Psychiatric/Mental health nursing - Foundations and modes of care

A nurse is preparing to teach a mental health course at a community health center. What information should the nurse include as one of the most effective ways to limit the occurrence of mental illness in the community? 1. Developing multiple coping strategies 2. Reporting strange behaviors by others 3. Correcting myths about mentally ill people 4. Addressing genetic issues related to mental illness

1 A variety of strategies gives people options when they are attempting to cope with stress. Different strategies work better in different situations. Reporting strange behaviors by others is too vague; the definition of "strange" may vary, depending on the individual. Correcting myths about mentally ill people is useful, it will not limit the occurrence of mental illness. Although some mental disorders may have familial tendencies and may have a genetic link, this information is too limited.

A nurse is assessing a client who has come to a walk-in mental health clinic. Which statement supports the assessment that the client is experiencing a crisis? 1. "I have these feelings of uneasiness. They come and go." 2. "Nothing I try works. Everything just keeps getting worse." 3. "Things have been building up slowly. I don't know what's causing it." 4. "I feel tense and irritable. When I concentrate on my work, I feel better."

2 A crisis occurs when usual methods of coping are no longer effective and the individual is so overwhelmed that emotional distress and cognitive impairment result. A crisis is precipitated by a known acute situation, not by a situation that comes and goes. Feelings of uneasiness, tension, and irritability are associated with anxiety. Feelings associated with a crisis cause such severe disequilibrium that the individual is unable to concentrate or function. (P. 491-503) (Fig 26.1)

After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client? 1. Projection 2. Repression 3. Suppression 4. Rationalization

2 Repression - coping with overwhelming emotions by blocking awareness or memory of the stressful event. Projection - attributing one's own unacceptable feelings and thoughts to others. Suppression - consciously keeping unacceptable feelings and thoughts out of awareness. Rationalization - the attempt to mask unacceptable feelings or behaviors by providing excuses and explanations. (P. 274)

A mother and her 5-year-old daughter have been referred to a child advocacy center for a forensic pediatric sexual examination. Before the child is examined or interviewed, the mother gives a detailed history, relaying her suspicion that the child's maternal grandfather sexually assaulted her. As the interview progresses, the mother suddenly says, "My father sexually molested me when I was a child, but I try not to think about it." What defense mechanism does the nurse recognize that the mother's statement demonstrates? 1. Introjection 2. Suppression 3. Reaction formation 4. Passive aggression

2 SUPPRESSION - voluntary refusal to admit an unacceptable idea or behavior. INTROJECTION - the unconscious incorporation of wishes, values, and attitudes of others as if they were one's own. PASSIVE-AGGRESSIVE BEHAVIOR - is the expression of anger and hostility toward others in an indirect and nonassertive way. REACTION FORMATION - the exact opposite of an unconscious feeling. (P. 274)

A client who has been pregnant for 5 months experiences a spontaneous abortion after an accident. The client tells the nurse that she feels depressed over the loss of her son. She describes how he would have looked and how bright he would have been. What is the client demonstrating? 1. Panic level of anxiety 2. Typical grief syndrome 3. Pathological grief reaction 4. Diminished ability to test reality

2 The client is grieving the loss of a fantasized child; talking about it is part of the typical grief reaction. The client is sad, not out of control or immobilized. The client is coping with the loss effectively. The client recognizes the loss, but is lamenting what could have been.

One morning, during the working phase of a therapeutic relationship after several sessions in which difficult issues were discussed, the client suddenly becomes very hostile. What is the most appropriate interpretation of this behavior by the nurse? 1. The client is exercising assertiveness, which implies improvement. 2. Flare-ups often occur even when there is a positive working relationship. 3. Hostility is being used as a defense because previous self-disclosure has raised anxiety. 4. The behavior is a form of regression, which implies some deterioration in the client's condition.

3 Emotional closeness after self-disclosure increases anxiety, which cannot be tolerated; hostility is used to keep the nurse at a distance. - Hostility is more extreme than assertiveness and is not an indication of improvement. - Although flare-ups often occur even when there is a positive working relationship, the expression of hostility is not a flare-up in this situation. - Regressive behavior is the resumption of behavior characteristic of an earlier stage of development; hostility does not fit this definition.

A parent who is visiting a hospitalized adolescent gets into an argument with the adolescent. Leaving the adolescent's room in tears, the parent meets the nurse and relates the argument, saying, "I can't believe I got so angry that I could have hit my child." What is the most therapeutic response by the nurse? 1. "Teenagers really can drive you to distraction." 2. "Bring a surprise for the child next time. It'll make you both feel better." 3. "Sometimes we find it difficult to live up to our own expectations of ourselves." 4. "You can't compare yourself to an abusive parent—after all, you didn't beat your child."

3 The response "Sometimes we find it difficult to live up to our own expectations of ourselves" is the best response because it reflects the feelings being expressed at this time. "Teenagers really can drive you to distraction" avoids the real issue. Telling the parent to bring a surprise for the adolescent on the next visit does not address the real concern; the parent's argument may have been justified, and the child's behavior should not be rewarded. The response "You can't compare yourself to an abusive parent—after all, you didn't beat your child" avoids the issue; the parent may fear that next time control will be lost and abuse will occur.

