patient's feelings as understandable, then assuring that the patient has a role in seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step. Taking over the care would not necessarily be what the patient wants; for example, despite his distress with the novice, he might not want her to "get into trouble" or be replaced. Asking him to be patient because of staffing needs puts the needs of staff and the hospital ahead of the needs of the patient. Reminding him that he was also once a novice in some respect could induce guilt and would be a disconfirming (nontherapeutic) statement in that it invalidates his anger.

A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, "Back off, bitch!" and then goes into the day room. The nurse follows the patient into the day room. Which intervention would be best at this time? a. Stay between the patient and the door for easy exit. b. Stand out of range of possible assault by the patient. c. Position oneself about 28 inches from the patient. d. Sit down in a chair near the patient to convey interest.

ANS: B When intervening with an agitated or potentially violent person, it is essential to stay far enough away that you are safe from a punch, kick, or other potential assault. Personal space needs increase when a person feels anxious, angry, or threatened. Standing between the patient and the door could be interpreted as confrontational or could cause the patient to feel trapped, increasing his fear and agitation. Standing within 28 inches places one within the patient's personal space and within range of being struck. Sitting would make it difficult to protect oneself from assault and is inadvisable until further assessment suggests the patient's aggression is abating.

An apartment house is on fire, and police and fire responders are unable to save two young children inside. As the fire is being brought under control, a wall suddenly collapses, killing one firefighter and injuring two others. The events unfold in full view of residents, fellow emergency responders, and the general public. You are asked to provide crisis debriefing for those affected. Which actions would be appropriate to take? Select all that apply. a. Arrange for counselors to meet individually with those who wish to seek help. b. Arrange group meetings for responders and witnesses, and encourage participation. c. Describe the purpose and ground rules of the sessions, and answer any questions. d. Encourage discussion of why the crisis occurred to help prevent more such events. e. Ask victims to discuss the worst aspect of the crisis, what they most want to forget. f. Normalize victim responses, and provide guidance regarding possible future responses.

ANS: B, C, E, F Critical Incident Stress Debriefing (CISD) is designed to reduce the short- and long-term negative outcomes of exposure to traumatic events, including reduction of the risk of developing disorders such as posttraumatic stress disorder. It is a group intervention that focuses on segments of those involved: emergency responders, casual witnesses, residents who knew the victims. CISD involves seven phases, including an introductory discussion of the purpose and ground rules of CISD sessions, opportunity to vent and discuss thoughts and feelings about what was witnessed, normalizing responses to trauma, and helping victims identify and respond to future responses such as nightmares or reexperiencing the event (including identifying responses that indicate a need for professional mental health treatment).

A woman is brought to the hospital after having been badly beaten. She is withdrawn and does not want to talk with anyone. She is thought to have a schizoid personality disorder. Which response(s) would likely be most useful for working with this patient? (Select all that apply.) a. To establish a therapeutic relationship, be especially friendly and nice. b. Explain clearly what to expect while assessing, and treat any injuries per routine. c. Address their delusional thinking or paranoia as you would in schizophrenia. d. Try to inject a bit of humor into the situation to relieve tension and anxiety. e. Connect the patient with her support system to help her deal with the trauma. f. Anticipate a somewhat detached response to the trauma and responders.

ANS: B, F Patients with schizoid personality disorder are primarily different in their disinclination to develop relationships with others and their restricted range of emotions. They seem detached socially and emotionally and may not react to trauma in the manner that most people do. Although they will still be distressed and traumatized, it may express itself in a muted fashion. They are commonly detached, not interested in developing a relationship with ER staff or emergency responders, and likely will not converse freely. Contact with reality is usually not significantly impaired, and delusions or paranoia are not typical of this disorder. They do not usually respond to humor. They typically do not have a support system, are not close to others, and tend to live a solitary life.

When a patient with a personality disorder uses manipulation as a way of getting needs met, the staff agree to use limit setting as an intervention. How does limit setting work to reduce manipulation? a. Limit setting indulges the patient's desire for attention from staff. b. It gives the patient a different concern on which to focus his anger. c. External controls provide security while internal controls are developing. d. When staff limit the patient's behavior, he is no longer anxious about it.

ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls are implemented until the patient is able to develop internal controls (i.e., to control his behavior on his own). Properly implemented, limit setting does not provide the patient with undue attention. Although patients may become angry when limits are set, limits are not designed to draw the focus of a patient's anger off some other target. Limit setting can sometimes reduce patient anxiety but in other cases can temporarily increase it.

A 40-year-old man has just helped his youngest child move away to college. On returning home, he feels empty and restless and has difficulty sleeping in the nights that follow. This is an example of a ______________ crisis. a. situational b. adventitious c. maturational d. midlife

ANS: C A maturational crisis is one that occurs predictably when a person arrives at a new stage in life. An example would be a parent whose children are assuming lives of their own, leaving the parent to transition to a new stage of life wherein the role of parent is deemphasized. A situational crisis is one that is specific to a particular external situation that others may not experience; these often involve losses, such as death of a loved one or loss of a job. An adventitious crisis involves an unpredictable traumatic event such as a natural disaster (tornado), manmade disaster (collapse of a building), or criminal event (mugging).

Which outcome would be most appropriate for a symptom-management group for persons with schizophrenia? Group members: a. state the names of their medications. b. resolve conflicts within their families. c. describe ways to cope with their illness. d. rate anxiety at least two points lower.

