Mental Health Chap 21
A client is seeking relief for undiagnosed pain. There is no history of significant physical illness. The history reveals that the client was laid off 4 months ago from her job. Which statement made by the client would most strongly suggest a somatoform disorder? A) "I have been having a hard time lately. It's hard not working like I'm used to." B) "I seem to have more pain now that I got laid off." C) "I probably just overexerted myself working around the house. It's hard to slow down." D) "I'm sure they will figure out what is wrong with me."
Ans: B Feedback: Clients are unlikely to be able to think about or to respond to questions about emotional feelings. They will answer questions about how they feel in terms of physical health or sensations. For example, the nurse may ask, "How did you feel about having to quit your job?" The client might respond, "Well, I thought I'd feel better with the extra rest, but my back pain was just as bad as ever." Recognizing the emotional difficulties of a lifestyle change or feeling relaxed about symptoms is not expected for a client with a somatic symptom illness.
Which statement would indicate to the nurse that the client has understood somatic symptom illness? A) "As soon as my symptoms go away, I'll be my old self again." B) "How I handle stress and emotions can affect my physical health." C) "I have to avoid stress all my life to avoid getting sick again." D) "Taking medication won't help my pain since it's caused by stress."
Ans: B Feedback: Clients who come to understand that how they cope with stress affects their physical health demonstrate an understanding of somatization disorder. Clients with somatization disorder eventually may be treated in mental health settings. It is an unreality to avoid all stress in one's life.
The client asks the nurse, "What does having psychosomatic symptoms mean?" What should the nurse reply? A) "It means you're not physically sick." B) "It means that stress and/or emotions are causing your symptoms." C) "It means that you'll be well when you get your life in order." D) "It means that your symptoms are a product of your imagination."
Ans: B Feedback: Clients who do not cope well with stress or emotions develop physical symptoms that are real as a means of coping. Answer choices A, C, and D are inappropriate responses.
An actor has prepared extensively for his first stage production. On the morning of the opening of the play, the actor awakens with laryngitis. From which disorder is the actor most likely suffering? A) Acute upper respiratory infection B) Conversion disorder C) Hysteria D) Somatization disorder
Ans: B Feedback: Conversion disorder, sometimes called conversion reaction, involves unexplained, usually sudden deficits in sensory or motor function (e.g., blindness, paralysis). These deficits suggest a neurologic disorder but are associated with psychological factors. There is usually significant functional impairment. The term hysteria refers to multiple physical complaints with no organic basis; the complaints are usually described dramatically. Somatization disorder is characterized by multiple physical symptoms and includes a combination of pain and gastrointestinal, sexual, and pseudoneurologic symptoms.
Which is the primary gain associated with developing physical symptoms in response to stress? A) Accept dependency B) Decrease anxiety C) Experience attention D) Suppress anger
Ans: B Feedback: Primary gain is always relief of stress, anxiety, or conflicting/unacceptable emotions. They are the direct external benefits that being sick provides, such as relief from anxiety, conflict, or distress.
A client with somatic symptom illness tells the nurse that she is sick so often that her husband and children take over most of the household duties, such as cooking, cleaning, doing laundry, and so forth. Which is this evidence of? A) Dysfunctional family unit B) Primary gain C) Role reversal D) Secondary gain
Ans: D Feedback: Secondary gains involve increased attention and relief from normal responsibilities and expectations when clients are ill. This is not an example of a dysfunctional family unit or role reversal. A primary gain is the direct external benefits that being sick provides.
Which are appropriate long-term treatment outcomes for clients who have somatic symptom illness? Select all that apply. A) The client will assume responsibility for self-care activities. B) The client will identify the relationship between stress and physical symptoms. C) The client will learn to vary his or her schedule. D) The client will verbally express emotional feelings. E) The client will demonstrate alternative ways to deal with stress, anxiety, and other feelings.
