Varcarolis’ Foundations of Psychiatric Mental Health Nursing A Clinical Approach 7th Edition By Margaret Jordan Halter

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Varcarolis’ Foundations of Psychiatric Mental Health Nursing A Clinical Approach 7th Edition By Margaret Jordan Halter

Chapter 02: Relevant Theories and Therapies for Nursing Practice

 

MULTIPLE CHOICE

 

  1. A parent says, “My 2-year-old child refuses toilet training and shouts ‘No!’ when given directions. What do you think is wrong?” Select the nurse’s best reply.
a. “Your child needs firmer control. It is important to set limits now.”
b. “This is normal for your child’s age. The child is striving for independence.”
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 plan.”

 

 

ANS:  B

This behavior is typical of a child around the age of 2 years, whose developmental task is to develop autonomy. The distracters indicate the child’s behavior is abnormal.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A 26-month-old displays negative behavior, refuses toilet training, and often says, “No!” Which stage of psychosexual development is evident?
a. Oral c. Phallic
b. Anal d. Genital

 

 

ANS:  B

The anal stage occurs from age 1 to 3 years and has as its focus toilet training and learning to delay immediate gratification. The oral stage occurs between birth and 1 year. The phallic stage occurs between 3 and 5 years, and the genital stage occurs between age 13 and 20 years.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22 (Table 2-1)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A 26-month-old displays negative behavior, refuses toilet training, and often says, “No!” Which psychosocial crisis is evident?
a. Trust versus mistrust c. Industry versus inferiority
b. Initiative versus guilt d. Autonomy versus shame and doubt

 

 

ANS:  D

The crisis of autonomy versus shame and doubt relates to the developmental task of gaining control of self and environment, as exemplified by toilet training. This psychosocial crisis occurs during the period of early childhood. Trust versus mistrust is the crisis of the infant. Initiative versus guilt is the crisis of the preschool and early-school-aged child. Industry versus inferiority is the crisis of the 6- to 12-year-old child.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A 4-year-old grabs toys from siblings and says, “I want that now!” The siblings cry, and the child’s parent becomes upset with the behavior. According to Freudian theory, this behavior is a product of impulses originating in which system of the personality?
a. Id c. Superego
b. Ego d. Preconscious

 

 

ANS:  A

The id operates on the pleasure principle, seeking immediate gratification of impulses. The ego acts as a mediator of behavior and weighs the consequences of the action, perhaps determining that taking the toy is not worth the mother’s wrath. The superego would oppose the impulsive behavior as “not nice.” The preconscious is a level of awareness. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 20-21     TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The parent of a 4-year-old rewards and praises the child for helping a younger sibling, being polite, and using good manners. The nurse supports this use of praise related to these behaviors. These qualities are likely to be internalized and become part of which system of the personality?
a. Id c. Superego
b. Ego d. Preconscious

 

 

ANS:  C

The superego contains the “thou shalts,” or moral standards internalized from interactions with significant others. Praise fosters internalization of desirable behaviors. The id is the center of basic instinctual drives, and the ego is the mediator. The ego is the problem-solving and reality-testing portion of the personality that negotiates solutions with the outside world. The preconscious is a level of awareness from which material can be retrieved easily with conscious effort.  This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 20-21     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse supports a parent for praising a child behaving in a helpful way. When this child behaves with politeness and helpfulness in adulthood, which feeling will most likely result?
a. Guilt c. Humility
b. Anxiety d. Self-esteem

 

 

ANS:  D

The individual will be living up to the ego ideal, which will result in positive feelings about self. The other options are incorrect because each represents a negative feeling.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21 | Page 28                            TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. An adult says, “I never know the answers,” and “My opinion doesn’t count.” Which psychosocial crisis was unsuccessfully resolved for this adult?
a. Initiative versus guilt c. Autonomy versus shame and doubt
b. Trust versus mistrust d. Generativity versus self-absorption

 

 

ANS:  C

These statements show severe self-doubt, indicating that the crisis of gaining control over the environment was not met successfully. Unsuccessful resolution of the crisis of initiative versus guilt results in feelings of guilt. Unsuccessful resolution of the crisis of trust versus mistrust results in poor interpersonal relationships and suspicion of others. Unsuccessful resolution of the crisis of generativity versus self-absorption results in self-absorption that limits the ability to grow as a person.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which patient statement would lead the nurse to suspect unsuccessful completion of the developmental task of infancy?
a. “I have very warm and close friendships.”
b. “I’m afraid to allow anyone to really get to know me.”
c. “I’m always absolutely right, so don’t bother saying more.”
d. “I’m ashamed that I didn’t do things correctly in the first place.”