ANS: C An appropriate psychoeducational focus for patients with schizophrenia is managing their symptoms; coping with symptoms such as impaired memory or impaired reality testing can improve functioning and enhances their quality of life. Names of medications might be appropriate for a medication education group but would be a low priority for symptom management. Addressing intrafamily issues would be more appropriate within a family therapy group or possibly a support group. Rating anxiety lower would be an expected outcome for a stress-management group.

A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, "Back off, bitch!" and then goes into the day room. Which intervention would be most important to undertake before the nurse follows the patient into the day room? a. Contact the patient's physician to obtain an order for seclusion. b. Review the patient's history for clues about his risk of violence. c. Assure that adequate staff are available and nearby for backup. d. Check for orders for PRN medication and prepare a sedative.

ANS: C Before responding to a potentially dangerous situation, it is essential that other staff be notified of the situation and that adequate numbers of staff are prepared to come to one's assistance immediately if needed. All other actions are of lower priority or would unduly delay the nurse's response to a situation requiring a prompt response. Having a peer complete such activities would enable the responding nurse to intervene more quickly.

A patient tells the nurse that he is planning to hire a private detective to follow his wife, who he believes is having an extramarital affair. The patient looks behind the door to be sure no one is eavesdropping and asks the nurse what she did with his medical record after he left. The patient's behaviors are most consistent with a diagnosis of: a. antisocial personality disorder. b. schizoid personality disorder. c. paranoid personality disorder. d. obsessive-compulsive personality disorder.

ANS: C DSM-IV-TR criteria for paranoid personality disorder include suspiciousness, lack of trust in others, fear of confiding in others, fear that personal information will be used against the individual, holding grudges, and interpreting remarks as being demeaning or threatening. Suspecting loved ones of infidelity or disloyalty is also a frequent feature in this disorder. The patient with antisocial personality disorder is aggressive, manipulative, and exploitative. The patient with schizoid personality disorder is socially avoidant and reclusive. The patient with obsessive-compulsive personality disorder is a perfectionist, is rigid, and is preoccupied with details and control issues.

During the initial interview at the crisis center, a patient reveals that his wife asked him for a divorce. He is so anxious that he "cannot think straight." Which response would best assess the patient's coping skills? a. "I can see you are upset. You can rely on us to help you feel better." b. "What would you like us to do to help you feel more relaxed?" c. "In the past, how did you handle difficult or stressful situations?" d. "Do you think you deserve to have things like this happen to you?"

ANS: C Exploring past responses to stressful events is the only option that assesses coping skills. Acknowledging distress is helpful, but assuming responsibility for the patient's feeling better is not therapeutic; neither assesses coping ability. Persons in crisis have difficulty with problem solving, so it would be unrealistic to ask them to provide instructions on how staff should help. Asking whether he deserves such experiences would provide information about self-esteem but not coping

A factory abruptly closes. An office worker tries to take it in stride and begins the job search. Three weeks later, he has not received a single call-back from a prospective employer despite submitting over 30 applications. He is having trouble sleeping, is irritable, does not want to interact with his family, paces, and spends several hours most days in a local bar. He is now applying for minimum-wage service jobs. Which phase of the crisis is he experiencing? a. Phase 1 b. Phase 2 c. Phase 3 d. Phase 4

ANS: C In phase 1, the person is anxious but beginning to make efforts to cope based on his usual coping style. In phase 2, the usual coping responses have fallen short, and anxiety continues to rise; functioning deteriorates, and coping efforts become disorganized or random. In phase 3, the random, disorganized attempts at coping have been ineffective, and anxiety has risen to severe or panic levels. Further efforts to cope are maladaptive, and the person may begin to redefine the crisis or compromise in resolving it. If the crisis does not resolve, the person enters phase 4, develops further maladaptive responses, becomes overtly depressed, and can act out violently towards others or himself. This person is in phase 3.

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "Please quiet down." b. "Hey, what's up?" c. "You seem upset. Tell me about it." d. "You need to go to your room to get control of yourself."

ANS: C Intervention should begin with analysis of the patient and the situation. With this response, the nurse is attempting to hear the patient's feelings and concerns. This leads to the next step of planning an intervention. Telling the patient he needs to quiet down or go to his room is controlling and does not seek to understand or de-escalate the patient's behavior. Such an approach is likely to close off communication instead of facilitating it. "Hey, what's up?" is a broad opening but is vague and would be difficult for a person at a high level of anxiety to process.

The nurse reports to the interdisciplinary team that an antisocial patient lies to other patients, verbally abuses a patient with Alzheimer's disease, flatters his primary nurse, and is detached and superficial during counseling sessions. Which behavior should be the priority focus of limit setting? a. Lying to other patients b. Flattering the nursing staff c. Verbally abusing other patients d. Superficiality during counseling

ANS: C Limits must be set in areas in which the patient's behavior affects the rights or safety of others. Limiting verbal abuse of another patient is thus the priority intervention. The other concerns should be addressed during therapeutic encounters but are lesser priorities.

The characteristic in individuals with personality disorders that makes it most necessary for staff to schedule frequent meetings is: a. flexibility and unconventional responses to stress. b. a desire to achieve emotional intimacy with staff. c. a tendency to evoke countertransference and conflict. d. an impaired ability to develop trusting relationships.

ANS: C One feature shared among the many personality disorders is an impaired or maladaptive style of relating to others. Another such shared factor is a tendency to rely on maladaptive coping mechanisms (such as splitting) to deal with anxiety. Those factors tend to stir strong emotional responses in staff, leading to countertransference responses (e.g., anger toward the patient), a loss of objectivity, reduced ability to be therapeutic, and possibly staff burnout. Staff meetings are one way to increase awareness of these dynamics and deal with them constructively as a group. Patients with personality disorder tend to be inflexible, demonstrate maladaptive responses to stress, and are unable to develop true intimacy with others and trusting relationships; some seek to avoid intimacy. The problem with trust exists but is not the characteristic that requires frequent staff meetings.

