MODULE 3: MENTAL HEALTH CONCEPTS
d. Many things have happened to you and your husband.... The client is telling the nurse that many things that have happened over time. These things did not occur at once, and it is important for the nurse to learn more from the couple and for the couple to hear each other. The correct option reflects this intervention. In stating, "Can you tell me how long you have felt like this and how much longer you plan to continue this way?," the nurse uses confrontation and sarcasm, both of which are nontherapeutic. Saying, "You sound as if you are disgusted with your husband. Is this an accurate assessment? Why not divorce him?" prematurely labels and judges the client's feelings. "You seem to have changed your feelings about your husband completely. This didn't happen overnight, so why are you here now?" is a 'why' question, and the way that the nurse is challenging the client is nontherapeutic in the initial phase of a relationship.
On the initial visit to the mental health clinic, a client says to the nurse, "When I married my husband, more than 30 years ago, he was a big, handsome, competent professional who never wanted me to work and was so loving. Well, two kids later he's a slob who gambles and loses one job after another. Now I'm the breadwinner and he's content to be a shiftless town joke." Which statement by the nurse would be therapeutic? a. "You sound disgusted with your husband. Is this an accurate assessment? Why not divorce him?" b. "Can you tell me how long you have felt like this and how much longer you plan to continue this way?" c. "You seem to have changed your feelings about your husband completely. This didn't happen overnight, so why are you here now?" d. "Many things have happened to you and your husband. Sounds as if you've both been struggling for some time. Would you like to have him come in with you to talk with me about all of this?"
d. You're questioning your job...". The fireman may be experiencing work-related stress that, if untreated, could evolve into posttraumatic stress disorder. In the correct option, the nurse offers an observation in a neutral style, stressing that the fireman will benefit from seeking treatment. With the suggestion "Maybe you could help the mother find a home for Rudy, and then your nightmares would go away," the nurse changes the subject, is insensitive, and is nontherapeutic. In saying, "Would you listen to yourself? You've seen firemen stress out before. What is your responsibility in all this?" the nurse nontherapeutically lectures and chastises the client. In stating, "You helped victims of some horrific fires lately, and yet you question your calling. Do you feel the need to resign?" the nurse reflects the fireman's positive contributions that he already knows and then asks him whether he is thinking of acting on his ruminations. Although the nurse clearly strives to determine the client's problems, it is nontherapeutically timed and the nurse has no basis for making this judgment.
A 45-year-old fireman says to the nurse, "I've worked at some fires recently that were just devastating, but last week was the worst. I carried this little girl from a fire — she was badly burned and lived just a few minutes after I brought her out, and she said to me, 'Tell my mom and Rudy I love them both very much.' Her mom told me that Rudy is their dog, and he just mopes around the house since the little girl died. I keep thinking about her and just don't know if I can go on." Which response by the nurse would be therapeutic? a. "Maybe you could help the mother find a home for Rudy, and then your troubling thoughts would go away." b. "Would you listen to yourself? You've seen firemen stress out before. What is your responsibility in all this?" c. "You've helped victims of some horrific fires lately, and yet you question your calling. Do you feel the need to resign?" d. "You're questioning your job because you're upset about the little girl you tried to save. Work stress can be treated and help you cope better. It is so important for you to seek treatment."
b. Because you seem to keep blaming yourself The client in this question is expressing guilt and anxiety regarding his cancer diagnosis and impending surgery. Because he is anxious, the most therapeutic approach is to avoid trying to convince him that he is blameless in his cancer diagnosis and to move to health teaching and anticipatory guidance that may help reduce his anxiety and relieve his guilt. In asking, "You started drinking at 12 years of age — is that why you feel that the cancer is retribution?" the nurse focuses on his early onset of alcoholism and the need to convince him that he's faultless. In stating, "Sounds like you feel that you're being punished for your drinking, yet you've been sober, so perhaps you're being rewarded by having a cancer that's curable," the nurse starts by trying to convince the client that he is blameless for the cancer and then tries to restructure but does not use logic. In stating, "You feel that you're being punished even though you've been sober 25 years. Your doctor must have told you that the cancer is unrelated to alcohol," the nurse reflects his guilt back to him.