 

 

ANS:  B

According to Erikson, the developmental task of infancy is the development of trust. The correct response is the only statement clearly showing lack of ability to trust others. Warm, close relationships suggest the developmental task of infancy was successfully completed; rigidity and self-absorption are reflected in the belief one is always right; and shame for past actions suggests failure to resolve the crisis of initiative versus guilt.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A patient is suspicious and frequently manipulates others. To which psychosexual stage do these traits relate?
a. Oral c. Phallic
b. Anal d. Genital

 

 

ANS:  A

The behaviors in the stem develop as the result of attitudes formed during the oral stage, when an infant first learns to relate to the environment. Anal-stage traits include stinginess, stubbornness, orderliness, or their opposites. Phallic-stage traits include flirtatiousness, pride, vanity, difficulty with authority figures, and difficulties with sexual identity. Genital-stage traits include the ability to form satisfying sexual and emotional relationships with members of the opposite sex, emancipation from parents, a strong sense of personal identity, or the opposites of these traits.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22 (Table 2-1)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A patient expresses a desire to be cared for by others and often behaves in a helpless fashion. Which stage of psychosexual development is most relevant to the patient’s needs?
a. Latency c. Anal
b. Phallic d. Oral

 

 

ANS:  D

Fixation at the oral stage sometimes produces dependent infantile behaviors in adults. Latency fixations often result in difficulty identifying with others and developing social skills, resulting in a sense of inadequacy and inferiority. Phallic fixations result in having difficulty with authority figures and poor sexual identity. Anal fixation sometimes results in retentiveness, rigidity, messiness, destructiveness, and cruelty. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22 (Table 2-1)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse listens to a group of recent retirees. One says, “I volunteer with Meals on Wheels, coach teen sports, and do church visitation.” Another laughs and says, “I’m too busy taking care of myself to volunteer to help others.” Which developmental task do these statements contrast?
a. Trust and mistrust c. Industry and inferiority
b. Intimacy and isolation d. Generativity and self-absorption

 

 

ANS:  D

Both retirees are in middle adulthood, when the developmental crisis to be resolved is generativity versus self-absorption. One exemplifies generativity; the other embodies self-absorption. This developmental crisis would show a contrast between relating to others in a trusting fashion and being suspicious and lacking trust. Failure to negotiate this developmental crisis would result in a sense of inferiority or difficulty learning and working as opposed to the ability to work competently. Behaviors that would be contrasted would be emotional isolation and the ability to love and commit oneself.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Although ego defense mechanisms and security operations are mainly unconscious and designed to relieve anxiety, the major difference is that:
a. defense mechanisms are intrapsychic and not observable.
b. defense mechanisms cause arrested personal development.
c. security operations are masterminded by the id and superego.
d. security operations address interpersonal relationship activities.

 

 

ANS:  D

Sullivan’s theory explains that security operations are interpersonal relationship activities designed to relieve anxiety. Because they are interpersonal, they are observable. Defense mechanisms are unconscious and automatic. Repression is entirely intrapsychic, but other mechanisms result in observable behaviors. Frequent, continued use of many defense mechanisms often results in reality distortion and interference with healthy adjustment and emotional development. Occasional use of defense mechanisms is normal and does not markedly interfere with development. Security operations are ego-centered. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 33-34 (Table 2-6)                   TOP:   Nursing Process: Analysis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A student nurse says, “I don’t need to interact with my patients. I learn what I need to know by observation.” An instructor can best interpret the nursing implications of Sullivan’s theory to this student by responding:
a. “Interactions are required in order to help you develop therapeutic communication skills.”
b. “Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills.”
c. “Observing patient interactions will help you formulate priority nursing diagnoses and appropriate interventions.”
d. “It is important to pay attention to patients’ behavioral changes, because these signify adjustments in personality.”

