ch. 7 Models for Working with Psychiatric Patients, ch. 9 Working with an Individual Patient

A charge nurse is discussing the characteristics of a nurse‑client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply.) A. The needs of both participants are met. B. An emotional commitment exists between the participants. C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established.

A. A therapeutic nurse-client relationship focuses on the needs of the client. B. A n emotional commitment between the participants is characteristic of an intimate or social relationship rather than one that is therapeutic. C. CORRECT: A therapeutic nurse-client relationship is goal-directed. D. CORRECT: A therapeutic nurse-client relationship encourages positive behavioral change. E. CORRECT: A therapeutic nurse-client relationship has an established termination date.

A nurse is planning care for the termination phase of a nurse‑client relationship. Which of the following actions should the nurse include in the plan of care? A. Discussing ways to use new behaviors B. Practicing new problemsolving skills C. Developing goals D. Establishing boundaries

A. CORRECT: Discussing ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase. B. P racticing new problem-solving skills is an appropriate task for the working phase. C. D eveloping goals is an appropriate task for the orientation phase. D. E stablishing boundaries is an appropriate task for the orientation phase

A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client, has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? A. Mild B. Moderate C. Severe D. Panic

A. I n mild anxiety, the client's ability to understand information may actually increase. B. CORRECT: Moderate anxiety decreases problem‑solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious. C. Severe anxiety causes restlessness, decreased perception, and an inability to take direction. D. D uring a panic attack, the person is completely distracted, unable to function, and may lose touch with reality.

A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements should the nurse make? A. "You and a group of other clients will meet to discuss your treatment plans." B. "Community meetings have a specific agenda that is established by staff." C. "You and the other clients will meet with staff to discuss common problems." D. "Community meetings are an excellent opportunity to explore your personal mental health issues."

A. I ndividual treatment plans are discussed during individual therapy rather than a community meeting. B. Community meetings may be structured so that they are client-led with decisions made by the group as a whole. C. CORRECT: Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit. D. P ersonal mental health issues are discussed during individual therapy rather than a community meeting

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.) A. Reassure the client that everything will be okay. B. Discuss prior use of coping mechanisms with the client. C. Ignore the client's anxiety so that she will not be embarrassed. D. Demonstrate a calm manner while using simple and clear directions. E. Gather information from the client using closed‑ended questions.

A. Providing false reassurance is an example of nontherapeutic communication. B. CORRECT: Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor. C. R ecognizing the client's current level of anxiety assists the client to begin the process of problem solving. D. CORRECT: Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others. E. Using open‑ended questions for client communication encourages the client to express feelings and identify the source of the anxiety

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? A. The client asks the nurse whether she will go out to dinner with him. B. The client accuses the nurse of telling him what to do just like his ex-girlfriend. C. The client reminds the nurse of a friend who died from a substance overdose. D. The client becomes angry and threatens harm to himself.

A. T his indicates the need to discuss boundaries but does not indicate transference. B. CORRECT: When a client views the nurse as having characteristics of another person who has been significant to his personal life, such as his ex-girlfriend, this indicates transference. C. T his indicates countertransference rather than transference. D. T his indicates the need for safety intervention but does not indicate transference.

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation

A. T his is not an example of reaction formation, which is overcompensating or demonstrating the opposite behavior of what is felt. B. CORRECT: This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real. C. T his is not an example of displacement, which is shifting feelings related to an object, person, or situation to another less threatening object, person, or situation. D. T his is not an example of sublimation, which is dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression.

A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements should the nurse make? A. "I feel very sorry for the loneliness you must be experiencing." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose a loved one."

A. T his statement focuses on the nurse's feelings and is sympathetic rather than empathetic. B. T his statement implies judgment and is therefore not an empathetic or therapeutic response. C. CORRECT: This statement is an empathetic response that attempts to understand the client's feelings. D. T his statement focuses on the nurse's experiences rather than the client's and is therefore not therapeutic.

A patient experiences severe panic attacks and uses denial, repression, and displacement. Nursing interventions should be directed toward: a. teaching more effective coping strategies. b. setting limits on use of the defense mechanisms. c. assisting the patient to change values and beliefs. d. helping the patient uncover unconscious conflicts.

ANS: A A desired outcome would be that the patient will use more effective coping strategies. Nursing intervention would focus on helping the patient identify and use more adaptive coping strategies. Setting limits on the use of defense mechanisms is impossible. Values clarification might be unnecessary. Uncovering conflicts is not a focus of nursing intervention

When the nurse formulates nursing diagnoses, it is necessary to be specific in describing dysfunctional behaviors so as to: a. select appropriate desirable behaviors for outcome criteria. b. analyze how the patient was feeling at the time of assessment. c. explore the context that precipitated the exacerbation of the illness. d. determine how the illness relates to the patient's total life experience.

ANS: A A goal or outcome specifies an adaptive behavior to replace one that is dysfunctional. The more specific the description of the dysfunctional behavior in the nursing diagnosis, the easier it is to specify an appropriate adaptive behavior. The other options are not relevant reasons for describing dysfunctional behaviors in nursing diagnoses.