During group therapy, the working phase usually begins when the group displays what? 1. Cohesiveness 2. Confrontation 3. Imitative behavior 4. Corrective recapitulation

1. When the group becomes united (cohesive), the clients can feel accepted, valued, and part of the group; this is the optimal time for the working phase to begin. Confrontation, imitative behavior, and corrective recapitulation all occur later in the working phase of group process, not in the beginning. (P. 611-614)

An executive busy at work receives a phone call from a friend relating bad news. The executive makes a conscious effort to put this information out of mind and continues to work at the task at hand. The next day executive remembers that the friend telephoned but is unable to recall the message. Which defense mechanism does this behavior represent? 1. Regression 2. Suppression 3. Reaction formation 4. Passive aggression

2 Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations. In regression, a person returns to an earlier and more comfortable developmental level. Passive aggression - the use of behaviors such as passivity, procrastination, and inefficiency that negatively affect others. Reaction formation - conscious behavior that is the opposite of an unconscious feeling. (P. 274)

One afternoon a male client on the inpatient psychiatric service complains to the nurse that he has been waiting for more than an hour for someone to accompany him to activities. The nurse replies, "We're doing the best we can. There are many other people on the unit who need attention too." This response demonstrates the nurse's use of what type of behavior? 1 Impulse control Correct2 Defensive behavior Incorrect3 Reality reinforcement 4 Limit-setting behavior

The nurse's response is not therapeutic because it does not recognize the client's needs but instead tries to make the client feel guilty for being demanding. Impulse control refers to a sudden driving force's being constrained or held back. Nothing in the nurse's statement demonstrates reality reinforcement or sets limits; the nurse is defensive, not therapeutic.

In an attempt to remain objective and support a client during a crisis, the nurse uses imagination and determination to project the self into the client's emotions. What is this technique known as? 1. Empathy 2. Sympathy 3. Projection 4. Acceptance

1 EMPATHY - the projection of self into another's emotions to share the emotions and the other's state of mind; this technique helps the nurse understand the meaning and significance of the experience to the client. SYMPATHY - a shared expression of sorrow over a real or imagined loss. PROJECTION - an unconscious defense mechanism, not a therapeutic technique. ACCEPTANCE - does not require the nurse to project the self into the client's emotions; rather, it involves accepting the client and the emotions.

What is the priority when the nurse is establishing a therapeutic environment for a client? 1. Ensuring the client's safety 2. Accepting the client's individuality 3. Promoting the client's independence 4. Explaining to the client what is being done

1 Safety is the priority before any other intervention is provided. Accepting the client's individuality, promoting the client's independence, and explaining to the client what is being done are all important, but less of a priority.

What is the basic therapeutic tool used by the nurse to foster a client's psychologic coping? 1. Self 2. Milieu 3. Helping process 4. Client's intellect

1 The SELF is often the most important tool available to the nurse to help a client cope; to be therapeutic, the nurse must be present, actively listening, and attentive. The MILIEU (environment) is important, but it is not the most basic tool. The nurse first must use the self before the HELPING PROCESS can begin. The CLIENT'S INTELLECT is not generally a therapeutic tool used by the nurse.

What is the most important tool a nurse brings to the therapeutic nurse-client relationship? 1. The self and a desire to help 2. Knowledge of psychopathology 3. Advanced communication skills 4. Years of experience in psychiatric nursing

1 The nurse brings to a therapeutic relationship the understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship. - Knowledge of psychopathology, advanced communication skills, and years of experience in the field all support the psychotherapeutic management model, but none is the most important tool used by the nurse in a therapeutic relationship.

A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? Select all that apply. 1. "I cry all the time; I'm just so sad." 2. "Since I retired I've been so depressed." 3. "I'd like to end it all with sleeping pills." 4. "The voices say I should kill all prostitutes." 5. "My boss makes me so angry—he's always picking on me."

3, 4 The statement about ending it all is a suicide threat; it is a direct expression of intent without action. Likewise, the threat to harm others must be heeded. Confiding feelings of sadness or depression does not indicate that the client plans to self-harm or harm others. The statement about the boss reflects the client's feelings of anger and the cause but does not indicate a threat to self or others.

During a phone conversation to a crisis hotline a client states, "I'm falling apart and can't put myself together. This goes on and on." What is the most therapeutic response by the nurse? 1 "Is there anyone there with you?" 2 "What do you think this means?" Incorrect3 "How do you usually handle this type of situation?" Correct4 "What's happening right now that prompted you to call?"

Getting the client's perception of what has prompted the call is essential to determining whether the client is in danger. The client has chosen to call the crisis line as a help-seeking behavior; asking whether someone else is there does not focus on the client's reaching out. "What do you think this means?" is a question that can be asked later to assist the client in gaining insight into the present situation. "How do you usually handle this type of situation?" is a question that may follow assessment of the situation.

The wife of a client who is dying tells the nurse that although she wants to visit her husband daily, she can visit only twice a week because she works and has to take care of the house and their cat and dog. What defense mechanism does the nurse conclude that the client's wife is using? 1. Projection 2. Sublimation 3. Compensation 4. Rationalization

4 RATIONALIZATION - is offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. PROJECTION - the denial of emotionally unacceptable feelings and the attribution of the traits to another person. SUBLIMATION - the substitution of a socially acceptable behavior for an unacceptable feeling or drive. COMPENSATION - making up for a perceived deficiency by emphasizing another feature perceived as an asset. (P. 274)

A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request? 1. Justice 2. Veracity 3. Autonomy 4. Beneficence

3 Autonomy is the ethical principle of respecting the independence and right to self-determination of others. In this situation the nurse focuses on helping the client make a choice. Justice is the ethical principle that requires all people to be treated fairly, regardless of sex, age, religion, diagnosis, marital status, or socioeconomic level. Veracity is the ethical principle that requires truthfulness. Beneficence is the duty to do good and promote the welfare of others.

