Chapter 3: Psychosocial Theories and Therapy

Which statement alerts the nurse to the use of suppression by a 19-year-old who lost a leg in a car accident?

"I don't remember anything about what happened to me." Explanation: The correct answer reflects the idea that the client has not remembered the event. The other options imply that the client is able to remember. Suppression protects one's self-esteem by providing a loss of memory about the event.

Individual psychotherapy consists of three phases. Which statement by the group therapist would reflect that the group is in the working phase of therapy?

"James, when Shane speaks, it seems you become angry and tend to withdraw." Explanation: During the working phase, client behaviors and feelings are shared, and conflicts may become apparent and be talked about in the group.

The nurse is responsible for leading a group that focuses on medication management. Which nurse response uses the technique of support?

"We really appreciate that you shared that medication side effect with us." Explanation: Support is a technique used by group leaders to give feedback that provides a climate of emotional support. The response by the nurse that exemplifies this technique is, "We really appreciate that you shared the medication side effect with us." The other responses respectively exemplify advice and suggestion, probing and questioning, and summarizing.

When using solution-focused behavior therapy (SFBT), which question is appropriate for the nurse to include in the initial session for a client who is experiencing anxiety?

"What is going on that made you choose to seek help for your anxiety?" Explanation: In SFBT, the nurse takes a position of curiosity in learning about the client, as opposed to an expert to whom the person has come to be helped. Questions used in eliciting the "problem" (frequently referred to as the "issue(s)" to avoid focusing on the "problem") seek extremely specific information, including, "What is going on that made you choose to seek help for your anxiety?", a question that is often included in the initial session with the client. The other questions are examples of exception questions, which are included as SFBT interventions that are rooted in the belief that nothing is constantly at the same level of intensity, so that there are fluctuations on how the client experiences the problem.

Which represents the best definition of a theory?

A person's or group's beliefs about how something happens or works Explanation: A theory is a person's or group's beliefs about how something happens or works. Theories have different explanations to account for human behavior. They also promote interventions consistent with the tenets of their theories.

Cognitive interventions are based on the concept of cognition. Who developed cognitive behavioral therapy?

Aaron Beck Explanation: Beginning in the 1960s, more cognitive-based theories and therapeutic approaches were developed, the most prominent being cognitive behavioral therapy by Aaron Beck.

Degree of agreement between the leader's norms and the group's norms, ability to deal with members' infractions, and conformity to group norms are characteristics of what kind of groups?

All groups Explanation: A group is three or more people with related goals. The following characteristics vary among different types of groups: size, homogeneity or heterogeneity of members, stability, degree of cohesiveness among members, climate, conformity to group norms, degree of agreement with the leader's and the group's norms, ability to deal with members' infractions, and goal-directedness and task orientation of the group's work.

Cognitive techniques focus on the client's patterns of which type of thinking?

Automatic Explanation: Cognitive techniques focus on the client's patterns of automatic thinking, first identifying what he or she is examining of recurrent patterns in everyday life and then testing the validity of these automatic thoughts. Cognitive techniques do not focus on delayed, delusional, or magical thinking.

The nurse is working with a family that has indicated a desire to learn better communication skills. The nurse role-plays assertive communication techniques with each family member. The role-play is an example of which type of family intervention?

Behavioral Explanation: Behavioral interventions assist family members to interact with one another differently. Behaviorism is a school of psychology that focuses on observable behaviors and what one can do to externally bring about behavior change. It does not attempt to explain how the mind works.

A nurse demonstrates a sound understanding of the use of ego defense mechanisms by providing which explanation?

Can be either a therapeutic or a pathological way to manage stress Explanation: Depending upon their use, ego defense mechanisms can be therapeutic or pathologic, because all defense mechanisms include a distortion of reality, some degree of self-deception, and what appears to be irrational behavior. Ego defense mechanisms are considered healthy protective barriers when appropriately used to manage instinct and affect in stressful situations. Ego defense mechanisms when appropriately used are coping skills used to resolve a mental conflict, to reduce anxiety or fear, to protect one's self-esteem, or to protect one's sense of security.

Which statement is inconsistent with the concept of milieu therapy, originally developed by Henry Stack Sullivan?

Clients work independently to solve day-to-day problems. Explanation: The concept of milieu therapy, originally developed by Sullivan, involved clients' interactions with one another, including practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems.