In clinical supervision, the nurse caring for the patient with a paranoid personality disorder tells the advanced practice nurse, "I tried being caring and empathetic, but the patient just kept telling me to stay away." Which response by the advanced practice nurse would be best? a. "Acting somewhat cynical and aloof, like they do, will make it easier for paranoid persons to bond with you over time. That, plus humor." b. "You may be trying too hard too soon. Back off, give him some time to get used to you, then try your caring and empathetic approach again." c. "Mistrustful people do not bond as others do, so first it's important to be realistic. Second, a neutral yet courteous approach will work better." d. "You are on the right track, but give it more time. Actively conveying empathy and care will work, but paranoid persons respond more slowly."

ANS: C Paranoid persons rarely bond with others in the way that most people do, and efforts to achieve this are counterproductive. Therefore, it is essential to understand the perspective of the patient and develop realistic expectations regarding the nurse-patient relationship. A detached, neutral, straightforward, and courteous approach is most effective. Overt expressions of caring, tenderness and other emotions which are not within the repertoire of the paranoid person tend to increase their suspiciousness. Acting in the manner of the patient (e.g., being mistrusting or cynical yourself) is never appropriate; if the patient believes he is being mimicked, it will increase his mistrust and drive him further away.

During an inpatient therapy group that uses existential/Gestalt theory, feelings experienced by patients at the time of their admission to the unit are discussed. As a silence falls, one member mentions, "We have heard from several people who describe feeling angry. I would like to hear from some people who experienced other feelings." The nurse identifies this comment as an example of the group role of: a. energizer. b. compromiser. c. encourager. d. self-confessor.

ANS: C The member is filling the role of encourager by acknowledging those who have contributed and encouraging input from others. An energizer encourages the group to make decisions or take an action. The compromiser focuses on reducing or resolving conflict to preserve harmony. A self-confessor verbalizes feelings or observations unrelated to the group.

A patient who had abdominal surgery has been hospitalized for 4 days. He has no history of psychiatric disorder but is described by his family as having "always been a difficult person who blames others for everything that goes wrong." From the day of admission, he has verbally abused the nurses for their inability to provide care that keeps him pain free and comfortable. Which history most likely explains this style of coping? a. Child-rearing that did not teach respect for others b. Exposure to violent role models in the media c. A personality style that externalizes problems d. Increased levels of the neurotransmitter serotonin

ANS: C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves—in others or in the environment. In this case, the patient displaces anger about his illness and resulting discomfort, and his distress is blamed on the nurses. This dynamic is supported by the patient's history. The other options are not supported or are less likely to have a bearing on his behavior.

The nurse who assesses a patient previously diagnosed as having paranoid personality disorder is most likely to describe the patient as: a. superficially charming. b. intense and impulsive. c. guarded and distant. d. friendly and open.

ANS: C Patients with paranoid personality disorder are mistrustful of others. They expect to be exploited or wronged by others and are wary; as a result, they remain apart from others to increase their sense of security. Patients with antisocial personality disorder may display superficial charm, but paranoid persons usually seem cold and aloof and would not seem friendly or open. Patients with borderline personality disorder are intense and impulsive, whereas patients with paranoid personality disorder tend to be controlled and superficial.

An appropriate outcome for a patient with a personality disorder and a nursing diagnosis of Ineffective coping as evidenced by use of manipulation would be that the patient will: _______. a. refrain from manipulative behavior at all times b. use manipulation only to get legitimate needs met c. acknowledge manipulative behavior when it is pointed out d. identify when he is experiencing feelings of anger

ANS: C People who are manipulative tend to use manipulation so regularly that it becomes almost an automatic, unconscious response. Being able to recognize or acknowledge when their behavior is manipulative is the first step to replacing manipulation with more adaptive ways of meeting one's needs, paving the way for taking greater responsibility for controlling manipulative behavior. Most people are at least occasionally manipulative, so a complete absence of manipulative behavior would be an unrealistic outcome expectation. Manipulation is maladaptive whether used to meet "legitimate" needs or illegitimate needs. Identifying anger would be helpful for managing maladaptive responses to that emotion but not for manipulation.

A physical therapist recently convicted of multiple counts of Medicare fraud is brought to the emergency department after taking an overdose of sedatives. He tells the nurse, "Sure I overbilled. Why not? Everybody takes advantage of the government. They have too many rules. No one can abide by all of them." These statements can be assessed as showing: a. glibness and charm. b. superficial remorse. c. lack of guilt feelings. d. excessive suspiciousness.

ANS: C Rationalization is being used to explain behavior and deny wrongdoing. The patient is not exhibiting regret or remorse, even superficially. A person who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The patient's remarks do not seem designed to use charm to deflect negative consequences, and he is not glib about his situation.

A patient in a group therapy session listens for a time and then remarks, "I used to think I was the only one who felt afraid. I guess I'm not as alone as I thought." This is an example of: a. ventilation. b. altruism. c. universality. d. group cohesiveness.

ANS: C Realizing that one is not alone and that others share the same problems and feelings is called universality. Ventilation refers to expressing emotions. Altruism refers to benefitting by being of help to others. Group cohesiveness refers to the degree of bonding among members of the group.