A 52-year-old client is admitted to the hospital for surgery to treat lung cancer. The client says to the nurse, "I was an alcoholic for 15 years, and now that I'm 25 years sober, I'm being punished." Which statement by the nurse would be therapeutic? a. "You started drinking at 12 years of age — is that why you feel that the cancer is retribution?" b. "Because you seem to be blaming yourself unnecessarily, perhaps we can talk about your illness and what you can expect after surgery." c. "Sounds like you feel that you're being punished for your drinking, yet you've been sober, so perhaps you're being rewarded by having a cancer that's curable." d. "You feel that you're being punished even though you've been sober for 25 years. Your doctor must have told you that the cancer is unrelated to alcohol."
d. It sounds like you and your daughter The therapeutic response is the one that reflects the client's thinking back to the client and makes observations for the client to organize, reflect on, and validate or discount. This will help place the information that the client's daughter is a lesbian into perspective. In stating, "Are you prejudiced against lesbian and gay people?" the nurse changes the focus and insensitively addresses the client's feelings about sexual orientation. In stating, "You're good at talking with middle schoolers, but how about young adults?" the nurse confronts the client by probing and making a premature judgment that is nontherapeutic. In stating, "How did your wife happen to tell you about this? Did your daughter ask her to tell you?" the nurse changes the focus of the client's concerns, which is nontherapeutic.
A 56-year-old client says to the nurse, "I'm a guidance counselor at the middle school, and the kids like to come to see me for help, but I just found out from my wife that my 22-year-old daughter is a lesbian, and now I'm the one who needs advice. How am I supposed to accept that? She was the boy we didn't have, and I made a tomboy of her by taking her to baseball games with me. Is that why she's gay?" Which statement by the nurse would be therapeutic? a. "Are you prejudiced against lesbian and gay people?" b. "You're good at talking with middle schoolers, but how about young adults?" c. "How did your wife happen to tell you about this? Did your daughter ask her to tell you?" d. "It sounds like you and your daughter were very close but she kept her sexual orientation from you."
d. "One of the things that I've found...". The therapeutic statement is the one that offers additional strategies to aid sleep and gauges whether the client can follow the suggestion. In stating, "So you've started having sleeping problems but no other problems?" the nurse probes the client for other problems, which is a nontherapeutic response. By stating, "Perhaps you should join the grieving spouses group that meets on Monday nights," the nurse changes the focus of the client's concerns and is nontherapeutic in prematurely suggesting the group therapy. In asking, "Since you've lost your husband, have you experienced any other problems besides trouble sleeping?" the nurse nontherapeutically reminds the client of her loss and links the sleeplessness to the loss.
A 68-year-old client whose husband died 2 months ago says to the nurse, "I'm having trouble sleeping lately, even though I don't nap in the daytime. I've been using warm milk without any results." Which statement by the nurse would be therapeutic? a. "So you've started having sleeping problems but no other problems?" b. "Perhaps you should join the grieving spouses group that meets on Monday nights." c. "Since you've lost your husband, have you experienced any other problems besides trouble sleeping?" d. "One of the things that I've found has helped others is a small snack with your warm milk before sleep and a moderate increase in walking during the day. Is that something you could try?"
b. "Seems as if you feel lost without your wife and maybe a bit ignored by your children." The client is exhibiting grief over the recent loss of his wife; feelings of insecurity, inexperience, and helplessness; weight loss (a vegetative sign of depression); evidence of poor nutritional habits; isolation; and a lack of safety in activities of daily living. The initial nursing statement should seek clarification of the client's feelings so that the nurse can estimate the extent of mood alteration. In stating, "I'm calling the doctor immediately to obtain a homemaker for you!" the nurse is responding too abruptly. Although the stated intervention may be a part of mutual planning, the client may not need or qualify for such support at this time; more data should be gathered. In stating, "First things first. What are you doing eating bacon and eggs? That's not a good meal for you," the nurse begins by ordering data from the client but veers off into expressing disapproval of the one meal that the client has cited, which may not be representative of his dietary habits. The nurse jumps to conclusions on the basis of inadequate information, and being judgmental is non-therapeutic. Saying, "Meals-on-Wheels can help you minimize your frustration. Are you a member of the local senior center?" jumps prematurely to referral to community resources that may be helpful. However, it is too early to address resources; a complete assessment of the client's stated complaints should be obtained first.