Ans: B, D, E Feedback: Somatic symptom illnesses are chronic or recurrent, so changes are likely to occur slowly. If treatment is effective, the client should make fewer visits to the physician as a result of physical complaints, use less medication and more positive coping techniques, and increased functional abilities. Improved family and social relationships are also a positive outcome that may follow improvements in the client's coping abilities. Treatment outcomes for clients with a somatic symptom illness may include the following: • The client will identify the relationship between stress and physical symptoms. • The client will verbally express emotional feelings. • The client will follow an established daily routine. • The client will develop alternative ways to deal with stress, anxiety, and other feelings. • The client will demonstrate healthier behaviors regarding rest, activity, and nutritional intake.
Which of the following terms are applicable when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a "hero" for saving the victim? A) Malingering B) Factitious disorder C) Munchausen's syndrome by proxy D) Induced illness
Ans: C Feedback: A variation of factitious disorder, imposed on others, is commonly called Munchausen's syndrome by proxy and occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a "hero" for saving the victim. Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms; it is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs. Factitious disorder, imposed on self, occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. Induced illness is another name for factitious disorder.
Which of the following accurately describes how somatic symptoms are distinguished from factitious disorders and malingering? A) Munchausen's syndrome cannot be controlled by persons who have it. B) Persons who experience somatic disorders intentionally produce symptoms for some external purpose or gain. C) In malingering or factitious disorders, people willfully control the symptoms, and in somatic symptom illnesses, clients do not voluntarily control their physical symptoms. D) People who experience somatic symptom illnesses can stop the physical symptoms as soon as they have gained what they wanted.
Ans: C Feedback: In malingering or factitious disorders, people willfully control the symptoms, and in somatic symptom illnesses, clients do not voluntarily control their physical symptoms. Munchausen's disorder is the common term for factitious disorder, imposed on self and occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. People with factitious disorders may even inflict injury on themselves to receive attention. Persons who experience somatic disorders are unable to control their symptoms. People who experience somatic symptom illnesses cannot stop their physical symptoms. However, people who malinger can stop the physical symptoms as soon as they have gained what they wanted.
Psychosocial theorists propose that somatic symptom illnesses are an indirect expression of stress and anxiety through physical symptoms. Which is the primary defense mechanism used in somatoform disorders? A) Somatization B) Identification C) Internalization D) Repression
Ans: C Feedback: Psychosocial theorists believe that people with somatic symptom illnesses keep stress, anxiety, or frustration inside rather than expressing them outwardly. This is called internalization. Clients express these internalized feelings and stress through physical symptoms (somatization). Both internalization and somatization are unconscious defense mechanisms. Identification is trying to ease distress by emulating others whom one admires. Repression is the unconscious exclusion of distressing situations from one's memory.
The nurse is planning care for a client with somatic symptom illness disorder. Which should the nurse plan to reassess on a daily basis? A) Sensory deficits experienced by the client B) Character of pain reported by the client C) Frequency of generalized somatic complaints D) Signs of possible neurologic disorders
Ans: C Feedback: Somatic symptom illness is characterized by multiple physical symptoms. The frequency of generalized somatic complaints will give the nurse information about the current status of the disorder. Conversion disorder involves unexplained, usually sudden deficits in sensory or neurologic motor function and might be manifested by sensory deficits being experienced by the client. Pain disorder has the primary physical symptom of pain and would be reassessed with the description of the character of any pain reported by the client. If the nurse would reassess for signs of possible neurologic disorders, it may serve to reinforce to the client that there might be something wrong.
The client states, "I can't go to group today. I have a very upset stomach this morning." Which would be the nurse's most appropriate response? A) "You have to go to group. The doctor has ordered it." B) "Okay, you can miss this time." C) "I know you don't feel well, but it's important for you to participate in therapy." D) "You aren't really feeling nauseous. It is part of your illness."
Ans: C Feedback: The challenge for the nurse is to validate the client's feelings while encouraging her or him to participate in activities. The nurse should not strip clients of their somatizing defenses until adequate assessment data are collected and other coping mechanisms are learned. The nurse should not attempt to confront clients about somatic symptoms or attempt to tell them that these symptoms are not "real." They are very real to clients who actually experience the symptoms and associated distress.