Which nursing strategy leads patients to respond more positivity to limit setting? a. Confront the patient with the inappropriateness of the behavior. b. Explore with the patient the underlying dynamics of the behavior. c. Reflect back to the patient an understanding of the patient's distress. d. State clear disapproval of the behavior, and support its consequences.

ANS: C Setting limits is better accepted by patients if staff first use empathetic mirroring without making a value judgment. Confrontation, while sometimes an appropriate nursing response, does not enhance the effectiveness of limit setting; neither does exploring the underlying causes of maladaptive behavior. Conveying disapproval is rarely therapeutic in general and does not enhance limit setting; it would tend instead to increase patient resistance and impede the therapeutic relationship.

A patient has sat in stony silence in the day room for 20 minutes after her appointment with her psychiatrist. She appears tense and vigilant. The nurse sees the patient abruptly stand up and pace back and forth across the day room, clenching and unclenching her fists. She then stops and stares intently into the face of the psychiatric technician seated at a table. The priority assessment that should be made is that the patient is: a. working off the energy of angry feelings. b. attempting to use relaxation strategies. c. exhibiting clues to potential aggression. d. trying to work through her anger.

ANS: C The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing. The patient's pacing may reduce some of the urge to respond physically, but this would be a secondary assessment and not as important to safety as are the signs of impending aggression and violence. The patient's behavior and nonverbal indicators are inconsistent with relaxation. The data are inadequate to determine whether the patient is trying to work through her anger, but this too would be a secondary observation.

A patient presents in crisis. She tells the nurse, "I cannot take it anymore! It has to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend." The problem that should be the focus for crisis intervention is: a. the possible cancer and mastectomy. b. the impact of her husband's infidelity. c. coping with her daughter's leaving. d. the disordered family communication.

ANS: C The focus of crisis intervention is on the most recent problem, "the straw that broke the camel's back." The patient had coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurred only with the introduction of the daughter leaving college and moving.

A group is in the working phase, and one member states, "That is the stupidest thing I've ever heard. I have never been in a group like this. Everyone is just whining and telling everyone else what to do when they have no clue, and people just sit there and take it. This is a waste of time." Which response by the group leader would be most therapeutic? a. "You seem to think you know a lot already; since you know so much, perhaps you can tell us why you are back in the hospital?" b. "I think you have made your views clear, but I wonder if others feel the same way. How does everyone else feel about the group?" c. "It must be hard to be so angry. Perhaps the group can be of help. Mary, you were angry at first but not now; what has helped you?" d. "I'd like to remind you that one of our group rules is that everyone is to offer only positive responses to the comments of others."

ANS: C The member's comments demean the group and its members and suggest that the member is very angry. Labeling the emotion and conveying empathy would be therapeutic. Focusing on members who are likely to be more positive can balance the influence of demoralizing members. "You seem to know a lot..." conveys hostility form the leader, who confronts and challenges the member to explain how he came to be readmitted if he was so knowledgeable, implying that he is less knowledgeable than he claims. This suggests countertransference and would be nontherapeutic. Shifting away from the complaining member to see if others agree seeks to have others express disagreement with this member, but that might not happen. In the face of his anger, they might be quiet or afraid to oppose him, or they could respond in kind by expressing hostility themselves. A rule that only positive exchanges are permitted would suppress conflict, reducing the effectiveness of the therapy group.

A nurse assigned to the well child clinic realizes that a number of the mothers have misconceptions about the most effective ways of disciplining their children. The nurse decides that forming a group to resolve this problem would be an effective strategy. The focus of the group should be: a. support. b. socialization. c. health education. d. symptom management.

ANS: C The nurse has diagnosed a knowledge deficiency. The focus of the group should be education. Support and socialization are beneficial but should not be the primary focus of the group, and symptoms are not identified for intervention here

"Last week we finished our first goal, and today we are starting on our second." a. Playboy b. Energizer c. Organizer d. Gatekeeper e. Follower

ANS: C The organizer keeps the group on task and organized in its work.

A patient with borderline personality disorder has been hospitalized several times after self-injurious behavior and suicide attempts. The patient has entered dialectical behavior therapy on an outpatient basis. During therapy, the advanced practice nurse has been counseling her regarding self-harm behavior management. Today the patient called the nurse and reported "feeling empty and anxious" and wants to cut herself. Which response would best help in this situation? a. Arrange for an emergency admission to a crisis unit. b. Arrange for an emergency admission to an inpatient unit. c. Assist the patient to identify and choose a coping strategy. d. Advise the patient to take an anxiolytic, then go to sleep.

ANS: C The patient has responded appropriately to the urge to harm herself by calling a helping individual. The nurse can assist the patient to choose an alternative to self-injury. Except when the patient is judged to be at risk of suicide as well, hospital or crisis center admissions are generally discouraged in favor of guiding the patient to use internal controls to manage urges to self-injure. This is designed to minimize dependence on hospitalization for safety and promote independence and adaptive coping. Taking a sedative and going to sleep should not be the first-line intervention, because sedation may reduce the patient's ability to weigh alternatives to mutilating behavior, and using medications to deal with stress (especially in the absence of other adaptive coping alternatives such as relaxation exercises) could increase the risk of drug abuse or dependence.

Which statement by a patient with borderline personality disorder best indicates the treatment plan is helping? a. "I think you are the best nurse on the unit." b. "I hate my doctor. He never gives me what I ask for." c. "I feel empty and want to cut myself, so I called you." d. "I'm never going to get high on drugs again."