A 79-year-old client, recently widowed, says to the nurse, "My wife kept up our condominium single-handedly, and now my kids expect me to cook and clean for myself. I'm not lazy, but I don't know how to cook and I've burnt myself twice just frying up what was supposed to be bacon and eggs. I'm so frustrated and I've already lost 10 lb this month." Which initial nursing statement should the nurse make to the client? a. "I'm calling the doctor immediately to obtain a homemaker for you!" b. "Seems as if you feel lost without your wife and maybe a bit ignored by your children." Correct c. "First things first. What are you doing eating bacon and eggs? That's not a good meal for you." d. "Meals-on-Wheels can help you minimize the frustration you are having cooking. Are you a member of the local senior center?"
d. The client will stop blaming himself... Expecting the client to stop blaming himself for the loss of belongings puts undue pressure on him by implying that the client was negligent and contributed to the loss of the belongings. The other options are realistic goals and represent positive movement toward improved self-esteem and problem-solving.
A client comes to the mental health clinic after losing all of his personal belongings in a hurricane. The client tells the nurse that the loss of his possessions is his fault because he didn't prepare for the storm. The nurse determines that the client is coping ineffectively and develops goals with the client. Which of the following goals is the least realistic? a. The client will identify effective coping skills. b. The client will develop and use adaptive coping patterns. c. The client will express and share his feelings about this crisis. d. The client will stop blaming himself for the loss of his belongings.
c. You seem to be going through quite a lot.... In the correct option, the nurse acknowledges the client's concerns, encourages the client to express his feelings and concerns, and addresses the family. Also, the client views the situation solely from his viewpoint, so it would be most therapeutic to work with the entire family; however, it is important to obtain the client's permission to invite the family. In asking, "Do the terms 'divorce' and 'leave the nest' mean anything to you or your family?" the nurse uses humor and sarcasm in a nontherapeutic way. Although the nurse is correct in viewing this as potentially being a family problem as well as an individual one, asking, "Would your family come in to see me so I can hear their version of the problems you cite?" is nontherapeutic, with the potential to cause a negative response from the client. In saying, "You tell me that you do everything. You don't say what happens when you stop doing everything. Does your wife understand that you are not able to work as you once did and that you need her help?" the nurse seems accusatory, which is nontherapeutic.
A client says to the nurse, "I have to do everything. My family can't plan or organize anything. My wife just wants to go out and socialize. My grown son and his wife live with us. They never do anything around the house but 'their' stuff, because they say they pay rent. We really need their rent money since I lost my job. My wife could work but she says 'it's too late to start over' for her. Well, that's what I'm doing—more work at far less money." Which response by the nurse would be therapeutic? a. "Do the terms 'divorce' and 'leave the nest' mean anything to you or your family?" b. "Would your family come in to see me so I can hear their version of the problems you cite?" c. "You seem to be going through quite a lot recently. I'd like to hear more from you about your concerns. Would your family come in and talk with us?" d. "You tell me that you do everything. You don't say what happens when you stop doing everything. Does your wife understand that you are not able to work as you once did and that you need her help?"
d. The development of interpersonal skills, resolution of family..." Group therapy is especially effective in helping clients develop interpersonal skills, resolve family problems, and use community support effectively. Group therapy is also used to solve everyday problems, to express feelings and emotions, to ask questions, and to share experiences. It does not provide social skills training and is not focused on social function or cognitive behavioral therapy.
A client who has been referred for group therapy asks the nurse about the therapy. The nurse tells the client that this type of therapy is focused on: a. Social skills training b. Social functioning in groups c. Cognitive behavioral therapy d. The development of interpersonal skills, resolution of family problems, and effective use of community support
c. "Your loss touches me so..." The parents in this question have experienced a truly devastating loss. Although there are no set strategies for this situation, certain actions are important. First, the nurse communicates to the parents that the terrible loss is sad for others and offer empathy. Second, the nurse gathers data about what has happened to the parents over the 9 months since the loss. In stating, "My parents would be devastated if they lost me and my sister, too. How can I be of service to you?" the nurse nontherapeutically uses a social response that personalizes and shifts the focus from their feelings. In stating, "Your feelings are appropriate for the extent of your loss and how their deaths happened," the nurse lectures and moves away from the parents' expressed feelings to intellectualize. By stating, "Your loss is incalculable. Perhaps you could consider some ways in which to commemorate their lives for you and in your community," the nurse is empathetic and then begins to try to guide them toward creating a memorial. There may be a time when the nurse can help the parents reframe what has happened and think of ways to commemorate their children's lives, but they have not moved to that level of mourning yet, probably because of the nature of their children's deaths.