What is the priority outcome in the planning of care for a client in crisis? 1. Referring the client for occupational therapy 2. Arranging follow-up counseling for the client 3. Restoring the client's psychological equilibrium 4. Having the client work to gain insight into the problem

3 Crisis intervention is short-term therapy with the major outcome of restoring the client to the precrisis state. Referring the client for occupational therapy is not an outcome, but an action to help achieve an outcome; it is not part of crisis intervention. Scheduling the client for follow-up counseling is not an outcome, but rather an intervention that may be necessary if psychological equilibrium cannot be restored. Having the client gain insight into the problem is not always necessary for a client to be able to function effectively. (P. 491-503)

A nurse is aware that a coworker's mother died 16 months ago. The coworker cries every time someone says the word "mother" and when the mother's name is mentioned. What does the nurse conclude about this behavior? 1. It is an expected response. 2. Most people cry when their mother dies. 3. The coworker may need help with grieving. 4. The coworker was extremely attached to the mother.

3 Crying is a release, but the individual should have developed effective coping mechanisms by this time. The coworker may need help with the grieving process. Excessive crying 16 months after the death of a loved one is not an expected response. People express grief in a variety of ways, not necessarily by crying. Concluding that the coworker was extremely attached to the mother is an assumption and is not a valid conclusion.

The nurse is caring for a client experiencing a crisis. What role is most important for the nurse to assume when providing therapeutic crisis intervention? 1. Passive listener 2. Friendly advisor 3. Active participant 4. Participant observer

3 To intervene in a crisis, the nurse must assume a direct, active role because the client's ability to cope is lessened and help is needed to solve problems. - Being a passive listener is insufficient to help the client. - Being a friendly advisor can blur the boundaries between a professional and a social relationship. The role of the nurse should not include giving advice. - Being a participant observer is insufficient to help the client.

A client in the mental health clinic who has been seeing a therapist for more than 6 months begins to talk and act like a therapist who is analyzing coworkers. What defense mechanism does the nurse identify? 1. Undoing 2. Projection 3. Introjection 4. Intellectualization

3. Introjection is treating something outside the self as if it is actually inside the self; it is unconsciously incorporating the wishes, values, and attitudes of another as if they were one's own. Undoing is taking some action to counteract or make up for a wrongdoing. Projection is attributing to another person or group one's own unacceptable attitudes or characteristics. Intellectualization is using logical explanations without feelings or an affective component. (P. 274)

A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. What does the nurse's behavior reflect? 1. Affiliation 2. Displacement 3. Compensation 4. Countertransference

4 Countertransference - professional provider of care exhibits an emotional reaction to a client based on a previous relationship or on unconscious needs or conflicts. Affiliation - turning to others for support and help when stressed or conflicted. Displacement - the discharge of pent-up feelings onto something or someone else that is less threatening than the original source of the feelings. Compensation - attempting to balance deficiencies in one area by excelling in another area.

While assessing an older adult in the emergency department the nurse notes that the client is upset. The nurse asks what is wrong, and the client describes the current situation and then offers information that goes further and further off the topic. What pattern of communication does this conversation reflect? 1. Perseveration 2. Thought blocking 3. Overcompensation 4. Tangential thinking

4 TANGENTIAL THINKING - the person never answers the question or returns to the central point of the conversation. It often is seen in people with dementia. PERSERVATION - the repetitive expression of a single idea in response to different questions; it is found most often in clients with cognitive impairments and those experiencing catatonia. THOUGHT BLOCKING - a sudden stoppage of the spontaneous flow of speaking for no apparent external reason; it is seen most often in clients who are experiencing auditory hallucinations. OVERCOMPENSATION (reaction formation) - is a defense mechanism, not a pattern of communication. (P. 438/439)

At what age is a client in Freud's phallic stage of psychosexual development and Erikson's psychosocial phase of initiative versus guilt? 1. Adolescence 2. 6 to 12 years 3. 3 to 5 years 4. Birth to 1 year

3 Three to five years is Freud's phallic stage and Erikson's stage of initiative versus guilt. - BAdolescence is Freud's genital stage and Erikson's stage of identity versus role confusion. - Six to twelve years is Freud's latency stage and Erikson's stage of industry versus inferiority. - Birth to 1 year is Freud's oral stage and Erikson's stage of trust versus mistrust.

A client states, "I get down on myself when I make a mistake." In a cognitive therapy approach, which nursing interventions are most appropriate? Select all that apply. 1. Teaching the client relaxation exercises to diminish stress 2. Exploring with the client past experiences that have caused distress 3. Providing the client with mastery experiences designed to boost self-esteem 4. Encouraging the client to replace these negative thoughts with positive thoughts 5. Helping the client modify the belief that anything less than perfection is unacceptable

4, 5 COGNITIVE THERAPY seeks to find underlying self-defeating beliefs and replace them with more reality-based positive beliefs. It encourages the use of cognitive restructuring (cognitive reframing) through positive self-talk and a rational mindset. - Teaching the client relaxation exercises to diminish stress reflects a behavioral approach. - Exploring with the client past experiences that have caused distress is a psychoanalytical approach. - Providing the client with mastery experiences to boost self-esteem is a behavioral approach.

Group Phases

Represent distinct periods or stages in the process of group development: Planning Phase Orientation Phase WORKING PHASE - when the nurse and the patient work together to solve problems and accomplish goals Termination Phase

An unmarried pregnant client who has been attending a crisis intervention clinic has decided to keep the baby and is looking forward to motherhood. The nurse identifies the decision to attend prenatal childcare classes as an example of what? 1. Intrinsic motivation 2. Extrinsic motivation 3. Operant conditioning 4. Behavior modification

1 INTRINSIC MOTIVATION - motivation that is stimulated from within the learner; it is most effective because the learner recognizes the need to know, is self-directed, and is ready to learn. EXTRINSIC MOTIVATION - is stimulation from outside sources and is often ineffective; desire should come from within. OPERANT CONDITIONING and BEHAVIOR MODIFICATION - are forms of therapy requiring reinforcement of desired behavior.