ANS: C The patient's seeking a staff member when distressed, instead of impulsively self-mutilating, shows that the patient has adopted an adaptive coping strategy. "You're the best nurse" demonstrates idealization, which is a symptom of the disorder and not a sign of improvement; the same is true of devaluing one's doctor. "I'm never going to use drugs" is a statement of a goal. It may be the patient's intention, but unless the patient demonstrates adaptive coping and sobriety-related behaviors, it is not necessarily an indication of progress.

A cognitively impaired patient who has been a widow for 30 years is frantically trying to leave the unit, saying, "I have to go home to start dinner before my husband comes home from work." To intervene with validation therapy, the nurse should say: a. "Please, you must come away from the door." b. "Mrs. Smith, you have been a widow for many years." c. "You want to go home to get your husband's dinner." d. "I think your husband said he is going to eat out tonight."

ANS: C Validation therapy meets the patient "where she or he is at the moment" and acknowledges the patient's perspectives on what she is experiencing. It does not seek to redirect, reorient, or probe. The other options do not validate patient feelings. Saying that her husband has other plans adds further to the patient's distorted view of reality.

A patient with borderline personality disorder has had 21 admissions to the mental health unit, each precipitated by a suicide attempt usually resulting in superficial cuts on the arm. On this admission, the patient has developed a relationship with a highly supportive nurse. The patient has progressed to having a pass to spend an afternoon in a nearby shopping mall. The nurse is shocked when the emergency department calls to say that the patient has just been brought in with multiple self-inflicted lacerations. The nurse asks a peer, "Why? Everything was going well. How could she do this to me?" Which response(s) by the other nurse reflects objectivity and understanding of the patient's personality disorder? (Select all that apply.) a. "I know what you mean. You put a lot of energy into working with this patient. It must be disappointing to have her do something like this." b. "I could have told you this would happen. A patient like this always gets you in the end. I hope this will teach you not to get so involved." c. "I know the patient's behavior seems personal, but it's really not. Patients with borderline personality disorder self-injure to relieve numbing or anxiety." d. She was doing well here, where she was adjusted to the milieu and the people, but I suspect leaving here for the pass really increased her anxiety." e. "I wonder if all this could have been avoided if I'd clued you in on the patient. This is a usual pattern for her. She burned me once too when I first worked here." f. "People do not necessarily improve in a steady, lasting fashion; sometimes there are setbacks. It does not mean she isn't progressing overall."

ANS: C, D, F Helping the upset nurse understand that the patient's behavior does not reflect on the nurse's efforts but on the patient's circumstances changing would help the nurse avoid self-blame and anger. Intolerable feelings (or the absence of feeling, numbness) lead to self-injury, and it is likely that the pass increased the patient's anxiety or led to other overwhelming feelings that in turn led to self-injurious behavior. Such events are part of the process of recovery and do not necessarily mean that improvement is not occurring overall. The distracters are examples of negative countertransference reactions and loss of professional objectivity.

A group has two more sessions before it ends. One member who previously has been vocal and has shown much progress has grown silent. What explanation most likely underlies his current silence? a. He has said what is on his mind and now has nothing more to offer. b. He wants to give quieter members a chance to talk in the time remaining. c. Quiet members are dominating now in order to talk more before group ends. d. He is having trouble dealing with his feelings about the group's ending.

ANS: D A chief task during the termination phase of a group is to take what has been learned in group and transition to life without the group. The end of a group can be a significant loss for members, who may experience loss and grief and respond with sadness or anger. It is unlikely he would have nothing to say; at the very least, he could be responding to the comments of others even if not focusing on his own issues. He may wish to give quieter members a chance to talk, but again, this would not require or explain his complete silence. Some members, faced with only two remaining sessions, may be becoming more dominant under this pressure of time, but here too this is unlikely to lead a previously active participant to fall completely silent.

During a group therapy session, a newly admitted patient suddenly says to the nurse, "How old are you? You seem too young to be leading a group." The most appropriate response the nurse might make is: a. "I am wondering what leads you to ask. Could you tell me more, please?" b. "I am old enough to be a nurse, so that would make me in my 20s at least." c. "My age is not pertinent to why we are here and should not really concern you." d. "You are wondering whether I have enough experience to lead this group."

ANS: D A question such as this is common in the initial phase of group development when the members are getting to know one another, dealing with trust issues, and testing the leader. Making explicit the implied serves to role-model more effective communication and prompts further discussion of the patient's concern. Asking the patient to tell the leader more about the question focuses on the reason for the member's concern rather than on the issue raised (the experience and ability of the leader) and is a less helpful response. "I am old enough to be a nurse" and "age is not pertinent" are somewhat defensive responses and are not therapeutic because neither addresses the patient's valid concern.

When told that he is scheduled to interview a patient with narcissistic personality disorder, the nurse can anticipate the assessment findings will include the following: a. charm, drama, seductiveness, and admiration seeking. b. preoccupation with minute details and perfectionism. c. difficulty being alone, indecisiveness, and submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

ANS: D According to the DSM-IV-TR, person with narcissistic personality disorder would have an exalted opinion of themselves, possess a sense of entitlement, and believe their needs should come first. A patient with histrionic personality disorder would be charming, seductive, and seek admiration. An individual with obsessive-compulsive personality disorder would demonstrate rigidity and perfectionism. Indecisiveness, submissiveness, and intolerance for being alone would characterize an individual with dependent personality disorder.