The family members of a client with somatic symptom illness report to the nurse that every time they invite the client to join in an activity the client declines, saying things like, "I wish I could, but I feel so terrible." Which of the following approaches should the nurse suggest to encourage activity? A) "What does your pain feel like right now?" B) "You are fine, the doctor said so. Let's go." C) "I know this is difficult, but exercise is important. It will be a short walk." D) "I'll let you rest. Let me know when you feel better."
Ans: C Feedback: The nurse must help the client and family learn how to establish a daily routine that includes improved health behaviors. Family members should expect resistance, including protests from the client that she or he does not feel well enough to do these things. The challenge is to validate the client's feelings while encouraging her or him to participate in activities.
A client with recurrent headaches has been told by the physician that the cause is likely psychosomatic. The client reports this conversation to the nurse and says, "That just can't be true! My head hurts so bad sometimes that it makes me sick to my stomach." Which is the nurse's best response? A) To give the client some privacy and time to calm down B) To say nothing and sit quietly with the client C) "The pain in your head is very real." D) "Well, that's not what your doctor thinks."
Ans: C Feedback: When the nurse says, "The pain in your head is very real," the nurse is validating the client's pain as real. The client is asking for some type of validation. In the situation presented, the client's headaches are very real to him or her. The client needs to talk out the feelings regarding what the physician has told him or her. It would be inappropriate for the nurse to say nothing. To give the client some privacy and time to calm down is not indicated. "Well, that's not what your doctor thinks," would put the client on the defensive.
Which is the primary gain for a client with conversion disorder? A) Emotional detachment B) Emotional support from family C) Identification of anxious feelings D) Relief from emotional conflict
Ans: D Feedback: An emotional conflict precedes the development of conversion disorder; the conversion disorder relieves that specific emotional conflict. Emotional detachment and emotional support from the family or identification of anxious feelings are not examples of primary gain in clients diagnosed with conversion disorder. Secondary gains are the internal or personal benefits received from others because one is sick, such as attention from family members.
The nurse is working with the client to develop emotion-focused coping strategies. Which should the nurse include as an emotion-focused coping strategy? A) Problem solving B) Assertiveness techniques C) Role-playing D) Deep breathing techniques
Ans: D Feedback: Emotion-focused coping strategies include progressive relaxation, deep breathing, guided imagery, and distractions such as music or other activities. Problem-focused coping strategies include learning problem-solving methods, applying the process to identified problems, and role-playing interactions with others.
A client is seen in the primary care clinic complaining of headaches. The client appears extremely distressed and insists that she must have a brain tumor. Which diagnosis is most probable for this client? A) Conversion disorder B) Pain disorder C) Brain cancer D) Hypochondriasis
Ans: D Feedback: Hypochondriasis is preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). It is thought that clients with this disorder misinterpret bodily sensations or functions. Conversion disorder, sometimes called conversion reaction, involves unexplained, usually sudden deficits in sensory or motor function. Pain disorder has the primary physical symptom of pain, which generally is unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance.
The nurse is caring for a client who was in a motorcycle accident 2 months ago. The client says he still has terrible neck pain, but he will be better once he gets "a big insurance settlement." What condition might the nurse suspect? A) Hypochondriasis B) La belle indifference C) Conversion reaction D) Malingering
Ans: D Feedback: Malingering is suspected when the client is exaggerating physical complaints for some type of material gain. Hypochondriasis is a preoccupation with the fear that one has a serious disease. La belle indifference is a seeming lack of concern or distress about a functional loss. A conversion reaction involves unexplained, usually sudden, deficits in sensory or motor function related to an emotional conflict the client experiences but does not handle directly.
A client with a somatic symptom illness asks what is causing her physical symptoms. Which would be the appropriate explanation for the nurse to offer? A) Physical symptoms can be attributed to an organic cause. B) Physical symptoms are deliberately expressed in order to benefit in some way. C) Physical symptoms are independent of the amount of the client's psychic distress. D) Physical symptoms are an involuntary way of dealing with psychic conflict.