A mother and her three young children arrive at the mental health clinic. The woman says that she is seeking help in leaving her husband. She reports that he has been beating her for years but just started hitting the children. What is the best initial action by the nurse? 1. Arranging for a staff member to watch the children so the mother and nurse can talk 2. Calling a facility where the mother and her children will be safe until the crisis is resolved 3. Determining whether the mother is ambivalent about this decision before making permanent plans 4. Suggesting that the mother and her husband return for couples counseling so the marriage can be saved

1 This emotionally charged topic should be discussed with the client in a confidential session; after the nurse has assessed the situation, the woman and the nurse can plan the family's future. Although a safe facility may be called, a determination of the client's ambivalence may be made, and couples counseling may be recommended eventually, all three actions are premature if a thorough assessment of the situation has not been made. (P. 491-503)?

Which statement demonstrates that a psychiatric nurse has fostered the most therapeutic nurse-client relationship? 1. "My clients and I are partners in the planning that helps meet their physical and mental health needs." 2. "Nurses and clients must develop a therapeutic relationship if appropriate mental and physical care is to be provided." 3. "Mental health is best achieved and maintained when the nurses and the clients exhibit respect and caring for each other." 4. "Without a mutually satisfying relationship between nurse and client, the process needed to maximize mental and physical wellness is greatly hindered."

1 Today's nurse-client relationship is one that demonstrates the nurse's clinical competence while recognizing the client's right to self-determination in decisions affecting both physical and mental health. - Although the development of a true therapeutic relationship is a goal, when that is not achievable because of the client's mental health status, appropriate nursing care is still achievable. - Although the demonstration of mutual respect and caring are basic elements, other factors also have an impact on the formation of a therapeutic nurse-client partnership. - A truly therapeutic nurse-client relationship provides satisfaction for both nurse and client; that may not be achievable because of the client's mental health status. The nursing process can still provide care that strives to meet client outcomes that are reflective of their potential for both physical and mental wellness.

What should nurses consider when working with depressed young children? 1. It is important to include the family in the treatment plan. 2. The goal of therapy is for the child to gain insight into problems. 3. Depressed children are treated in much the same way as depressed adults. 4. Antidepressant medication is the treatment of choice for depressed children.

1 When a young child demonstrates symptoms of emotional discord, usually this is a response to some type of family dysfunction. Because of their cognitive development, children are usually incapable of insight into their problems. Psychiatric interventions are different for children than for adults. Psychotropic medications are not the treatment of choice for children because their side effects are more dangerous in children than in adults.

A disturbed client who has been out of touch with reality has been hospitalized for several weeks. One day the nurse notes that the client's hair is dirty and asks whether the client wants to wash it. The client answers, "Yes, and I'd like to shower and change my clothes, too." What can the nurse conclude about the client in relation to this response? 1. The client has some feelings of self-worth. 2. The client is open to suggestions from others. 3. The client may be entering a hyperactive phase. 4. The client has a need for social reassurance from others.

1 When individuals express interest in physical appearance, it demonstrates a rebuilding of the self-image and the return of feelings of worth and concern for how others see them. The client's response goes further than the nurse's suggestion to wash the hair. The client has identified the need to shower and change clothes. The client's response is well within the expected range; it does not indicate the beginning of a hyperactive phase. The information provided does not demonstrate a need for social reassurance or approval.

When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, what should the nurse do? 1. Ignore the client's stories. 2. Listen to what the client is saying. 3. Explain that no one can get through the door. 4. Ask for an explanation of where the information was obtained.

2 Listening to what the client is saying demonstrates that the nurse believes that what the client has to say is important; it also encourages verbalization of feelings. Ignoring the client's stories may increase the client's feelings of worthlessness and persecution. Explaining that no one can get through the door will accomplish little; a paranoid individual cannot be talked out of his or her feelings. These are feelings, not information, and they cannot always be explained; asking where the information came from forces the client to further develop the delusional system.

A 44-year-old single woman loses her job and has been unable to find a job for 8 months. She has exhausted her savings and is overwhelmed. She comes to the crisis intervention center because she is despondent and feels hopeless. What type of crisis does the nurse identify? 1. Subjective 2. Situational 3. Adventitious 4. Maturational

2 SITUATIONAL crisis involves an unanticipated loss that is apparent to others. Examples include loss of a job, death of a loved one, and a change in health status such as an amputation. SUBJECTIVE (internal) crisis threatens a person's well-being but is not obvious to others. Examples of subjective crises include aging, lack of independence, and loss of faith. ADVENTITIOUS crisis involves natural (e.g., hurricane, tsunami) or man-made (e.g., arson, terrorist attack) traumatic events. These crises often involve numerous losses. MATURATIONAL crisis occurs in response to stress as a person experiences a predictable change. Examples of maturational crises include adolescence, marriage, parenthood, and retirement. (P. 274)?, (P. 491-503)

A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives at the emergency department? 1. Fearful 2. Confused 3. Charming 4. Indifferent

3 Abusers are often extremely CHARMING to mask their abusive tendencies and convince the abused mate and others that change is possible. After an abusive episode there is often a "honeymoon" period because the tensions of the abuser have been released. Abusers mask their FEARS by becoming angry and aggressive. Abusers are not CONFUSED; they are manipulative of others. Abusers are rarely INDIFFERENT; they tend to be opinionated and demanding.

A nurse is counseling a recently widowed client, who says, "His death has complicated my life even more than the hassles he caused when he was alive!" The nurse realizes the client is having difficulty with the grieving process and concludes that the relationship with the husband was probably what? 1. Loving 2. Long-term 3. Ambivalent 4. Subservient

3 If the relationship was AMBIVALENT, the surviving spouse now has feelings of both anger and guilt to resolve. LOVING relationship - evokes fewer feelings of guilt and is followed by a less complicated grieving process. lONG-TERM - length of the relationship seems to have little to do with the ease or difficulty in completing the grieving process. Individuals in the SUBSERVIENT role usually have learned to accept directions and either find a new director or are relieved to have a chance to express their own feelings.