A student grumbles to an instructor, "I do not see the value of process recordings." The best justification of a process recording is that it is a: a. tool for analyzing communication. b. verbatim record of a patient interview. c. legal document that becomes part of the medical record. d. note written at the time of a patient interview to provide information to team members.

ANS: A A process recording is a tool for the nurse to learn about the effectiveness of communication and interventions during an interpersonal interaction. It is more than a verbatim record. It is for use by the nurse, rather than the interdisciplinary team. It is not placed into the medical record.

A realistic outcome for a patient with situational low self-esteem who will have a short inpatient stay would be for the patient to: a. write a list of strengths, abilities, and talents. b. role-play with others to improve social skills. c. replace a negative self-image with a positive one. d. respond with positive self-esteem in all encounters.

ANS: A A short-term goal is one that can be attained in 4 to 6 days. Identification of strengths, abilities, and talents is attainable within this time frame. The other options are long-term goals.

A patient shouts at a nurse who just entered the room, "You're an incompetent fool. Leave me alone." The nurse's response should be based on which rationale? a. The anger was created by a situation or significant person, not the nurse. b. The reaction probably results from transference and countertransference. c. The patient is probably reacting to fear of loss of emotional control. d. The patient has a right to openly express negative feelings.

ANS: A Anger toward the nurse is often displaced anger that has arisen from some situation or significant person in the patient's life. Nurses feel the brunt of the anger because they are "handy" and might be considered by the patient to be a safe object for the displacement. Knowing that the nurse is not the true object of the anger allows the nurse to plan a therapeutic strategy for helping the individual manage the emotion. None of the other options provides an accurate basis for planning intervention

A nurse tells a patient, "I know how you feel. My spouse can be very insensitive too. I am also considering divorce." Analysis suggests that the nurse is: a. self-disclosing inappropriately. b. experiencing countertransference. c. using empathy to establish trust with the patient. d. encouraging the patient to express negative feelings.

ANS: A Brief self-disclosure is used to help the patient clarify specific issues, to feel less vulnerable, or to feel more "normal." When used appropriately, self-disclosure benefits the patient. When used inappropriately, it benefits the nurse. In this case, the self-disclosure burdens the patient with the nurse's problems. Empathy focuses on the patient. Countertransference would result in different behaviors. Encouraging expression of negative feelings would be more direct.

A patient diagnosed with lung cancer continues to smoke and says, "I think my cancer is more the result of a bad gene than of smoking." The patient shows the use of which defense mechanism? a. Denial b. Compensation c. Intellectualization d. Reaction formation

ANS: A Denial is the unconscious refusal to admit an unacceptable idea or behavior, as shown in this example. Compensation refers to covering a weakness by overemphasizing a desirable trait. Intellectualization involves using a logical explanation without expressing emotion or affect. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.

A patient uses defense mechanisms excessively. The nurse should expect to find evidence that: a. the patient has difficulty with problem solving. b. the patient has an increased risk for psychosis. c. emotions are experienced with great intensity. d. reality is denied.

ANS: A Excessive use of defense mechanisms results in the distortion of reality. When reality is not perceived accurately, problem solving is impaired. The other options might or might not be experienced by the patient.

The nurse caring for a hyperactive patient should be particularly concerned about assessing: a. physical safety. b. emotional trauma. c. manipulative behaviors. d. feelings about the relationship.

ANS: A Hyperactive patients are at high risk for injury and physical exhaustion, both of which compromise physical safety. Safety needs take priority over emotional needs.

A patient is withdrawn and avoids talking to the nurse. The best initial intervention for the nurse would be to: a. offer to listen and help. b. directly ask why the patient does not wish to talk. c. involve the patient in a group activity to decrease isolation. d. respect the patient's desire not to talk and leave the patient alone.

ANS: A Patients might be afraid or unable to approach nurses. Nurses must take the initiative to approach the patient, thus acknowledging the patient's worthiness and conveying acceptance. "Why" questions usually elicit rationalization. Leaving the patient alone does not foster trust. Decreasing isolation will not build trust in the nurse.

A patient with suicidal ideation is hospitalized. What is the priority intervention? a. Negotiating a no-harm contract b. Facilitating attendance at groups c. Administering a psychotropic drug d. Determining the precipitating situation

ANS: A Preservation of patient safety is of higher priority than any of the other interventions.

A nurse and patient agree on problems to be addressed during a brief hospital stay. Which inference is correct? a. The relationship is moving into the working stage. b. The nurse should reinforce messages about termination. c. The nurse needs to direct the patient to begin journaling. d. Management of emotions must be ensured before work can continue.

ANS: A Problems are defined and priorities for work are set as the nurse and patient collaborate during the orientation stage. This sets the stage for transition into the working stage. Management of emotions can occur during the working stage.

Objective data obtained in an initial assessment of a patient are of particular value when: a. the patient is too ill to participate. b. the patient's admission is involuntary. c. family members have admitted the patient. d. the patient has been transferred from a subacute setting.