Which treatment modality explains the presence of emotions like sadness, anxiety and anger?

Cognitive therapy Explanation: Cognitive therapy, which focuses on immediate thought processing—how a person perceives or interprets his or her experience and determines how he or she feels and behaves. Basic emotions of sadness, elation, anxiety, and anger are reactions to perceptions of loss, gain, danger, and wrongdoing by others.

The nurse therapist is setting goals for a family in therapy. One goal is for the family to adopt a healthy family structure. Which would be an appropriate outcome criterion for this goal?

Conflicts are resolved in a rational manner Explanation: The five roles of the "energized" or healthy family include responding to family members' needs, coping actively with life's problems and stresses, accomplishing family tasks with equal distribution of power, encouraging interaction among family members and the community, and promoting positive personal health practices.

A nurse therapist feels sad after sessions with a client. The client's passiveness reminds the nurse of a family member who led a very unhappy life. What is the term for this emotional dynamic?

Countertransference Explanation: Countertransference occurs when nurses have extreme emotional responses (positive or negative) to clients.

During a care conference, the nurse therapist receives feedback from a colleague who says that the therapist seems "blind" to a client's manipulative behavior. The nurse therapist's "blind spot" is an example of which processes?

Countertransference Explanation: Countertransference refers to the feelings and thoughts that service providers have toward the client. In countertransference the provider may harbor certain images of the client that result in "blind spots," which can be destructive or disruptive to the therapeutic process. Transference refers to feelings and thoughts that clients have toward the service provider. Respondent conditioning happens when a response and a stimulus become connected through repetition. Distorted cognitions are self-defeating thoughts that lead to self-defeating behaviors.

While a nurse is performing an admission assessment for a client in an inpatient mental health setting, the client states, "All of my problems are caused by my parents." The client statement reflects which factor that influences mental health?

Emotional development Explanation: Psychological influences on mental health include interactions, intelligence quotient, self-concept, skills, creativity, and emotional developmental level. Neuroanatomy is a biologic influence on mental health. Values, beliefs, and religion are sociocultural influences on mental health.

The nurse observes an elderly client teaching an adolescent how to crochet a pot holder. The nurse evaluates this behavior as evidence of resolution of Erickson's developmental stage of what?

Generativity vs. stagnation Explanation: The ability to teach and help others reveals progression through the developmental stage of generativity (in which individuals are industrious and offer themselves to society) vs. stagnation (characterized by introversion and lack of outward connection with others).

In group, Client 1 talks about how stressful and important Client 1's job is. Client 2 comments that Client 1 seems to think Client 1 is "better than the rest of us." Client 3 supports Client 1's comment and says Client 3 doesn't understand why everyone wants Client 1 to "break down and cry." This dynamic illustrates what?

Group process Explanation: Content and process are important concepts of group communication. What is being said during discussion is the content. How the group handles its communication is process. Who talks to whom, what is said, and what is left unspoken are examples of process.

Which theorist viewed interpersonal relations as a basis of human development and behavior?

Harry Stack Sullivan Explanation: Harry Stack Sullivan viewed interpersonal relations as a basis of human development and behavior. B. F. Skinner studied operant behavior or conditioning. Frederick Perls believed that the root of human anxiety is frustration with an inability to express natural biological and psychological desires in modern civilization. In nursing, Maslow's model is used to prioritize care; basic needs should be met before higher-level needs.

Which nursing theorist was opposed to the idea that the client passively receives treatment?

Hildegard Peplau Explanation: Hildegard Peplau was opposed to the idea that the client passively receives treatment and the nurse passively acts out doctor's orders. Peplau believed that the nurse serves as a stranger, resource person, teacher, leader, surrogate, and counselor.

Which nursing theory focuses on the nurse-client relationship and development of problem-solving skills?

Interpersonal theory Explanation: Hildegard Peplau's interpersonal theory focuses primarily on the nurse-client relationship, in which problem-solving skills are developed. The theory incorporates communication and relationship concepts from Harry Stack Sullivan's interpersonal theory. Orem's self-care deficit theory is a behavioral nursing theory. Roy's adaptation theory states that humans are biopsychosocial adaptive systems who use coping mechanisms to adapt to both internal and external stimuli. Parse's theory of human becoming posits that quality of life from each person's own perspective is the goal of nursing practice.