What is most important for the nurse to do to assist a couple to cope with their feelings about the husband's terminal illness? 1. Referring the husband to a psychotherapist for help in dealing with his anger 2. Placing the couple in a couples' therapy group that addresses terminal illness 3. Helping the couple express to each other their feelings about his terminal illness 4. Encouraging the wife to verbalize her feelings to a therapist during individual therapy sessions

3 It is important for the couple to discuss their feelings to maintain open communication and support each other. - Referring the husband to the psychotherapist for help in dealing with his anger will not meet the needs of this couple because it focuses only on the client's needs and ignores the partner's needs; in addition, most psychotherapy is a long-term process. - Placing the couple in a couples' therapy group that addresses terminal illness may be useful in the future, but at this time it is premature; clients need to work through their own feelings first. - Encouraging the wife to verbalize her feelings to a therapist during individual therapy sessions may elicit feelings but will not improve communication between the husband and wife; this is a long-term goal.

A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. What defense mechanism does the nurse know is being utilized by this woman? 1. Projection 2. Regression 3. Repression 4. Displacement

3 REPRESSION occurs when an individual unconsciously excludes distressing emotions, thoughts, or experiences from her awareness. It is a mechanism to help her deal with the shock of stressful emotional experiences. A repressed memory is "forgotten" and cannot be deliberately brought to awareness. PROJECTION - occurs when an individual attributes his or her own unacceptable feelings and thoughts to others, allowing the individual to blame others for personal shortcomings. REGRESSION - occurs when an individual reverts to an earlier stage of development involving less mature behavior and responsibility as a way of coping with a stressful situation; it often results in more dependent behavior. DISPLACEMENT - occurs when an individual releases pent-up feelings on people perceived to be less dangerous than those who initially aroused the emotion. For example, after receiving a speeding ticket from the police a man yells at his wife when she asks him how his day went. (P. 274)

A nurse is counseling a client who has had an angry episode that subsided after several minutes. What is the most important short-term objective for the client? 1. Continuing to vent angry feelings 2. Recognizing the ways in which anger hurts others 3. Talking about situations that cause angry outbursts 4. Requesting increased medication when feelings of anger occur

3 Talking about situations that precipitate anger is the first step in helping a client to cope with his or her feelings. - Continuing to vent angry feelings is nonproductive; it may escalate the feelings of anger and result in aggressive behavior. - The client, not others, should be the focus of short-term objectives. - The client needs to learn acceptable ways of coping with positive and negative feelings. Medication does not help the client learn new ways of coping.

When a nurse is working with a client with psychiatric problems, a primary goal is the establishment of a therapeutic nurse-client relationship. What is the major purpose of this relationship? 1. Increasing nonverbal communication 2. Presenting an outlet for suppressed hostile feelings 3. Assisting the client in acquiring more effective behavior 4. Providing the client with someone who can make decisions

3 The therapeutic nurse-client relationship provides an opportunity for the client to try out different behaviors in an accepting atmosphere and ultimately to replace pathologic responses with more effective responses. Verbal communication, not nonverbal communication, is the objective of the therapeutic relationship. The nurse, although accepting of the client's hostile feelings, uses the therapeutic relationship to redirect hostile feelings into more acceptable behaviors. The nurse provides the support and acceptance that encourage clients to make their own decisions.

A depressed client whose spouse recently died attends an inpatient group therapy session in which the nurse is a co-leader. When another client talks about being divorced and the resulting feelings of abandonment, the nurse notices that tears are running down the depressed client's face. What should the nurse do to support this client? 1. Ask group members to return to discuss this client's feelings. 2. Have another client stay and spend time talking with the client. 3. Observe the client's behavior carefully during the next several hours. 4. Accompany the client to his or her room and encourage a discussion of his or her feelings.

4 Helping a client cope with unresolved grief involves assisting the client in expressing thoughts and feelings about the lost object or person as a necessary part of grief work. Asking group members to return to discuss this client's feelings is too threatening; at this point the client needs therapeutic one-on-one interaction. Having another client stay and spend time talking with the client is the responsibility of the nurse; another client does not have the expertise to help this client. The current nonverbal behavior indicates that the client is dealing with feelings; an opportunity should be provided for a verbal exploration rather than merely observing the client. Test-Taking Tip: Look for answers that focus on the client or that are directed toward the client's feelings.

A nurse is caring for an adult client who immigrated to this country 5 years ago. What does the nurse know about the past experiences of clients who have immigrated to this country? 1. They affect their inherited traits. 2. They have little effect on their lives today. 3. They are important in assessment of their values. 4. They establish personal interactions throughout life.

3 Past experiences are important and must be recognized because they set the parameters for the individual's enduring values throughout life. Past experiences do not affect inherited traits. Past experiences play an important role in an individual's life. Nothing establishes how an individual responds over a lifetime; new experiences continue to influence future responses.

An older retired client is visiting the clinic for a regularly scheduled checkup. The client tells the nurse about the great life he has lived and the activities that he enjoys at the senior center. According to Erikson, what developmental conflict has been resolved by this client? 1. Trust versus mistrust 2. Integrity versus despair 3. Generativity versus self-absorption 4. Autonomy versus shame and doubt

2 The tasks of older individuals are ego integrity, satisfaction with life, and acceptance of the future versus despair, remorse, and fear of the future. - Trust versus mistrust is the conflict associated with infancy. - Generativity versus self-absorption is the conflict associated with later adulthood. - Autonomy versus shame and doubt is the conflict associated with early childhood.