Ans: D Feedback: Somatic symptom illnesses can be characterized as the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis to account fully for them. The three central features of somatic symptom are as follows: physical complaints suggest major medical illness, but have no demonstrable organic basis; psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the symptoms; and symptoms or magnified health concerns are not under the client's conscious control.
The nurse has encouraged the client with a somatic symptom illness to keep a journal. Which treatment outcome might be met by journaling? A) The nurse will control external stressors that trigger the patient's physical symptoms. B) The nurse will assess the onset of physical symptoms. C) The client will express emotions privately. D) The client will identify the occurrence of physical symptoms when stressed.
Ans: D Feedback: Teaching about the relationship between stress and physical symptoms is a useful way to help clients begin to see the mind-body relationship. Clients may keep a detailed journal of their physical symptoms. The nurse might ask them to describe the situation at the time such as whether they were alone or with others, whether any disagreements were occurring, and so forth. The journal may help clients to see when physical symptoms seemed worse or better and what other factors may have affected that perception.
The nurse performs a thorough physical examination for a client being admitted for a somatic symptom illness. Which of the following is the best rationale for the physical exam? A) Ease the client's mind that the nurse is looking for physical illness. B) Physical disorders underlie somatic disorders. C) Physical exams are reimbursed by third-party payers. D) Underlying pathology should be ruled out.
Ans: D Feedback: The nurse must investigate physical health status thoroughly to ensure that there is no underlying organic pathology requiring treatment. When a client has been diagnosed with a somatic symptom illness, it is important not to dismiss all future complaints because at any time the client could develop a physical condition that would require medical attention.
A client yells at the nurse, "You are all quacks! Can't you see I am sick?" Which knowledge would help the nurse to work most effectively with this client? A) Client progress is expected to be very slow. B) Physical illness is the root of the client's problems. C) The client will never be free of somatic symptoms. D) The nurse has done everything possible to treat the client.
Ans: A Feedback: Clients who cope through physical symptoms can be frustrating for the nurse. Initially, they are unwilling to consider that anything other than major physical illness is the root of all their problems. The client's progress is slow and painstaking, if any change happens at all. The nurse should be realistic about the small successes that can be achieved in any given period. To enhance the ongoing relationship, the nurse must be able to accept the client and his or her continued complaints and criticisms while remaining nonjudgmental.
A middle-aged client goes to the physician falsely complaining of hip pain. The client's intention is to fake chronic hip pain to apply for disability benefits from the government. Which best reflects the client's potential diagnosis? A) Malingering B) Hypochondriasis C) Factitious disorder D) Munchausen's syndrome by proxy
Ans: A Feedback: Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms; it is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs. Hypochondriasis is preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). Factitious disorder occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. Munchausen's syndrome by proxy occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a "hero" for saving the victim.
A newly graduated nurse is scheduled to take the NCLEX-RN examination in 3 days. On awakening today, the graduate cannot see anything at all but tells fellow classmates, "Oh, don't worry; it will all work out." Which might this statement result from? A) La belle indifference B) Regression C) Malingering D) Undoing
Ans: A Feedback: People with a conversion disorder may be seemed to lack concern or distress about the functional loss. This is called la belle indifference. Regression would be when the person reverted to a previous level of functioning. Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs. This is not an example of undoing.
The nurse is identifying outcomes for a client with a somatic symptom illness. Which is an appropriate outcome to include in the plan of care? A) The client will verbally express his or her emotions. B) The client will be free from stress. C) The client will demonstrate alternative ways to avoid stressful situations. D) The client will verbalize acceptance of physical symptoms.
Ans: A Feedback: Treatment outcomes for clients with a somatic symptom illness may include the following: the client will identify the relationship between stress and physical symptoms; the client will verbally express emotional feelings; the client will follow an established daily routine; the client will demonstrate alternative ways to deal with stress, anxiety, and other feelings; the client will demonstrate healthier behaviors regarding rest, activity, and nutritional intake. It is unrealistic for the client to be free from stress or avoid stressful situations.