A patient who is known to be angry and impulsive is hospitalized after an automobile accident in which he sustained severe orthopedic injuries. When in pain, he loudly berates nursing staff, saying, "You jerks don't even know enough to give a patient pain medicine when he needs it." The patient's nursing diagnosis is Ineffective coping. Which nursing intervention would best address this situation? a. "If you could tell us about wanting the medicine before your pain becomes this bad, it would help." b. "I can see you are frustrated, but rudeness toward nurses will not help you get your medication any sooner." c. "I'm concerned that there may be something we overlooked; I'm going to ask a psychiatric specialist to evaluate you." d. "Pain can make anyone miserable; I will ask your doctor to change the order so you get medicine regularly without having to ask."

ANS: D Acknowledging and normalizing the patient's pain, along with scheduling the medication at specific intervals, will help the patient anticipate when the medication can be given and help correct his perception of nurses as uncaring or unskilled. Receiving the medication promptly on schedule, rather than expecting nurses to intuitively know his pain level, should minimize his discomfort and reduce his acting out of anxiety and anger. Suggesting that the patient might behave differently also implies that he is at fault; telling a person who already believes staff are incompetent that he is at fault is likely to evoke more anger, not less. Confronting the patient with his rudeness may meet the nurse's need to confront the patient, but it does not address the patient's pain and is likely to increase the adversarial nature of the current patient-staff relationship, when the opposite is desired instead. Unless there is specific indication of a mental illness, which is not the case here, a psychiatric consult is not indicated, and the desire to blame a mental illness suggests that the nurse is angry and retaliating. Suggesting to the patient that he is mentally ill is also likely to intensify his anger and make the nurse-patient relationship even less therapeutic.

A factory abruptly closes during hard economic times. Six weeks later, an office worker has not received a single call-back from a prospective employer. He cannot sleep, is irritable, does not want to interact with his family or peers, paces frequently, and spends several hours most days alone in a local bar. Bills are piling up. He has given up applying for jobs. Which nursing intervention would be most important at this time? a. Explore his feelings supportively and guide him to focus on one concern at a time. b. Discuss ways to improve mood and reduce anxiety, such as exercise and interaction. c. Help him apply for financial assistance such as food stamps and utility reductions. d. Work with patient and family to assure that any guns have been removed from the home.

ANS: D All of these interventions would be appropriate, but given his risk to self secondary to depression, hopelessness, ineffective coping, and isolation, safety is the highest priority. Persons in phase 4 of a crisis can also become violent towards others. Removing weapons from the home removes a common, lethal means of harming others.

An appropriate question for the nurse to ask to assess support systems is: a. "Has anything upsetting occurred in the last few days?" b. "What led you to seek help at this time?" c. "How does this problem affect your life?" d. "Who can be helpful to you during this time?"

ANS: D Asking who can be helpful at this time focuses on who can serve as a source of support to the patient. The other options focus on the patient's perception of the precipitating event.

The nursing diagnosis of Powerlessness related to impaired problem solving has been established for a patient seeking crisis counseling. An appropriate outcome for this nursing diagnosis would be that the patient will: a. agree to sign a no-suicide contract within 30 minutes. b. resume meeting pre-crisis role expectations within 36 hours. c. state he feels less anxious within 4 hours of the interview. d. describe two possible solutions during the first interview.

ANS: D Determining possible solutions to the problem is the only outcome that addresses the etiology statement of the nursing diagnosis. The diagnosis does not suggest a risk for self-directed violence, and it would be unrealistic to expect such a quick return to previous functioning in a crisis situation. Reducing anxiety is unrelated to the specified nursing diagnosis.

A patient, aged 42 years, seeks crisis intervention. She tells the nurse, "I cannot take it anymore! It has to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast that the doctor is watching closely, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend." Which comment or concern should be the priority for further assessment? a. What support persons and coping skills the woman has to draw upon b. The status of the marriage and whether the husband is involved in the affair c. How the patient feels about the possibility of having a mastectomy d. What the patient has in mind when she says she "cannot take it anymore"

ANS: D During crisis intervention, the priority concern is patient safety, so it is most important to assess whether the patient is a risk of self-harm (or other-directed violence). Assessing coping skills and resources, assessing her response to the possible breast cancer and her daughter's plans, and the current status of her marriage would all be assessed subsequent to establishing her safety.

A patient tells a nurse, "The others won't give me my pain meds early, but you are more understanding, you know what it's like to be in pain, and you don't want to see your patients suffer. Could you find a way to get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," then ignore subsequent requests for early meds. b. "I'll have to check with your doctor about that; I will get back to you after I do." c. "It would be unsafe to give the medicine early; none of us will do that." d. "I understand that you have pain, but giving medicine too soon would not be safe."

ANS: D Empathetic mirroring, wherein the nurse reflects back to the patient an understanding of the patient's distress or situation in a neutral manner that does not judge it, helps elicit a more positive response to the limit that is being set. The other options would not be nontherapeutic, but they lack the empathetic mirroring component that tends to elicit a more positive response from the patient.

1. A patient tells the members of the inpatient therapy group that he hears voices saying his doctor is going to poison him. Another patient replies, "I used to hear voices too. They sounded real, but I found out later they were my imagination. The voices you hear are not real either." Which phenomenon common to groups is exemplified in this interchange? a. Ventilation b. Universality c. Imitative behavior d. Interpersonal learning

ANS: D Here a member gains insight into his own experiences from hearing about the experiences of others through interpersonal learning. Ventilation refers to expressing feelings. Universality refers to members realizing their feelings are common to most people and not abnormal. Imitative behavior involves copying or borrowing the adaptive behavior of others.