Which phase of individual psychotherapy involves establishing mutual boundaries of the relationship between the client and the mental health nurse?

Introductory Explanation: During the introductory phase, the therapist and the client establish boundaries of the relationship. Resolution occurs in the working phase. The working phase occurs when the therapist and the client focus on the client's problems and reach an understanding of why the problems have occurred. The termination phase occurs when the client has achieved the maximum benefit of therapy.

A 55-year-old client is being treated for narcissistic personality disorder. The therapist shows caring and appropriate regard for the client. The therapist's behavior is an example of which concept of behavior theory?

Modeling Explanation: Modeling involves demonstrating desired behavior patterns to a learner. Therapists model behaviors when they teach social skills, such as caring and appropriate regard for others. The therapist models regard for others with the expectation that the learner will copy that behavior. The caring behavior is then reinforced. Given sufficient practice of the caring behavior paired with its reinforcement, regard for others gradually becomes part of the client's behavioral inventory.

A newly admitted client has joined an anger management group as part of treatment in the hospital. Which type of group would be appropriate for this client?

Open Explanation: In an open group, new members may join, and older members may leave the group at different sessions. Cohesion is the ability of a group to stick together. In a closed group, members begin the group at one time, and no new members are admitted. A dyad is a group of two people.

What is the most basic need, according to Maslow's hierarchy of needs?

Physiological Explanation: The most basic needs—the physiological needs of food, water, sleep, shelter, asexual expression and freedom from pain—must be met first.

Calling the client by name and spending time with the client are examples of what?

Positive regard Explanation: Positive regard is an unconditional, nonjudgmental attitude. Acceptance occurs when the nurse does not become upset or respond negatively to a client's outbursts, anger, or acting out. Empathy is the ability of the nurse to perceive the meaning and feelings of the client and to communicate that understanding to the client. Values are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living.

The psychiatrist states that repressed memories in the client's unconscious are causing depression. This reasoning implies that the psychiatrist uses which theory?

Psychoanalytic theory Explanation: Central to psychoanalytic theory is the idea of the unconscious. A goal of psychoanalysis is to expand awareness of unconscious functioning and its relation to daily living.

The nurse is providing hygiene care for a 70-year-old client in a nursing home who states that the client does not like the physician. Later, when the physician enters the room, the nurse notes that the client is very friendly with the physician, complimenting the physician's care. Which defense mechanism is this client displaying?

Reaction-formation Explanation: Reaction-formation is displaying a behavior, attitude, or feeling opposite to that which one would normally exhibit in the same situation. Displacement is unconsciously transferring feelings onto another person or object. Rationalization is trying logically to justify irrational, socially, or personally unacceptable behaviors or feelings. Projection is attributing to another person one's unacceptable thoughts and feelings.

Which action reflects group development in the initial stage?

Seeking similarities Explanation: The initial stage of group development is characterized by a group that works on getting acquainted, depends on the leader for direction, searches for purpose of the group, restricts content, searches for similarity, and gives advice.

A client is engaging in conscious resistance to the psychiatric unit's rules when the client does what?

Stating that, "I don't make my bed at home and I'm not making it here." Explanation: Resistance is the conscious or unconscious psychological defense against engaging in a behavior that is usually expected or a part of the client's therapy. Conscious resistance requires the client to actively and knowingly resist the behavior. A client is engaging in conscious resistance to the psychiatric unit's rules when stating, "I don't make my bed at home and I'm not making it here."

A student nurse does not want to think about the upcoming final exam. The student nurse will start studying for the exam tomorrow. The student nurse is exhibiting which type of defense mechanism?

Suppression Explanation: Suppression is the voluntary rejection of unacceptable thoughts or feelings from conscious awareness. Denial is unconscious refusal to face thoughts, feelings, wishes, needs, or reality factors that are intolerable. Regression is the retreat to past developmental states to meet basic needs. Conversion is the unconscious expression of a mental conflict as a physical symptom to relieve tension or anxiety.

The nurse is observing a child in the pediatric unit at the hospital. Which behavior would alert the nurse that the child is in Piaget's preoperational stage of intellectual development?