ANS: A Some patients are too ill to participate in or complete the assessment interview. When this is the case, the interviewer uses objective data obtained from patient observation and the reports of family or others present at the time of admission. The other options do not reflect situations in which objective data have maximal value.

A student nurse says, "I don't need to interact with my patients. I learn by observing them." The instructor can best interpret the nursing implications of Sullivan's theory to this student by responding: a. "Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills." b. "Observing patient interactions can help you formulate priority nursing diagnoses and appropriate interventions." c. "I wonder how accurate your assessment of the patient's needs can be if you do not interact with the patient." d. "It is important to note patient behavioral changes because these signify changes in personality."

ANS: A Sullivan believed that the nurse's role includes educating patients and assisting them in developing effective interpersonal relationships. Mutuality, respect for the patient, unconditional acceptance, and empathy are cornerstones of Sullivan's theory. These cornerstones cannot be demonstrated by the nurse who does not interact with the patient. Observations provide only objective data. Priority nursing diagnoses usually cannot be accurately established without subjective data from the patient. The other distracters relate to Maslow's theory and behavioral theory.

A patient has identified the need for better anger management and tells the nurse, "I'm afraid that someday I might explode." The best strategy for reducing this patient's fear of losing control is to: a. talk about these feelings openly and directly. b. discuss feelings in general without reference to the patient. c. avoid talking about the feelings until the patient feels comfortable. d. reassure the patient that expressing feelings is the first step to resolving them.

ANS: A Talking openly about feelings conveys the message that feelings are natural and can be handled. Once feelings can be discussed, the focus can shift to learning to cope more effectively with them. The other options are either avoidant or nontherapeutic.

A 26-month-old child displays negative behaviors. The parent says, "My child refuses toilet training and shouts 'No!' when given direction. What do you think is wrong?" Select the nurse's best reply. a. "This is normal for your child's age. The child is striving for independence." b. "The child needs firmer control. Punish the child for defiance and saying 'no.'" c. "There may be developmental problems. Most children are toilet trained by age 2." d. "Some undesirable attitudes are developing. A child psychologist can help you develop a remedial plan."

ANS: A The distracters indicate that the child's behavior is abnormal when, in fact, this behavior is typical of a child around the age of 2 years whose developmental task is to develop autonomy.

A nurse plans an intervention to supports a patient's ego. This intervention is therapeutic, because the individual's ego: a. provides rational, logical reality testing. b. is primarily concerned with right and wrong. c. uses primary process imagery to meet basic needs. d. is derived from the individual's pattern of thinking.

ANS: A The ego focuses on the reality principle and uses secondary-process thinking, a logical, rational operation to maintain the well-being of the individual. The superego is concerned with right and wrong. The id uses primary process. Ego formation is influenced by heredity, environment, and maturation.

Which goal is most likely to be chosen by the nurse for a patient who uses the interpersonal model as a basis for practice? a. The patient will develop mature, satisfying relationships that are relatively free of anxiety. b. The patient will rid himself of irrational beliefs, including "shoulds," "oughts," and "musts." c. The patient will learn to meet basic needs responsibly. d. The patient will manage stress adaptively.

ANS: A The goal of interpersonal therapists is to assist the patient in developing healthy interpersonal relationships that are relatively anxiety-free. The other distracters state a goal appropriate for cognitive therapy, reality therapy, and stress management therapy, respectively.

Following the admission interview, a spouse of a patient asks the nurse, "Why did you ask my partner all those questions? Some of them had nothing to do with current problems." The nurse's best response is, "Those questions help us understand: a. the patient's current status." b. the complete family history." c. the patient's past experiences." d. what the patient's prognosis will be."

ANS: A The mental status examination (MSE) is designed to provide information about the patient's current level of functioning. Other specific information might be obtained that contributes to the overall picture. The MSE does not provide information relating to the other options.

A patient tells the nurse, "I was raped a month ago. Since then I've felt anxious and have been unable to talk normally to my husband. I've had frequent thoughts about cutting my wrists." What is the priority nursing concern regarding this patient? a. The risk for self-directed violence b. The development of rape traumatic syndrome c. The damage that could result in poor self-esteem d. The demonstration of signs and symptoms of acute anxiety

ANS: A The risk for self-injury is of highest priority, because patient safety is involved.

The nurse believes that a patient is having emotional pain. Which remark is most therapeutic? a. "I hear how painful this is for you. I would like to help you deal with it." b. "I'm so sorry this has happened to you. You don't deserve it." c. "What would you like me to do to help you through this?" d. "I don't think this is as serious as you believe it is."

ANS: A This remark uses empathy to acknowledge the patient's feelings and then offers help. Using empathy tells the patient that his or her feelings are understood. Offering help implies hope for a positive resolution. Empathy, rather than sympathy, is a useful tool. Asking what to do for the patient implies helplessness on the part of the nurse. Minimizing the problem is demeaning to the patient.