A patient on a medical unit has a history of hostile and menacing behavior toward staff and sometimes even strikes them. Which plan would be best for forestalling such incidents? a. Give the patient lorazepam (Ativan) every 4 hours to reduce anxiety. b. Explain that the response to any violence will be to use restraints. c. Arrange for security personnel to stand by during all nursing care. d. Point out the problem and help the patient identify things that are causing frustration.

ANS: D Identification of triggers to violent acting-out incidents allows the patient and nurse to plan interventions to avert such triggers and reduce frustration. This also provides practice in coping more adaptively in general. Benzodiazepines can reduce anxiety but would not give him skills that might also benefit him in other situations; benzodiazepines can also sometimes increase impulsiveness by disinhibiting the patient. Setting limits and indicating what consequences to expect can be a helpful adjunct, but as a primary intervention, it does not teach new skills to use to avoid problem behaviors in the first place; expecting the patient to behave differently without giving him the skills to do so is setting him up for failure and further frustration. Using security personnel would be expensive and disruptive to their work, but it would be a possible intervention if all other options prove unsuccessful.

A patient with paranoid personality disorder is noted to sit alone in a corner of the unit living room. When anyone approaches, the patient is haughty or simply ignores the other person. When staff invite her to join an activity, she tells them, "I do not care to be with people who do not like me." A nursing diagnosis that should be considered is: a. splitting. b. activity intolerance. c. powerlessness. d. impaired social interaction.

ANS: D Impaired social interaction is a state in which an individual participates in an insufficient (or excessive) quantity or quality of social exchange. A defining characteristic is dysfunctional interaction with others. The patient's suspiciousness, rigidity, and distortions of reality related to projection are likely responsible in this case. Splitting, powerlessness, and activity intolerance are not evident in this scenario.

Which remark would the nurse expect to hear during the working stage of group therapy? a. "My problems are very personal and private; how do I know you people will not tell others what you hear in group?" b. "I have enjoyed this group; hard to believe that only a few weeks ago I couldn't even bring myself to talk here." c. "One thing everyone seems to have in common is that sometimes it's hard to be truly honest with those you love most." d. "I don't think I agree with that; it might help you, but it seems like it would upset your family."

ANS: D In the working stage, members actively interact to help each other accomplish goals, and trust is more developed, allowing conflict and disagreement to be expressed. Focusing on trust and confidentiality typically occur in the orientation phase as part of establishing group norms. Commonality and universality are also themes typically expressed in the orientation phase, whereas reflecting on progress is a task addressed in the termination phase.

For which behavior(s) would limit setting be most essential? a. A patient clings to the nurse and asks for advice about inconsequential matters. b. A woman is flirtatious and provocative toward staff members of the opposite sex. c. An elderly man displays hypervigilance and refuses to attend unit activities. d. A young woman urges a suspicious patient to hit anyone who stares at him.

ANS: D In urging a paranoid patient to strike anyone who stares at him, the patient is being manipulative, trying to get another patient to act violently while staying "innocent" of actual violence herself. Because manipulation violates the rights of others, limit setting is absolutely necessary. It would be appropriate to set limits relative to any significantly inappropriate behavior, but the highest priority here would be behavior which endangers others, such as enticing the paranoid person to strike anyone who stares at him. Setting limits on sexually provocative behavior would be appropriate but a lower priority than potentially assaultive behavior. Clingy behavior and nonadherence to treatment are not priorities, and interventions other than limit setting would likely be more appropriate.

An elderly patient with multi-infarct dementia is striking out with her arms and kicking at people who walk past in the hall. After making contact with the patient, which intervention would be most appropriate? a. Administering PRN sedation to calm the patient. b. State: "You may not hit others; you are safe here." c. Distract the patient into playing a board game. d. State: "I notice you are trying to hit people."

ANS: D Of the available choices, the next action that should be undertaken is to determine possible causes of the patient's behavior. Pointing out what the nurse is observing focuses the patient on those behaviors and prompts her to elaborate about them, beginning a conversation that could yield the desired assessment data. Sedation often increases disorientation and worsens delirium; it should be a last resort. Setting limits can be helpful in certain situations, but in order to decide whether this applies in this case, the nurse would first need to explore and understand the causes of the patient's behavior. Limit setting and distraction fail to address any underlying causes for the behavior.

A patient with antisocial personality disorder tells Nurse A, "You're a much better nurse than Nurse B said you were." The patient tells Nurse B, "Nurse A's upset with you for some reason." To Nurse C the patient states, "You'd like to think you're perfect, but I've seen three of your mistakes this morning." These comments can best be assessed as: a. seductive. b. detached. c. guilt producing. d. manipulative.

ANS: D Patients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the antisocial person is left to operate as he or she pleases. Seductive behavior uses sexuality to achieve one's aims and is not evident here. The patient is interacting actively rather than detaching from those around him. Guilt is not overtly evident, although Nurse C might experience guilt in response to his criticism.

To plan effective interventions, the nurse should understand that the underlying reason a patient with paranoid personality disorder is so critical of others probably lies in the patient's: a. need to control all aspects of the world around him. b. use of intellectualization to protect against anxiety. c. inflexible view of the environment and the people in it. d. projection of blame for his own shortcomings onto others.

ANS: D Projection allows the patient to disown negative feelings about himself and see these feelings as being directed at him from an outside source (the nurse) instead. The patient then can justifiably retaliate by being hostile to the nurse. To realize that the patient is accusing the nurse of his or her own faults makes the criticism easier to manage without retaliation. The other options are not related to the dynamics of critical behaviors on the part of the patient.