A client's son and daughter were killed during a fellow student's murderous rampage at their high school 9 months ago. The client says to the nurse, "My wife and I just feel empty and exhausted. I can't believe that I had a vasectomy after our son and daughter were born because we wanted to give them both whatever they needed. We have college funds for both of them that they'll never use now." The nurse should make which appropriate statement to the client? a. "My parents would be devastated if they lost me and my sister, too. How can I be of service to you?" b. "Your feelings are appropriate for the extent of your loss and how your children's deaths happened." c. "Your loss touches me so. How truly devastated you both must be. Can you share what things you have been doing to grieve?" d. "Your loss is incalculable. Perhaps you could consider some ways in which to commemorate their lives for you and in your community."
d. Blocking out more time... The young parents of a new baby are likely working hard to cope with anxiety and to deal with their fears of doing something wrong with the baby. Therefore the nurse should block out more time for the next visit and schedule another visit as soon as possible to assess how they are coping and gauge their level of anxiety. Ordering a follow-up visit to the family pediatrician and mental health clinical specialist is incorrect because it is premature without a total assessment of the parents' coping skills. Informing all home care nurses to schedule their visits to the couple as their last visit of the day and having the home care office secretary call the nurse's cell phone 20 minutes after starting the visit to expedite the nurse's departure are unprofessional. Additionally, the nurse needs to be assertive enough to set limits on the duration of the meetings.
A home care nurse makes a new-baby visit to a young husband and wife. The visit takes two-and-a-half hours because the parents are so detailed in giving information and asking questions of the nurse. Which intervention by the nurse would be therapeutic? a. Ordering a follow-up visit to the family pediatrician and mental health clinical specialist b. Informing all home care nurses to schedule their visits to the couple as their last visit of the day c. Having the home care office secretary call the nurse's cell phone 20 minutes after starting the visit to expedite the nurse's departure d. Blocking out more time for the next visit and scheduling a follow-up visit as soon as possible to assess how they are coping and gauge their level of anxiety
a. "You seem to be feeling regret." The therapeutic response is one that seeks to promote the client to re-frame a situation. In stating, "Don't blame yourself. Some people just turn out bad no matter what," the nurse uses a social generalized response. In stating, "All we can do is give our children love and do our very best. The rest is up to them," the nurse uses trite, cliche social, non-therapeutic communication. In asking, "Do I hear you saying that you feel that your son's behavior was caused by his upbringing?" the nurse uses an inappropriate and inaccurate interpretation, which is insensitive.
A nurse is talking to a client with depression when the client says, "I don't know why my son turned out like he did. I never thought that he would rob a bank! I don't know what I did wrong. I know that he didn't grow up with a father, but I gave him everything. I wish I could start over and do things differently." Which response by the nurse would be therapeutic? a. "You seem to be feeling regret." b. "Don't blame yourself. Some people just turn out bad no matter what." c. "All we can do is give our children love and do our very best. The rest is up to them." d. "Do I hear you saying that you feel that your son's behavior was caused by his upbringing?"
d. Joining the family and, after they have been able to be with their son for some time, helping them relinquish their son's body to the nurses. This question presents a sad and troubling story of a family needing time to grieve in the face of a catastrophic loss. The nurse's plan to join the family will provide support to the family. The nurse should call the family priest but first must ascertain that the family does wish to talk to a priest. Telling the student not to disturb the family until the end of shift does not provide support to the family. Asking the emergency department physician to join the student in requesting that the family let the nursing staff care for their son is inappropriate. This also represents a redundancy of tasks for personnel in a busy emergency department.