The child is naming stuffed animals in the toy collection. Explanation: The preoperational stage of a child involves the use of symbols such as mental images, words, or gestures to represent objects with language development. The child naming stuffed animals is developing the ability to use words to name objects such as stuffed animals and is in the 2-7 year old range. The child classifying the art supplies is an older child in the period of formal operations and is age 11- adolescence. The child that is learning object permanence, such as the parent that returns when not seen, and the child developing motor and sensory reflexes, are both in the sensorimotor period.

The nurse is caring for a 4-year-old child during a well-child visit. According to the Sullivan's stages of development, which behavior would the nurse expect to find in this child?

The child performs actions to earn praise from parents. Explanation: According to Sullivan's life stages, this child is in the childhood stage. During this stage, children look at their parents as sources of praise and appreciation. If the child is in the infant stage (0-language), the child's primary need is to have bodily contact and tenderness and would most likely prefer to sit in the mother's lap. The preadolescent child (8-12 years) tends to move away from family as the primary satisfaction in the relationship and start making friends. In the juvenile stage (5-8 years), the child learns to negotiate individual needs. Expressing views and ideas to the parents begin at this age.

A psychiatric mental health nurse is applying Erikson's theory of psychosocial development in the care of a young adult client. What outcome should the nurse identify to best address the developmental conflict that this client is experiencing at this age?

The client demonstrates new interpersonal skills to promote the development of intimate relationships Explanation: The developmental conflict of young adulthood is intimacy versus isolation. Improved interpersonal skills would promote the development of intimacy. All of the other listed outcomes are beneficial, but none directly address Erikson's developmental conflict of young adulthood.

When assessing a client from a Freudian developmental perspective, the nurse determines that the client is functioning in the latency stage based on which behavior?

The client is beginning to develop inner control over aggressive impulses. Explanation: The latency stage, according to Freud, is the stage in which the child is beginning to develop internal control over aggressive impulses.

While assessing a client, the nurse notes the client is functioning at the fourth level according to Maslow's hierarchy of needs. Which observation of the client led the nurse to conclude this?

The client longs to have validation for success and accomplishments. Explanation: According to Maslow's hierarchy of needs, the fourth level involves the need related to esteem needs, which includes the need for self-esteem and respect from others. Hunger and sexual expression are captured within the first level of Maslow's hierarchy of needs. Feeling unsafe indicates the client is functioning on the second level and is focused on security needs.

A couple is going to marital counseling. During a session, the husband states that, after working long hours at the office, he just wants to come home and relax. He reports that his wife often "bombards" him with problems as soon as he settles down, which results in a prolonged argument. The wife admits that she does this, but states that she feels neglected and that her husband does not take the family problems seriously. She doesn't want her marriage to turn out like her parents' marriage. How would a behaviorist explain the wife's actions?

The long argument in which she and her husband participate positively reinforces her behavior. Explanation: Behavioral theory considers how reinforcement influences behavior. Through reinforcement, a person learns to perform a certain response (behavior) either to receive a reward or to avoid a punishment. The reward in this case is that the wife gets the needed attention from her husband even though it is in the form of an argument.

Which explains why theories are important to psychiatric-mental health nursing?

Theories lead to the expansion of knowledge. Explanation: Theories lead to the collection of relevant empirical (factual) data or relations not yet observed, leading to the expansion of knowledge in a field. Theories also incorporate known empirical findings within a logically consistent and reasonably simple framework.

Which are two of the most important reasons that nurses utilize theories in their approach to helping clients with psychiatric disorders?

Theories provide knowledge expansion in the field, and they are a way of incorporating known findings into a framework for understanding clients. Explanation: Theories provide frameworks on which to interpret assessment findings and anticipate the effectiveness of interventions. Theories lead to the collection of relevant empirical (factual) data or relations not yet observed; they help to expand knowledge in a field. Theories also serve as a way to incorporate known empirical findings within a logically consistent and reasonably simple framework. Theories do not give health care providers a basis for administering medications or intervening with clients, nor are they the basis for reimbursement of health care costs.

Why are the developmental theories important to nursing practice?

They outline the process of human growth and development. Explanation: Developmental theories outline the process of growth and development of humans as orderly and predictable, beginning with conception and ending with death. Nurses apply this knowledge to develop interventions for people across the lifespan. Systems theory, adaptation theories, and legal/ethical care are also important to nursing, but these do not explain the importance of human growth and development in nursing care.