A patient hospitalized for 6 days has made little progress toward outcomes written at the time of admission. The nurse decides that the lack of progress toward goals indicates that: a. needs for reassessment exist. b. discharge should be delayed. c. nursing diagnoses were incorrect. d. nursing interventions were inadequate.

ANS: A When the evaluation is made that goals are not being attained, reassessment should take place. Nursing diagnoses might need to be reformulated, more realistic outcomes identified, or nursing interventions changed, but none of these measures can be determined to be appropriate until the reassessment has been completed.

A psychiatric aide asks, "Can you give me some examples of how we provide structure for patients?" The nurse should offer which suggestions? Select all that apply. a. Set limits on destructive behavior. b. Direct a patient to go to a quiet place. c. Sit with a withdrawn, isolated patient. d. Distract a patient who is hallucinating. e. Help a patient contemplate needed change.

ANS: A, B, C, D Providing structure means that staff members meet patient needs for organizing elements in the environment to produce specific outcomes. Contemplating change is the only option that would not be considered an example of structuring.

A nurse plans to teach a group of patients the basics of the change process. How should the elements be sequenced for the presentation? a. Assess the success of new behaviors. b. Observe to gain awareness. c. Draw conclusions about the problem. d. Test new behaviors. e. Determine that change is necessary.

ANS: A, B, C, D, E This sequence proceeds logically from assessment of the problem to analysis of the problem to determining that change is necessary to testing new behaviors and evaluating their efficacy.

When the nurse conducts a developmental assessment with a new patient, the assessment can be expected to yield information regarding what? a. The use of defense mechanisms b. The degree of mastery of critical tasks c. Strategies to help the patient make rational decisions d. The mobilization of defenses against the patient's stressors

ANS: B According to Erikson's developmental theory, a developmental assessment is conducted for the purpose of determining the extent to which an individual has successfully mastered the critical task of each stage of development up to his or her chronologic age. Lack of mastery or partial mastery will yield clues about issues to be addressed in working with the patient. Because of its focus, the developmental assessment might yield only minimal information about defense mechanism use and defenses used to cope with stress. Rational decision making is not expected to be fostered as a result of developmental assessment.

Which statement by an adult would lead a nurse to suspect deficits in mastery of the developmental task of infancy? a. "I have many warm and close friendships." b. "I am afraid to let anyone really get to know me." c. "I am always right. Keep your opinion to yourself." d. "I am ashamed I did that wrong. Please forgive me."

ANS: B According to Erikson, the developmental task of infancy is the development of trust. The the only statement clearly showing the lack of ability to trust others mentions being "afraid to let anyone really get to know me".. The distracters suggest that the developmental task of infancy was successfully completed: rigidity rather than mistrust, and failure to resolve the crisis of initiative versus guilt.

A young adult has a realistic sense of self, a commitment to reasonable career goals, a satisfying intimate-partner relationship, and a circle of loyal friends. This person says, "I volunteer for important projects in my community." The nurse can draw which conclusion? a. There is lack of mastery of critical tasks associated with the stage of industry versus inferiority. b. Mastery of critical tasks associated with the stage of identity versus role diffusion is evident. c. Fear of criticism and affection affect mastery of critical tasks associated with intimacy. d. The person vacillates between dependence and independence.

ANS: B Adult behavior reflecting mastery of the critical tasks associated with the stage of identity versus role diffusion includes confident sense of self, emotional stability, commitment to career planning, sense of having a place in society, establishing a relationship with the opposite sex, fidelity to friends, and development of personal values. The behaviors given in the scenario are not indicators of any of the other options.

A young adult reports overwhelming guilt about minor social errors, feels self-pity, and says, "I stay on the sidelines of life so I can avoid the embarrassment of being noticed." The nurse can assess deficits in mastery of critical tasks associated with which developmental stage? a. Trust versus mistrust b. Industry versus inferiority c. Autonomy versus shame and doubt d. Generativity versus self-absorption

ANS: B Adult behaviors reflecting developmental problems associated with the stage of industry versus inferiority include excessive guilt and embarrassment, passivity, apathy, rumination and self-pity, assumption of the victim role, and underachievement of potential. The behaviors given in the scenario reflect the critical tasks of industry versus inferiority. Tasks of the other stages are entirely different.

An older retired executive reports, "I am unable to say 'no' when asked to help with community causes. These projects overtax my strength, but if I don't do them, who will?" The nurse can assess that this person is having difficulty with critical tasks related to which developmental stage? a. Trust versus mistrust b. Integrity versus despair c. Identity versus role diffusion d. Autonomy versus shame and doubt

ANS: B Adult behaviors reflecting problems associated with the developmental stage of integrity versus despair include inability to reduce activities, overtaxing strength, and feeling indispensable, or the opposite: feeling helpless, useless, or lonely; focusing on past mistakes; and inability to occupy oneself with satisfying activities. Tasks of the other stages are not described in the scenario.

Assessment findings by the multidisciplinary team after a patient-intake interview are used primarily to: a. confirm ongoing discharge planning. b. expand and confirm the initial assessment. c. verify the appropriateness of nursing diagnoses. d. analyze the patient's feelings about hospitalization.