A nursing student is assigned to work in the emergency department to assist victims after a tornado. The student says to the nurse in charge, "I don't know how to help these parents. Their son was just decapitated by a flying piece of glass, and they won't leave him. They did mention that they are Catholic." Which intervention does the nurse suggest for inclusion in a plan of immediate care for the family? a. Telling the student not to disturb the family until the end of shift b. Calling their family priest immediately to come help them to let their son go c. Asking the emergency department physician to join the student in requesting that the family let the nursing staff care for their son d. Joining the family and, after they have been able to be with their son for some time, helping them relinquish their son's body to the nurses
b. "It seems that you're blaming yourself for something that was beyond your control." The correct option involves the use of the communication technique of reflection and encourages the client to further verbalize his thoughts and feelings. In stating, "I don't know what to say. It was a terrible fire. I'm so sorry this happened," the nurse is using a social response and the non-therapeutic communication technique of agreeing. In stating, "It seems to me that you're making this all about you when many people died in that fire," the nurse is using the non-therapeutic communication techniques of disapproval and judging. In stating, "You should be thankful that you're a survivor. The victims and their families lost, not you," the nurse is non-therapeutically lecturing the client.
A survivor of a nightclub fire that killed more than 100 people says to the nurse, "It should have been me. How come I got out and they didn't?" Which response by the nurse is appropriate? a. "I don't know what to say. It was a terrible fire. I'm so sorry this happened." Incorrect b. "It seems that you're blaming yourself for something that was beyond your control." Correct c. "It seems to me that you're making this all about you when many people died in that fire." d. "You should be thankful that you're a survivor. The victims and their families lost, not you."
d. "You can't seem to meet someone that you care about?" Reframing is a positive response in which the client redefines a situation to view both its positive and negative sides. The correct statement is the one that helps the client redefine the situation in this fashion and see how the situation could be used to the client's advantage. In stating, "Sounds as if you're exaggerating your situation and looking only at the half-full glass," the nurse gives advice and expresses an opinion, both of which are nontherapeutic. In stating, "It seems that you measure your life and what you need to do against the behaviors of others," the nurse uses the therapeutic response of reflection, but it does not teach the client reframing. "Aren't you a little young to be thinking in such negative terms? You do still have plenty of time before your biological clock winds down" is sarcastic and belittles the client; hence it is nontherapeutic.
A young adult client says to the nurse, "All my friends are married and have children. I can't seem to meet anyone, and I know I'll never be happy until I meet someone I can care about enough to marry." Which statement by the nurse would assist the client in reframing the situation? a "Sounds as if you're exaggerating your situation and looking only at the half-full glass." b. "It seems that you measure your life and what you need to do against the behaviors of others." c. "Aren't you a little young to be thinking in such negative terms? You do still have plenty of time before your biological clock winds down." d. "You can't seem to meet someone that you care about? You can still find enjoyment in friendships, work, books, and other things as well."
b. "Sounds as if you're feeling angry and pretty helpless right now." Anger is not uncommon during the first month of grief and at times throughout the first year after the loss of a loved one. The nurse should not be surprised to hear the bereaved husband displace his anger onto the healthcare providers. The nurse's use of reflection will help him explore sadness and loss more easily. By saying nothing and simply saying "Mm-hmm" noncommittally, the nurse uses a response that may mislead the bereaved husband to think that the nurse agrees with his displaced anger. Although it may be a therapeutic response, it will not help the husband focus on his feelings. By stating, "Let's not focus on what was not done, but what was done for your wife," the nurse uses a social response of distraction and does not facilitate expression of the husband's feelings. "Your doctor did all he could for your wife. You know, physicians can only apply their best clinical judgment" is defensive and lecturing.