The following statements are heard in a group: "You can't say that because you don't really know me." "I wonder if the therapist is going to leave?" and "I'm not sure whether or not I can really talk freely." These best reflect which group theme?

Trust and belonging Explanation: The theme expressed in these statements represents the latent lack of trust in the leader or other group members. These statements are not related to guilt and punishment, fear for safety, or loss and abandonment.

A client is being discharged from the psychiatric unit this afternoon, and a nurse needs to teach the client about discharge medications. The client is exhibiting signs of moderate anxiety about the upcoming discharge. Based on Peplau's views regarding anxiety, the nurse would expect to implement the education plan at which time?

When the client's anxiety decreases to a mild level Explanation: Mild anxiety is useful for learning; therefore, it would be appropriate to begin educating the client when anxiety decreases to a mild level. Severe anxiety interferes with learning. Anxiety should be relieved as much as possible, but it would be unrealistic to expect that the client would become completely free of anxiety.

According to Yalom (2005), there are 11 therapeutic factors through which changes occur in group psychotherapy. Which factor correlates with learning to give to others?

altruism Explanation: Altruism is learning to give to others. Universality refers to finding out that others have similar problems. Catharsis is the open expression of affect to purge or "cleanse" oneself. Group cohesiveness is the group members' relationship to the therapist and other group members.

The most superficial and accessible levels of cognition and generally the first to be targeted in treatment are ...

automatic thoughts. Explanation: The most superficial and accessible levels of cognition and generally the first to be targeted in treatment are automatic beliefs.

For Freud, the therapist's emotional reactions to the client based on personal unconscious needs and conflicts is termed ...

countertransference. Explanation: For Freud, the term countertransference means the therapist's emotional reactions to the client based on personal unconscious needs and conflicts. Countertransference interferes with the therapeutic relationship.

The nurse leader of a group observes a group member attempting to stimulate the group to action or decision. The nurse interprets this member as fulfilling which role?

energizer Explanation: The energizer attempts to stimulate the group to action or decision. The recorder writes suggestions, keeps minutes, and serves as group memory. The orienter defines the position of the group with respect to its goals. The coordinator shows or clarifies the relationships among various ideas and suggestions.

Which is an overarching treatment goal for the client who is prescribed cognitive behavioral therapy (CBT) for the treatment of depression?

engaging in self-care Explanation: The use of CBT assumes that individuals have the innate ability to solve their own problems; thus, the overarching treatment goal is for the client to be able to engage in self-care, independent of professional assistance. Although medications may be prescribed in addition to CBT, this is not a goal of this type of therapy. In addition, goals are developed in partnership and supply a forward-looking focus for what "can be" in the future as opposed to "what happened" in the past. The present serves as a platform from which current perceptions of earlier events can be reexamined

The nurse creates a genogram while conducting a family assessment. Which symbol does the nurse use to designate the client's father?

square Explanation: Genograms can be particularly useful in understanding family history, composition, relationships, and illnesses. Male members of the family are designated with a square when creating a genogram. A circle is used to designate a female member of the family. Horizontal lines represent marriages with dates; vertical lines connect parents and children.

Which concept should the nurse consider prior to a formal client referral to a therapeutic group?

the client's social skills Explanation: The nurse considers several questions prior to making a formal client referral to a therapeutic group, including asking, "Does the potential member have the social skills to function comfortably in the group?" Although clients are more likely to find success in a group setting when the group is larger in size and the members are of similar age and ethnicity, these are not specific questions posed by the nurse prior to consider a formal client referral for a therapeutic group.

The nurse provides care for a client who is hospitalized in an acute inpatient psychiatric setting. The client experiences hallucinations. Which is the best approach to include in this client's plan of care?

the use of solution-focused therapy Explanation: Solution-focused therapy is one of the brief cognitive therapies used by psychiatric nurses in acute inpatient psychiatric settings. SFBT's emphasis on strengths fits well with the values of psychiatric nurses, and the techniques used are well within their scope of practice. Solution-focused approaches have been effective with hospitalized people who were experiencing delusions, hallucinations, and/or loosening of associations. The other choices are examples of cognitive therapeutic techniques that are useful in the inpatient setting; however, they may not be best for the client who is experiencing hallucinations.