ANS: B As members of the multidisciplinary team interact with the patient, their impressions might support or differ slightly from the initial assessment. The findings are synthesized and used in planning ongoing treatment. The other options have less relevance or are not applicable.

Which nursing intervention will initially be most helpful for trust building with a suspicious patient? a. Enforcing rules b. Keeping appointments and promises c. Agreeing not to document the patient's disclosures d. Openly challenging unclear statements by the patient

ANS: B Consistency and honesty regarding intentions are behaviors that promote patient trust. Enforcing rules is important but not necessarily related to trust building. The other options are nontherapeutic.

During an MSE a patient says, "I am a special messenger sent to provide the world a cure for cancer." The patient's statement indicates the presence of: a. a phobia. b. a delusion. c. hypervigilance. d. loose associations.

ANS: B Delusions are false beliefs. Grandiose delusions are beliefs that one possesses greatness or special powers. A phobia is an excessive fear. Hypervigilance refers to being hyperalert and suspicious. Loose associations refer to a thought disorder in which ideas are only loosely connected.

The nurse performing a mental status examination wants to assess for hallucinations. The nurse should ask: a. "Can you tell me where you are now?" b. "Do you hear or see things when others don't?" c. "Do your moods shift more than those of other people?" d. "What would you do if you found a stamped, addressed letter on the floor?"

ANS: B Hallucinations are false sensory perceptions. The correct answer directly inquires about possible hallucinations. The other options seek information about other aspects of the MSE.

The nurse who uses the interpersonal model as a basis for practice will focus assessment on identifying: a. intrapsychic conflicts. b. relationship problems. c. how the environment affects behavior. d. the patient's achievement of development tasks.

ANS: B Interpersonal therapists assess for current difficulties in the patient's relationships with others. Learning new, more effective interpersonal skills becomes a goal of therapy. Psychoanalytic therapists focus on intrapsychic conflicts. The other options are not the focus of the model.

Realistic short-term goals for a patient who is newly admitted to the hospital should be achievable in: a. 1 to 2 days. b. 4 to 6 days. c. 1 to 2 weeks. d. 2 to 4 weeks.

ANS: B Short-term goals are those achievable in 4 to 6 days for hospitalized patients and somewhat longer for patients in other settings. A period of 1 to 2 days allows too little time. The other options suggest longer times than necessary.

A nurse considers interventions for a diabetic patient who needs to change eating habits and lose weight. The nurse will base strategies on which principle? a. The nurse's primary responsibility is to encourage the change. b. Patient-initiated change is more successful than imposed change. c. For successful change, both the benefit and the risk to the patient must be high. d. Patients value advice from nurses because of the trusting dimensions of the relationship.

ANS: B The answer indicates that the patient is invested in the change process. Nurses have multiple responsibilities in the change process, including education and reinforcement. Nurses should avoid giving advice.

A patient says, "I went out drinking only one time last week. At least I'm trying to change." The nurse responds, "I appreciate your effort, but you agreed to abstain from alcohol completely." The nurse is: a. using cognitive restructuring. b. preventing manipulation. c. showing empathy. d. using flooding.

ANS: B The correct comment prevents the nurse from being manipulated by the patient. The nurse should address what happened, along with the expectations. The remaining options do not attempt to address the patient's manipulation of the situation.

A young adult lives with his parents, has few interpersonal relationships, and says, "Most people can't be trusted." This person makes decisions only after consulting with his parents. Using Erikson's developmental theory, the nurse can draw which conclusion? a. The patient has evidence of inferiority and lacks a sense of direction. b. Developmental deficits in early life have impaired the patient's adult functioning. c. The patient's developmental problems will probably lead to a serious mental illness. d. It is impossible for the patient to proceed to the next developmental stage until mastering earlier stages.

ANS: B The patient achieved only partial mastery of the trust-versus-mistrust stage. Deficits in development carried from one stage to the next interfere with functioning at the adult level. Individuals do progress from stage to stage when mastery is not attained; however, adjustment is usually impaired. Developmental problems might lead to a serious mental disorder but might also produce less serious results.

When interacting with patients, it is important for the nurse to recognize that defense mechanisms: a. keep id impulses from gaining control. b. protect the ego from excessive anxiety. c. access unconscious feelings and memories. d. prevent conflict among the id, ego, and superego.

ANS: B Theorists widely accept the Freudian concept that ego defense mechanisms operate unconsciously to lower anxiety. The function of defense mechanisms is limited to anxiety control, so the other options are incorrect.

An individual diagnosed with alcohol dependence will begin motivational enhancement therapy. The nurse will explain this therapy to significant others as a way of: a. altering the patient's irrational thoughts. b. enhancing the patient's willingness to change behavior. c. managing anxiety through satisfying interpersonal interactions. d. mastering critical developmental tasks not attained earlier in life.