The 45-year-old husband of a client with breast cancer who just died says to the nurse, "If our doctor had operated sooner, my wife would be alive now." Which statement by the nurse would be therapeutic? a. Say nothing. Simply nod and say "Mm-hmm" noncommittally. b. "Sounds as if you're feeling angry and pretty helpless right now." c. "Let's focus not on what was not done but instead on what was done for your wife." d. "Your doctor did all he could for your wife. You know, physicians can only apply their best clinical judgment."
d. "I am going to begin by..." Family therapy is a good idea when violence is part of a crisis or if the family requests help. By offering ways to cope and support the client, the nurse can relieve any hesitation on the part of the family about discussing their concerns. In stating, "I must begin by saying that I am uncomfortable meeting without your son here to talk for himself," the nurse uses a confrontational style of speaking that is not pertinent to the issues at hand. The family members have a right to their own counseling and to teaching on how to assess mood and suicidal ideation. At the appropriate time the nurse can request that the client be invited to attend the family therapy sessions. In stating, "Let's start by introducing ourselves and talking about what is most troubling to each of you about having your son home," the nurse uses an orientation and broad opening technique that may be helpful but is not the best of the options provided. By stating, "Why don't we all introduce ourselves and say what our relationship is to your son? I'll begin, because I'm the nurse who'll be seeing him after he comes home," the nurse uses a style that is introductory, but then the nurse changes the focus to herself, which is not therapeutic.
The family of a client who is being discharged after trying to kill himself with one of his father's guns asks for a family meeting with the nurse to discuss their son's situation. Which statement by the nurse would be the most therapeutic start to the meeting? a. "I must begin by saying that I am uncomfortable meeting without your son here to talk for himself." b. "Let's start by introducing ourselves and talking about what is most troubling to each of you about having your son home." c. "Why don't we all introduce ourselves and say what our relationship is to your son? I'll begin, because I'm the nurse who'll be seeing him after he comes home." d. "I am going to begin by talking in general terms about your son's return home and some of the things that might happen. I can suggest measures that might be helpful, and then you can ask questions."
c. "Are there other options for you to take work leave?" etc. In end-of-life nursing care, the caregiver is often asked, "How long?" or "What should I do?" by family members and the dying clients themselves. The nurse can convey information and make limited but realistic predictions, such as presenting the client's stable or deteriorating physiological condition. Discussing options and alternative solutions with the family that can be added to the process of decision-making can be helpful. Simple alternatives can be used as examples if the family or client seems unable to begin to problem-solve. By stating, "Only you and your husband can determine how you should best allocate your work leave," the nurse avoids any discussion with the family member. By stating, "Your husband has managed to be active up to now, so he could live longer than predicted, but his lifespan remains unclear," the nurse begins to discuss physiological issues but is so vague that in the end the statement offers no support. By stating, "Why not write down the pros and cons of taking work leave all at once and any other options, and then decide with your husband and family which would be most helpful?" the nurse makes suggestions but leaves the family member with little to use for decision-making.
The wife of a client who is dying says to the nurse, "I am able to take off the 6 months from work our doctor feels that my husband will live, but what if he lives beyond that time?" Which therapeutic response should the nurse make? a. "Only you and your husband can determine how you should best allocate your work leave." b. "Your husband has managed to be active up to now, so he could live longer than predicted, but his actual lifespan remains unclear." c. "Are there other options for you in taking work leave? Perhaps you could simply reduce your work hours at first so that you can extend your compassionate leave." d. "Why not write down the pros and cons of taking work leave all at once and any other options and then decide with your husband and family which would be most helpful?"
c. The lack of money has stopped The therapeutic response reflects the information in the question and encourages the client to express her feelings. In saying, "You're having a very difficult time, and the problem stems entirely from your husband's drinking," the nurse is judgmental and places all blame on the husband. In stating, "It's a shame. So many troubling things have been happening to you both because of the disease of alcoholism," the nurse provides a closed-ended response. In saying, "You're codependent with your husband. Don't you see this? Are you willing to attend some group meetings to learn about ways to deal more effectively with your problem?" the nurse is nonempathetic and belittling.
The wife of an alcoholic client says to the nurse, "I can't afford to bail my husband out of this mess. Our business is filing for bankruptcy, and the Internal Revenue Service has posted a notice of auction on our home." Which statement by the nurse would be therapeutic? a. "You're having a very difficult time, and the problem stems entirely from your husband's drinking." b. "It's a shame. So many troubling things have been happening to you both because of the disease of alcoholism." c. "The lack of money has stopped you from saving your husband? It sounds like you need to help yourself right now. What do you think?" Correct d. "You're codependent with your husband. Don't you see this? Are you willing to attend some group meetings to learn about ways to deal more effectively with your problem?"