The nurse is scheduled to be the co-leader of a therapy group being formed in the mental health clinic. When planning for the first meeting, it is of primary importance that the nurse consider what? 1. Number of clients in the group 2. Needs of the clients being included 3. Diagnoses of the clients being included 4. Socioeconomic status of the clients in the group

2 When planning a group, the nurse must ensure that clients have similar needs to promote relationships and interactions; diverse needs do not foster group process. Although important, the number of clients is not a primary consideration. Behavior and needs, rather than diagnoses, are of primary importance. The socioeconomic status of the clients in the group has little effect on group process.

A nursing assistant is frequently late for work and often tells the nurse manager that although he leaves his apartment early, he is delayed by heavy traffic. What defense mechanism is being used by the nursing assistant? 1. Undoing 2. Repression 3. Rationalization 4. Overcompensation

3 RATIONALIZATION - the use of contrived, socially acceptable, and logical explanations to justify unacceptable behavior and thus keep it out of the consciousness. UNDOING - an attempt to compensate for an action or communication that is considered unacceptable—for instance, by giving a gift after a disagreement. REPRESSION - the unconscious and involuntary forgetting of painful ideas, events, or behaviors. REACTION FORMATION, (Overcompensation) - conscious behavior that is the opposite of an unconscious feeling. (P. 274)

A nurse in the mental health clinic concludes that a client is using confabulation when the client does what? 1. The flow of thoughts is interrupted. 2. Imagination is used to fill in memory gaps. 3. Speech flits from one topic to another with no apparent meaning. 4. Connections between statements are so loose that only the speaker understands them.

2 CONFABULATION - using imagination to fill in memory gaps; it is a defense mechanism used by people experiencing memory deficits. THOUGHT BLOCKING - Interruption of the flow of thoughts. FLIGHT OF IDEAS - Flitting of speech from one topic to another with no apparent meaning. ASSOCIATIVE LOOSENESS - connections between statements so loose that only the speaker understands them. (P. 274)

A psychiatric nurse is hired to work in the psychiatric emergency department of a large teaching hospital. While reviewing the manuals, the nurse reads, "People with mental health emergencies shall be triaged within 5 minutes of entering the emergency department." What does the nurse consider this statement to represent? 1. Hospital policy 2. Standard of care 3. Hospital procedure 4. Mental Health Bill of Rights

1 HOSPITAL POLICY - statements that help define a course of action; WHAT is to be done is stated in policies, and HOW a task or skill is to be performed is defined in a procedure manual. STANDARD OF CARE - published by the American Nurses Association; they reflect current knowledge and represent levels of practice agreed on by experts within the specialty; in legal terms, the standard of care is that level of practice that a reasonably prudent nurse would provide. HOSPITAL PROCEDURE - defines how a task or skill is to be performed. THE MENTAL HEALTH BILL OF RIGHTS - states that all clients have the right to respectful care, confidentiality, continuity of care, relevant information, and refusal of treatment, except in an emergency or by law.

A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The most critical factor for the nurse to determine during crisis intervention is the client's what? 1. Developmental history 2. Available situational supports 3. Underlying unconscious conflict 4. Willingness to restructure the personality

2

Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings? 1. Behaviorist model 2. Psychoanalytic model 3. Psychobiologic model 4. Social-interpersonal model

2 PSYCHOANALYTIC MODEL - studies the unconscious and uses the strategies of hypnosis, dream interpretation, and free association to encourage the release of repressed feelings. (P. 19/20)? BEHAVIORIST MODEL - holds that the self and mental symptoms are learned behaviors that persist because they are consciously rewarding to the individual; this model deals with behaviors on a conscious level of awareness. PSYCHOBIOLOGIC MODEL - views emotional and behavioral disturbances as stemming from a physical disease; abnormal behavior is directly attributed to a disease process. This model deals with behaviors on a conscious level of awareness. SOCIAL-INTERPERSONAL MODEL - affirms that crucial social processes are involved in the development and resolution of disturbed behavior; this model deals with behavior on a conscious level of awareness.

A client in a psychiatric hospital requests an unaccompanied pass, but it is denied, and the client vocalizes anger toward the staff. The nurse concludes that this anger results from feelings of what? 1. Hopelessness 2. Indecisiveness 3. Powerlessness 4. Worthlessness

3 Anger is a common feeling when people do not have control over decisions that affect them. There is no information to indicate that the client is feeling hopeless, indecisive, or worthless.

Which outcome specific to a client with impaired verbal communication related to a psychologic barrier should be documented in the client's clinical record? 1. Freedom from injury 2. Engaging independently in solitary craft activities 3. Identifying the consequences of acting-out behavior 4. Interacting appropriately with others in the therapeutic milieu

4 Interacting appropriately with others in the therapeutic milieu is an outcome related to the identified problem and is appropriate and measurable. Freedom from injury - not related to the identified problem; this is true for everyone. Engaging independently in solitary craft activities - will not encourage verbal communication. Identifying the consequences of acting-out behavior is inappropriate and not related to the identified problem.

A terminally ill client is moving gradually toward resolution of feelings about impending death. In a plan of care based on Elisabeth Kübler-Ross' research, the nurse should use nonverbal interventions after having assessed that the client is in which stage? 1. Anger stage 2. Denial stage 3. Bargaining stage 4. Acceptance stage

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

It is most helpful to the nurse who is attempting to apply the principles of mental health to consider what? 1 Emotionally ill people will initially reject psychological support. 2 People with emotional illnesses can empathize easily with others. Incorrect3 Mental illness is characterized by signs and symptoms of socially inappropriate behavior. Correct4 Emotional health is promoted when there is a sense of mastery of self and the environment.

An individual must feel a sense of control over self and the environment to feel secure, reduce anxiety, and function at an optimum level. Most emotionally ill people are too introspective to empathize with others. Although some emotionally ill people will reject help, many are in pain and recognize that they need psychological support. Some clients actively seek out care on the basis of positive past experiences and the secondary gain of getting attention. Many individuals with mental illness do not demonstrate observable signs of socially inappropriate behavior.