ANS: B This variation of cognitive-behavioral therapy uses motivational interviewing to bolster the patient's readiness and willingness to change habits related to the addiction. Motivational enhancement therapy is a nonconfrontational approach that uses empathy and promotes self-efficacy. The other options are consistent with interpersonal therapy, cognitive therapy, and the use of Erikson's model.

Which patient behavior would require the most immediate limit-setting? a. The patient makes self-deprecating remarks. b. At a goal-setting meeting, the patient interrupts others to express delusions. c. A patient shouts at a roommate, "You are perverted! You watched me undress." d. During dinner, a patient manipulates an older adult patient to obtain a second dessert.

ANS: C Behaviors that require the most immediate limit-setting are verbal and physical aggression, self-destructive behavior, fire setting, alcohol or drug use, manipulation, inappropriate sexual behaviors, and attempts to leave the hospital without consent. In this case the verbal aggression toward the roommate requires immediate intervention to prevent further escalation.

Which statement by a patient would the nurse interpret as willingness to collaborate in the nurse-patient relationship? a. "I know you are here to help me, and will do whatever you tell me to do." b. "I didn't want to deal with this at first, but I'm glad you made me face it." c. "I realize that I have some issues that I need help resolving." d. "I will do anything to get out of this hospital."

ANS: C Collaboration takes place when patients recognize problems and the need for assistance. The other responses suggest coercion or simple compliance. They fail to demonstrate the element of self-reflection on the part of the patient.

After an episode of self-mutilation, a patient diagnosed with borderline personality disorder will begin individual therapy and group skills training. The goals are to decrease use of dissociation, increase distress tolerance, and regulate affect. Which type of therapy is evident? a. Rational-emotive behavioral b. Motivational enhancement c. Dialectical behavioral d. Interpersonal

ANS: C Each of the components described in the scenario is a component of dialectical behavioral therapy. The scenario information is not consistent with the components of any of the other types of therapy given as options.

Complete this goal statement for a newly admitted patient in the orientation stage. "By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate: a. greater independence." b. increased self-responsibility." c. trust and rapport with two staff members." d. ability to problem-solve one issue."

ANS: C Establishing trust is the primary task of the orientation stage of the nurse-patient relationship. The other options are too ambitious for this early stage.

A novice nurse says, "I have more important things to do than play games with patients. These activities are not a worthwhile use of my time." Select the nurse manager's best response. a. "Games are part of the therapeutic milieu." b. "Patients need a break from intensive individual therapy." c. "Informal activities help patients develop social skills and take risks." d. "Please review material on the psychotherapeutic management model."

ANS: C Nurses who engage in therapeutic activities with patients recognize that each encounter with patients is part of an overall therapeutic picture. Patients discuss real problems and solutions and practice skills needed in real-life situations. These encounters offer opportunities for assessment, for patients to process feelings, and for validation and feedback, as well as for tension relief. The correct answer is the most global response. The distracters do not educate the new nurse about the purpose of informal activities.

A patient playing pool with another patient throws down the pool cue and begins swearing. The nurse should initially intervene by: a. asking other patients to leave the room. b. calling for assistance to restrain the patient. c. suggesting a time-out in the patient's room. d. restating rules of the milieu related to swearing.

ANS: C Suggesting a time-out in the patient's room is often an effective initial strategy, because it permits the patient to go to an area with fewer stimuli. It also removes the patient from other patients who are at risk for injury if the patient's behavior escalates. Restating the rules of the milieu does not help the patient diffuse the anger. Removing other patients is unnecessary unless the patient's behavior escalates.

As the nurse plans care for a newly admitted patient, identification of dysfunctional behaviors will provide the focus for: a. evaluation. b. nursing diagnosis. c. nursing interventions. d. outcome identification.

ANS: C The nurse recognizes that dysfunctional behaviors are behaviors that would benefit the patient to change. These dysfunctional behaviors are written as defining characteristics in the nursing diagnosis. Nursing interventions are formulated that address changing dysfunctional behaviors to more adaptive behaviors. The focus of evaluation is patient progress; the focus of nursing diagnosis is patient problems; the focus of outcome identification is adaptive behaviors.

A psychotic patient tells the nurse, "Get away from me or I'll hit you. You're sucking the thoughts out of my head." To best de-escalate the situation, the nurse should: a. direct the patient to a chair. b. deny taking the patient's thoughts. c. increase the distance between nurse and patient. d. tell the patient, "You will be restrained if you hit me."

ANS: C The nurse should do as the patient requests when the request is reasonable. Patients perceiving alterations in reality often need increased personal space to feel less anxious. Denials, touching, and threatening are likely to promote escalation of violent behavior.

A patient is hospitalized for severe depression. Knowing that the patient will be discharged after a short stay, what is the nurse's first priority? a. Maximize the benefits of milieu management. b. Immediately begin to explore acute patient issues. c. Develop a goal-directed, problem-centered relationship. d. Choose a specific theoretical model as the basis for care.

ANS: C Therapeutic relationships are planned, patient-centered, and goal-directed. This is of particular importance if progress is to be made when the duration of the relationship will be brief. The other options are not the priority. Exploration of patient issues requires trust development before it can proceed.