When a patient's aggression quickly escalates, on which principle should nursing intervention be based? a. Staff should match their tone of voice and level of intensity to the patient's. b. When there is no time to de-escalate, immediate use of restraint is necessary. c. Always ask the patient what will be most helpful to increase his sense of control. d. Choose the least restrictive measure that will keep the patient and others safe.

ANS: D Regardless of the situation, the fundamental principle underlying all interventions with agitated, escalating, hostile, aggressive, or violent patients is to use the least restrictive measure that will provide for the safety of everyone involved. The other options either should not guide practice or are of secondary importance.

A patient remanded by the court after his wife had him jailed for battery told the judge how sorry he was and suggested he needed psychiatric help. His history reveals acting-out behaviors as an adolescent and several adult arrests. The nurse interviews him about his relationship with his wife. Which statement by the patient is most consistent with a diagnosis of antisocial personality disorder? a. "I've done some stupid things in my life, but I've learned a lesson." b. "I'm feeling terrible about the way my behavior has hurt my family." c. "I have a quick temper, but I can usually keep it under control." d. "I hit her because she nags at me. She deserves it when I beat her up."

ANS: D The antisocial patient often impulsively acts out feelings of anger and usually feels no guilt or remorse. This patient rarely seems to change the behavioral patterns or otherwise learn from experience, commonly has problems with anger management and impulse control, and rarely feels true remorse.

The nurse is co-leader of a group. The guidelines followed by the leaders include focusing on recognizing dysfunctional behavior and thinking patterns, then identifying and practicing alternate behaviors and thinking that are more adaptive. What theory is represented by this group approach? a. Behavioral b. Interpersonal c. Psychodynamic d. Cognitive-behavioral

ANS: D The characteristics described are those of cognitive-behavioral therapy, in which patients learn to reframe dysfunctional thoughts and extinguish maladaptive behaviors. Behavioral therapy focuses solely on changing behavior rather than thoughts, feelings, and behaviors together. Interpersonal theory focuses on interactions and relationships. Psychodynamic groups focus on developing insight to resolve unconscious conflicts.

A patient is admitted for psychiatric observation after being arrested for breaking windows in the home of his former girlfriend, who had refused to see him. His history reveals abuse as a child by a punitive father, torturing family pets, and one arrest for disorderly conduct. The priority nursing diagnosis that should be considered is: a. Stress overload. b. Ineffective coping. c. Risk for self-directed violence. d. Risk for other-directed violence.

ANS: D The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in the scenario.

A patient who sought help in a crisis agrees after the first interview to return to the clinic for daily sessions. The nurse offers many suggestions for lifestyle changes the patient should make as crisis intervention progresses and provides after-hours phone support as well. After several sessions, which response on the nurse's part should most alert the nurse to a need for clinical supervision? a. Occasionally thinking about the patient's situation b. Searching for other possible interventions to use c. Feeling empathy for the patient's recent losses d. Wishing that the patient would be less clingy

ANS: D The nurse feels unrealistic responsibility to "cure" the patient's problems and may be motivated by a need to be needed. The daily sessions and after-hours phone contact suggest possible overinvolvement, and the patient's clinginess indicates that dependence has developed. The nurse is developing resentment in response. The nurse has failed to maintain appropriate professional boundaries, is experiencing countertransference, and should seek supervision to help her regain her objectivity and resolve the dependency in a therapeutic manner. Occasionally thinking about a patient's situation outside of sessions is neither unusual nor indicative of a need for supervision. Searching for additional interventions is not a red flag for supervision unless one is doing so in a manner that is very disproportionate to that exhibited in caring for other patients. Empathy is a therapeutic response and does not merit supervision (though sympathy might).

Which information noted in a patient's history most suggests a need for careful assessment of risk for violence in a newly admitted medical patient? a. Childhood abuse b. Family estrangement c. Academic problems d. Chemical dependence

ANS: D The nurse should suspect marginal coping skills in a patient with chemical dependence. They are often anxious, may be concerned about inadequate pain relief or going into withdrawal, and may have personality styles that externalize blame. The other options do not signal as high a degree of risk of violence.

The nurse is asked by the spouse of a patient seeking crisis intervention to give an example of an adventitious crisis. The nurse should mention: a. the death of a child from sudden infant death syndrome. b. being fired from one's job because of company downsizing. c. the retirement of a 64-year-old man after 30 years' service. d. a riot at a rock concert that results in multiple casualties.

ANS: D The rock concert riot is unplanned, violent, traumatizing, and not a part of everyday life. The death of a child and being fired are examples of situational crises. Retirement is an example of a maturational crisis.

A young female member in a therapy group relates to an older female patient as one might to a mother, accusing her of trying to control her whenever the older member offers observations or suggestions to her. Which therapeutic factor of a group is represented by this behavior? a. Instillation of hope b. Existential resolution c. Development of socializing techniques d. Corrective recapitulation of the primary family

ANS: D The younger patient is demonstrating an emotional attachment to the older patient that mirrors patterns within her own family of origin, a phenomenon called corrective recapitulation of the primary family group. Feedback from the group then helps the member gain insight about this behavior and leads to more effective ways of relating to her own family members. Instillation of hope involves conveying optimism and sharing progress. Existential resolution refers to the realization that certain existential experiences such as death are part of life, aiding the adjustment to such realities. Development of socializing techniques involves gaining social skills through the group's feedback and practice within the group.

"You folks have had good ideas so far, so whatever you guys say is OK with me." a. Playboy b. Energizer c. Organizer d. Gatekeeper e. Follower

ANS: E The follower agrees with whatever the group believes or wishes.