A nurse is concerned about helping reduce the incidence of mental illness in the community. What action is most appropriate for the nurse to implement? 1 Encouraging individuals to attend religious services Correct2 Speaking to high school students about coping with anxiety 3 Teaching families to control the expression of negative feelings 4 Encouraging genetic counseling for families with members who are mentally ill

Education about strategies to cope with problems may reduce anxiety and help prevent mental illness. Encouraging individuals to attend religious services may or may not be helpful in reducing anxiety and mental illnesses. Controlling the expression of negative feelings may increase, rather than decrease, anxiety. There are few genetic markers or specific hereditary patterns for most mental illnesses.

What must the nurse understand about breaks with reality such as those experienced by clients with schizophrenia? 1 Extended institutional care is necessary. Correct2 Clients believe that what they feel that they are experiencing is real. 3 Electroconvulsive therapy produces remission in most clients with schizophrenia. Incorrect4 The clients' families must cooperate in the maintenance of the psychotherapeutic plan.

Failure to accept the client and the client's fears is a barrier to effective communication. Today mental health therapy is directed toward returning the client to the community as rapidly as possible. Electroconvulsive therapy is not the treatment of choice for clients with schizophrenia. Family cooperation is helpful but not an absolute necessity.

The nurse is assessing a client who enters a walk-in mental health clinic. Which statements support an existent crisis situation? Select all that apply. Correct1 "I feel so overwhelmed. I don't know what to do." Correct2 "I feel very tense and irritable. I can't concentrate." 3 "I have these vague feelings of uneasiness that come and go." Incorrect4 "This has been building up slowly. I don't know what's causing it." Correct5 "Nothing I have tried has helped the situation. It keeps getting worse."

Feelings of being overwhelmed are symptomatic of crisis. A crisis causes an increased level of anxiety that leads to adaptations of emotional distress and cognitive impairment. Crises occur when usual methods of coping are no longer effective. Crises are acute situations, not situations that come and go; they are associated with feelings of being overwhelmed, not vague feelings of uneasiness, and are precipitated by specific identifiable events.

A client with a history of depression tells the nurse about planning to retire from work next year. What common dynamic about retirement should the nurse consider when interacting with this client? 1 It is damaging to self-esteem. Correct2 It is a developmental task of significance. 3 It is a negative event associated with the concept of aging. 4 It is a milestone that is eagerly anticipated by most older people.

The response to retirement varies, but it is a task representing a developmental milestone for all people who work. Retirement may or may not be damaging to self-esteem; it depends on the individual and the circumstances. Whether retirement is dreaded or eagerly anticipated depends on the individual and the circumstances.

A 17-year-old client is found to have anorexia nervosa. The psychiatrist, in conjunction with the client and the parents, decides to institute a behavior modification program. What does the nurse recall is a major component of behavior modification? 1. Rewarding positive behavior 2. Reducing necessary restrictions 3. Deconditioning fear of weight gain 4. Reducing anxiety-producing situations

1 In behavior modification, POSITIVE BEHAVIOR is reinforced, and negative behavior is not reinforced or punished. Reducing the number or complexity of necessary restrictions, deconditioning the fear of weight gain, and reducing the number of anxiety-producing situations may all be part of the program, but none is a major component. (P. 351 (BOX 18.4))

According to Erikson, what will an individual who fails to master the maturational crisis of adolescence most often do? 1. Rebel at parental orders. 2. Experience role confusion. 3. Experience interpersonal isolation. 4. Become a substance abuser.

2 According to Erikson, adolescents are struggling with identity versus role confusion. - Rebellion against parental orders reflects part of the struggle for independence; it does not indicate failure to resolve the conflicts of adolescence. - Adolescents tend to be group oriented, not isolated; they struggle to belong, not to escape. - Adolescents may experiment with drug and alcohol use, but most of them do not become abusers. (P. 21)

One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. The nurse identifies the defense mechanism that the client is using as what? 1. Projection 2. Dissociation 3. Displacement 4. Intellectualization

3 DISPLACEMENT - reduces anxiety by transferring the emotions associated with an object or person to another emotionally safer object or person. PROJECTION - the attempt to deal with unacceptable feelings by attributing them to another. DISSOCIATION - an attempt to detach emotional involvement or the self from an interaction or the environment. INTELLECTUALIZATION - the use of facts or other logical reasoning rather than feelings to deal with the emotional effect of a problem. (P. 274)

A 68-year-old client who has metastatic carcinoma is told by the practitioner that death will occur within a month or two. Later the nurse enters the client's room and finds the client crying. Before responding, which factor should the nurse consider? 1. Crying relieves depression and helps the client face reality. 2. Crying releases tension and frees psychic energy for coping. 3. Nurses should not interfere with a client's behavior and defenses. 4. Accepting a client's tears maintains and strengthens the nurse-client bond.

4 Crying is an expression of an emotion that, if not expressed, increases anxiety and tension; the increased anxiety and tension use additional psychic energy and hinder coping. Crying does not relieve depression, nor does it help a client face reality. It is not universally true that nurses should not interfere with a client's behavior and defenses. In most instances the client's defenses should not be taken away until they can be replaced by more healthy defenses. The nurse must interfere with behavior and defenses that may place the client in danger, but the client's current behavior poses no threat to the client. It is not always true that accepting a client's crying maintains and strengthens the nurse-client bond. Many clients are embarrassed by what they consider a "show of weakness" and have difficulty relating to the individual who witnessed it. The nurse must do more than just accept the crying to strengthen the nurse-client relationship.