Which are the factors that are currently considered to be possible reasons for the increased incidence of somatization in women? Select all that apply. A) Boys in the United States are taught to be stoic and to "take it like a man," causing them to offer fewer physical complaints as adults. B) Women seek medical treatment more often than men, and it is more socially acceptable for them to do so. C) Childhood sexual abuse, which is related to somatization, happens more frequently to girls. D) Women more often receive treatment for psychiatric disorders with strong somatic components such as depression. E) Unexplained female pains result from migration of the uterus throughout the woman's body.
Ans: A, B, C, D Feedback: Somatization is associated most often with women, as evidenced by the old term hysteria (Greek for "wandering uterus"). Ancient theorists believed that unexplained female pains resulted from migration of the uterus throughout the woman's body. Psychosocial theorists posit that increased incidence of somatization in women may be related to various factors: • Boys in the United States are taught to be stoic and to "take it like a man," causing them to offer fewer physical complaints as adults. • Women seek medical treatment more often than men, and it is more socially acceptable for them to do so. • Childhood sexual abuse, which is related to somatization, happens more frequently to girls. • Women more often receive treatment for psychiatric disorders with strong somatic components such as depression.
Which of the following are possible with psychosomatic illness? Select all that apply. A) Real symptoms can begin. B) Real symptoms can continue. C) Real symptoms can worsen. D) Unrelated symptoms can occur. E) Clients can control these symptoms.
Ans: A, B, C, D Feedback: The term psychosomatic is used to convey the connection between the mind (psyche) and the body (soma) in states of health and illness. Essentially, the mind can cause the body to create physical symptoms or to worsen physical illnesses. Real symptoms can begin, continue, or be worsened as a result of emotional factors. Examples include diabetes, hypertension, and colitis, all of which are medical illnesses influenced by stress and emotions. In addition, stress can cause physical symptoms unrelated to a diagnosed medical illness. Clients do not willfully control the physical symptoms.
Psychosomatic illness refers to physical symptoms that are either created or worsened by psychic influences. Which conditions are thought to be attributed to the connection between mind and body? Select all that apply. A) Diabetes B) Arthritis C) Hypertension D) Headache E) Colitis
Ans: A, C, D, E Feedback: The term psychosomatic is used to convey the connection between the mind (psyche) and the body (soma) in states of health and illness. Essentially, the mind can cause the body to create physical symptoms or to worsen physical illnesses. Real symptoms can begin, continue, or be worsened as a result of emotional factors. Examples include diabetes, hypertension, and colitis, all of which are medical illnesses influenced by stress and emotions. In addition, stress can cause physical symptoms unrelated to a diagnosed medical illness such as "tension headaches."
The husband of a client with hypochondriasis has accompanied his wife to the follow-up doctor's visit. While waiting for the doctor, the husband expresses to the nurse his frustration with his wife's obsession about illness. He asks the nurse, "What can I do?" The best response by the nurse would be, A) "Try ignoring her complaints, and they should subside." B) "Try finding an activity you enjoy doing together to help her feel better overall." C) "Try to be the client and understand that she is worried that she is sick." D) "Try to give her some sort of reward when she resists complaining about her illnesses."
Ans: B Feedback: Building a trusting relationship with the client, providing empathy and support, and being sensitive to rather than dismissive of complaints are skills that the nurse can use in any setting where clients are seeking assistance. Encouraging clients to find pleasurable activities or hobbies may help to meet their needs for attention and security.
The husband of a woman with a somatic symptom illness asks the nurse why the doctors cannot find anything wrong with her. Which would be the appropriate explanation for the nurse to offer? A) "She is not really experiencing the symptoms. She is making them up to get attention." B) "There is no physical cause. Mental distress is causing the symptoms, even though she is not aware of it." C) "She controls the symptoms when she isn't feeling much stress. It is hard to diagnose when the symptoms are intermittent." D) "There is a physical cause. It just has not been detected yet."
Ans: B Feedback: Clients are convinced they harbor serious physical problems despite negative results during diagnostic testing. They actually experience these physical symptoms as well as the accompanying pain, distress, and functional limitations such symptoms induce. Clients do not willfully control the physical symptoms. Nurses must remember that these clients really experience the symptoms they describe and cannot voluntarily control them.