Select the best outcome for a nurse to include in the care plan for a withdrawn patient who says, "I would like to have more friends." Within 3 days, the patient will: a. be more outgoing. b. develop greater independence. c. participate in one group activity. d. increase socialization with others.

ANS: C This outcome is behavioral, measurable, and related directly to the problem of social isolation. The other outcomes are neither measurable nor relevant to socialization.

An inpatient says, "Last time I was here, a primary nurse talked with me every day. This time, different nurses work with me. How can I make progress?" Select the nurse's best response. a. "Your comments are interesting. With your permission I will share them with the treatment team." b. "We are using a new system because of managed-care requirements. We are hopeful it will be effective." c. "Shift reports, care plans, and progress notes help different nurses work with all patients toward their individual goals." d. "It sounds like you are feeling dissatisfied with your care. After you are discharged, you will receive a form to provide feedback."

ANS: C This reply explains how many nurses are able to share responsibility and accountability for the care of patients. Good communication enables the nurses to be "on the same page" when it comes to working toward the achievement of patient-centered goals that are appropriate for each stage of the nurse-patient relationship. The other options fail to provide the information the patient needs to understand the current practices.

A nurse says, "What step would you like to take next to resolve this issue?" The patient stands up and shouts, "You are so controlling! You want me to do everything your way." What is the likely basis of the patient's behavior? a. Projection b. Dissociation c. Transference d. Emotional catharsis

ANS: C Transference involves a patient's emotional reaction to the nurse that is actually based on an earlier relationship or experience. In this case, the transference is negative and might be related to an earlier experience with an authority figure. Although projection is a possibility, it is less obvious. Dissociation and emotional catharsis do not apply.

As a patient and nurse move into the working stage of a therapeutic relationship, the nurse's most beneficial statement is: a. "I want to be helpful to you as we explore your problems and the way you express feelings." b. "A good long-term goal for someone your age would be to develop better job-related skills." c. "Of the problems we have discussed so far, which ones would you most like to work on at this time?" d. "When someone gives you a compliment, I notice that you become very quiet and appear uncomfortable."

ANS: C With this remark, the nurse seeks patient collaboration and offers the opportunity to set priorities for the work toward change that will be undertaken. The distracters relate to the orientation stage.

A student goes to a party the night before a test and then fails the exam. After seeing the score, the student slams a book on the table and says, "I have to work so much and have no time to study. It wouldn't matter anyway because the teacher is unreasonable." The nurse identifies use of which defense mechanisms? Select all that apply. a. Denial b. Compensation c. Rationalization d. Projection e. Displacement f. Reaction formation

ANS: C, D, E The student slams down the book, displacing anger, rationalizes (makes excuses), and projects blame onto the teacher. Compensation involves making up for a perceived weakness by emphasizing a desirable trait. Projection refers to blaming others or attributing unacceptable thoughts or behaviors to others. Reaction formation involves doing the opposite of an unacceptable desire.

A nurse clinician uses rational-emotive therapy with a patient who is chronically depressed. The initial step in this process is to help the patient: a. identify developmental tasks and progress. b. manage environmental stressors more effectively. c. explore childhood influences on the patient's emotional state. d. recognize how irrational beliefs are related to painful feelings.

ANS: D Cognitive therapists believe that irrational beliefs or automatic thoughts cause self-defeating behaviors to be maintained. Individuals can challenge their self-defeating behaviors once they identify irrational beliefs and see their connection to painful feelings. The other options reflect interventions that might occur later.

A newly admitted patient tells the nurse, "The voices are bothering me." The nurse should first: a. ignore the patient's reference to voices. b. distract the patient from the hallucinations. c. tell the patient that the voices do not exist. d. seek a description of the voices and identify themes.

ANS: D Early assessment of hallucinations is based on the content of the messages. Content often reveals the dynamics of the patient's symptoms and typically revolves around a theme such as powerlessness, hate, guilt, or loneliness. Ignoring the reference is nontherapeutic and thwarts assessment. Distraction is a possible strategy after the nurse understands the content of the hallucinations. Saying that the voices do not exist negates the patient's experience. Saying you do not hear them is preferable.

A patient asks, "Why is it important to uncover memories and conflicts hidden in the unconscious?" A Freudian therapist would explain that bringing unconscious information to consciousness will: a. resolve developmental issues, fears, and crises. b. allow an individual control over the id and superego. c. suppress painful feelings and increase rational thinking. d. provide insight into behavior and allow meaningful change to occur.

ANS: D Freud believed that uncovering unconscious material generates an understanding of behavior that enables individuals to make choices about behavior and thus improve mental health. It will not, however, automatically resolve issues, give the patient control over id and superego strivings, or result in rational thinking.

A nurse and patient who developed a therapeutic relationship enter into the final phase of their relationship as the patient prepares for discharge. An important nursing intervention for this stage is for the nurse to: a. provide structure and intensive support. b. inform the patient of the progress made. c. encourage the patient to describe goals for change. d. discuss feelings about termination with the patient.