A client who has recently been found to be infected with human immunodeficiency virus (HIV) comments to the nurse, "There are so many terrible people around. Why couldn't one of them get HIV instead of me?" What is the best response by the nurse? 1. "It seems unfair that you should have this disease." 2. "I'm sure you really don't wish this on someone else." 3. "It might be good for you to speak with your religious leader." 4. "I'm sure you know that HIV infection is now considered a chronic illness."

1 The client is in the anger, or "why me," stage of grieving; encouraging the client to express feelings will help the client resolve them while moving toward acceptance. "I'm sure you really don't wish this on someone else" is a judgmental response that may create a rift in the nurse-client relationship. Suggesting that the client speak with a religious leader may precipitate guilt feelings and ignores the current concern. "I'm sure you know that HIV infection is now considered a chronic illness" does not reflect what the client said; people with newly diagnosed chronic illnesses grieve for their loss of health.

The nurse and client have entered the working phase of a therapeutic relationship. What can the nurse expect the client to do during this phase? Select all that apply. Correct1 Initiate topics of discussion. 2 Focus the conversation on the nurse. 3 Repress emotionally charged material. Correct4 Accept limits on unacceptable behavior. Correct5 Express emotions related to transference.

1, 4, 5 This phase is focused on developing the client's problem-solving skills while addressing the areas in the client's life that are causing problems. The nurse helps clients identify these topics for discussion. Focusing the conversation on the nurse occurs during the orientation phase, before trust is established. Repressing emotionally charged material occurs during the orientation phase, before trust is established. Resistant behaviors usually are overcome by the working phase. During the working phase of a therapeutic relationship trust is established on the basis of mutual respect. Once trust is established the client will feel comfortable enough to express feelings; feelings of transference and countertransference usually awaken during the working phase of a therapeutic relationship.

A 15-year-old client tearfully states that her father has been sexually abusing her for the past 8 years. What statement should the nurse initially respond with? 1. "Which type of incidents preceded the abuse?" 2. "Sharing this information is a positive step in getting help." 3. "I have to report this to child protective services right now." 4. "What kinds of things does he do to you when he abuses you?"

2 "Sharing this information is a positive step in getting help" is an emotionally supportive response; it demonstrates that sharing this information is acceptable and provides hope that the client will get help. - The client needs support, and asking what incidents preceded the abuse may precipitate or increase feelings of guilt. - Telling the client that the abuse must be reported immediately to child protective services is not a priority at this time and may interfere with future sharing; the client needs immediate emotional support. - Asking what the father did as part of the abuse implies that the client does not know what she is talking about; the client needs support, whether the abuse is real or imagined.

The nurse should first discuss terminating the nurse-client relationship with a client during which phase? 1. Working phase, when the client initiates it 2. Orientation phase, when a contract is established 3. Working phase, when the client shows some progress 4. Termination phase, when discharge plans are being made

2. When the nurse and client agree to work together, a contract should be established and the length of the relationship should be discussed in terms of its ultimate termination. The client may discuss termination during the working phase; however, the subject should initially be discussed during the orientation phase. Termination and discharge plans may be discussed more thoroughly during this phase, but the subject should initially be discussed during the orientation phase. (P. 611-614)

A male college student who is smaller than average and unable to participate in sports becomes the life of the party and a stylish dresser. What defense mechanism does the nurse determine that the client is using? 1. Introjection 2. Sublimation 3. Compensation 4. Reaction formation

3 By developing skills in one area, the individual COMPENSATES for a real or imagined deficiency in another, thereby maintaining a positive self-image. Had the student incorporated the qualities of the college athlete, that would be INTROJECTION. SUBLIMATION is related to unacceptable impulses that may pose a threat. This person is trying to make amends not for unacceptable feelings (REACTION FORMATION), but rather for a believed deficiency and an inadequate self-image. (P. 274)

A clinic nurse observes a 2-year-old client sitting alone, rocking and staring at a small, shiny top that she is spinning. Later the father relates his concerns, stating, "She pushes me away. She doesn't speak, and she only shows feelings when I take her top away. Is it something I've done?" What is the most therapeutic initial response by the nurse? 1. Asking the father about his relationship with his wife 2. Asking the father how he held the child when she was an infant 3. Telling the father that it is nothing he has done and sharing the nurse's observations of the child 4. Telling the father not to be concerned and stressing that the child will outgrow this developmental phase

3 The nurse provides support in a nonjudgmental way by sharing information and observations about the child. This child exhibits symptoms of autism, which is not attributable to the actions of the parents. Asking the father about his relationship with his wife or how he held the child when she was an infant indirectly indicates that the parent may be at fault; it negates the father's need for support and increases his sense of guilt. Telling the father not to be concerned and stressing that the child will outgrow this developmental phase is false reassurance that does not provide support; the father recognizes that something is wrong.

What is it imperative for a mental health nurse to prevent clients from doing? 1. Breaking contracts 2. Using delusional thinking 3. Harming themselves or others 4. Engaging further in hallucinatory thoughts or behaviors

3. The physical safety of the client and others is the priority. Although it is important for clients to avoid breaking contracts, it is not imperative and cannot always be prevented. The nurse cannot control clients' thinking and perceptions.

A nurse is caring for several clients who have severe psychiatric disorders. What is the major reason that a primary healthcare provider prescribes an antipsychotic medication for these clients? 1. To improve judgment 2. To promote social skills 3. To eliminate neurotic tendencies 4. Manage symptoms of psychosis

4 Antipsychotics are a class of medications primarily used to manage signs and symptoms associated with psychoses, including hallucinations, delusions, paranoia, and disorganized speech. These drugs are used to minimize psychotic, not neurotic, signs and symptoms. Improved judgment and social skills may be outcomes related to managing the psychoses but are not prime reasons that antipsychotic drugs prescribed.