ANS: D Healthy closure is facilitated when the patient discusses his or her reactions to termination and the feelings that she or he might be experiencing. The nurse serves as a role model during termination. Providing structure is related more to the orientation and working stages. Informing the patient of progress is paternalistic. The process of termination is facilitated by collaborative work. Describing goals takes place with passage from the orientation to the working stage.

The nurse writing a discharge summary for a patient should include achievements as well as: a. care plan updates. b. a list of patient strengths. c. effective nursing interventions. d. outcomes that still need to be addressed.

ANS: D Information included in discharge summaries includes outcomes attained, outcomes still to be attained, discharge instructions, medication instructions, and follow-up appointments. The other items are not part of a discharge summary.

A patient tells the nurse, "The reason I use drugs is because everybody nags me to do things that don't interest me." The patient shows use of which defense mechanism? a. Sublimation b. Introjection c. Identification d. Rationalization

ANS: D Rationalization is an attempt to prove that one's behaviors or feelings are justifiable and involves making justifications of feelings or behaviors. Sublimation channels instinctual drives into acceptable channels. The patient is not modeling after another person or incorporating another's values.

A patient is mute, curled in a fetal position, and incontinent of urine. The patient eats small amounts only if spoon-fed. The nurse assesses this behavior as most indicative of: a. displacement. b. compensation. c. conversion. d. regression.

ANS: D Regression is defined as the return to an earlier, more comfortable developmental state—in this case, infancy. Displacement involves discharging feelings to an object that is less threatening. Compensation refers to covering a weakness by overemphasizing a desirable trait. Conversion refers to the unconscious expression of conflict symbolically through physical symptoms.

During an interdisciplinary team meeting, a nurse says, "The patient's psychological distress seems to result from automatic thoughts that cause self-defeating behaviors." The nurse is conceptualizing the patient's problem from the viewpoint of which model? a. Interpersonal b. Psychoanalytic c. Stress-adaptation d. Cognitive-behavioral

ANS: D The cognitive-behavioral model recognizes the role of automatic thoughts (irrational beliefs) in promulgating self-defeating behaviors. The information given in the scenario does not reflect conceptualization using any of the other models.

A patient with a history of self-mutilation says to the nurse, "I want to stop hurting myself." What is the initial step of the problem-solving process to be taken toward resolution of a patient's identified problem? a. Deciding on a plan of action b. Determining necessary changes c. Considering alternative behaviors d. Describing the problem or situation

ANS: D The nurse learns how well the patient understands the problem by asking for a detailed, in-depth description of situations, thoughts, feelings, and behaviors relevant to the identified problem. This step must be completed before moving through the problem-solving process. The other actions are premature.

A patient diagnosed with schizophrenia says to the nurse, "I feel really close to you. You're the only true friend I have." Select the nurse's most therapeutic response. a. "We are not friends. Our relationship is a professional one." b. "I feel sure there are other friends in your life. Can you name some?" c. "I am glad you trust me. Trust is important for the work we are doing together." d. "Our relationship is professional, but let's explore ways to strengthen friendships."

ANS: D The patient's remarks call for the nurse to remind the patient of the parameters of their relationship and take the opportunity to discuss the issue of friends. Only this option incorporates both desired elements.

A patient says, "It's my fault because I always make bad decisions. I should never have taken that job." Using a rational-emotive approach, how would the nurse respond? a. "What can you do to solve your problems at work?" b. "You're experiencing a great deal of stress right now. How can you manage it more effectively?" c. "Can you describe a time in your childhood when your parents blamed you for things you didn't do?" d. "Consider the words you are using to talk about yourself. Let's try to change those words to more positive ones."

ANS: D The therapist using rational-emotive therapy helps the patient identify irrational thoughts and replace them with new, more positive self-statements to enable the patient to think, feel, and behave differently. The other options do not make use of the combination of cognitive, emotive, and behavioral components.

A patient tells the nurse, "I want to have sex with you." Which nursing responses are appropriate? Select all that apply. a. "I will forget you said that." b. "Your suggestion frightens me." c. "You must keep your distance." d. "Sex is not part of our relationship." e. "We are here to work on your problems."

ANS: D, E The correct responses provide information to the patient about the purpose of the relationship and recognize the underlying need. The other options are ineffective.

After being informed of a diagnosis of lung cancer, a patient says in a cheerful voice, "I feel fine. I will do some reading online about it. Right now, I want to take a nap." The nurse assesses the use of which defense mechanisms? Select all that apply. a. Repression b. Undoing c. Introjection d. Reaction formation e. Intellectualization f. Suppression

ANS: D, E, F The cheerful voice is probably the result of reaction formation. The wish to read more about the diagnosis reflects intellectualization. Taking a nap is suppression and allows the patient to avoid having to think about the problem. Repression results in unconscious forgetting. Undoing involves doing something to make up for an unacceptable act. Introjection is incorporating values and attitudes of others as if they were one's own.