 

 

ANS:  B

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. The nurse who does not interact with the patient cannot demonstrate these cornerstones. 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 and behavioral theory. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 33-34 (Table 2-6)                   TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse consistently encourages patient to do his or her own activities of daily living (ADLs).  If the patient is unable to complete an activity, the nurse helps until the patient is once again independent.  This nurse’s practice is most influenced by which theorist?
a. Betty Neuman c. Dorothea Orem
b. Patricia Benner d. Joyce Travelbee

 

 

ANS:  C

Orem emphasizes the role of the nurse in promoting self-care activities of the patient; this has relevance to the seriously and persistently mentally ill patient.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 30-31     TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse uses Maslow’s hierarchy of needs to plan care for a patient with mental illness. Which problem will receive priority? The patient:
a. refuses to eat or bathe.
b. reports feelings of alienation from family.
c. is reluctant to participate in unit social activities.
d. is unaware of medication action and side effects.

 

 

ANS:  A

The need for food and hygiene are physiological and therefore take priority over psychological or meta-needs in care planning.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 31-32 (Figure 2-5)                  TOP:   Nursing Process: Planning/Outcomes Identification

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Operant conditioning is part of the treatment plan to encourage speech in a child who is nearly mute. Which technique applies?
a. Encourage the child to observe others talking.
b. Include the child in small group activities.
c. Give the child a small treat for speaking.
d. Teach the child relaxation techniques.

 

 

ANS:  C

Operant conditioning involves giving positive reinforcement for a desired behavior. Treats are rewards and reinforce speech through positive reinforcement.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 27 (Fig 2-3)                            TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. The parent of a child diagnosed with schizophrenia tearfully asks the nurse, “What could I have done differently to prevent this illness?” Select the nurse’s best response.
a. “Although schizophrenia results from impaired family relationships, try not to feel guilty. No one can predict how a child will respond to parental guidance.”
b. “Schizophrenia is a biological illness resulting from changes in how the brain and nervous system function. You are not to blame for your child’s illness.”
c. “There is still hope. Changing your parenting style can help your child learn to cope effectively with the environment.”
d. “Most mental illnesses result from genetic inheritance. Your genes are more at fault than your parenting.”

 

 

ANS:  B

The parent’s comment suggests feelings of guilt or inadequacy. The nurse’s response should address these feelings as well as provide information. Patients and families need reassurance that the major mental disorders are biological in origin and are not the “fault” of parents. One distracter places the burden of having faulty genes on the shoulders of the parents. The other distracters are neither wholly accurate nor reassuring.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 33          TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse influenced by Peplau’s interpersonal theory works with an anxious, withdrawn patient. Interventions should focus on:
a. rewarding desired behaviors.
b. use of assertive communication.
c. changing the patient’s self-concept.
d. administering medications to relieve anxiety.

 

 

ANS:  B

The nurse-patient relationship is structured to provide a model for adaptive interpersonal relationships that can be generalized to others. Helping the patient learn to use assertive communication will improve the patient’s interpersonal relationships. The distracters apply to theories of cognitive, behavioral, and biological therapy.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient had psychotherapy weekly for 5 months. The therapist used free association, dream analysis, and facilitated transference to help the patient understand conflicts and foster change. Select the term that applies to this method.
a. Rational-emotive behavior therapy c. Cognitive-behavioral therapy
b. Psychodynamic psychotherapy d. Operant conditioning

 

 

ANS:  B

The techniques are aspects of psychodynamic psychotherapy. The distracters use other techniques.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 20-21 | Page 34 (Table 2-6)    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Consider this comment from a therapist: “The patient is homosexual but has kept this preference secret. Severe anxiety and depression occur when the patient anticipates family reactions to this sexual orientation.” Which perspective is evident in the speaker?
a. Theory of interpersonal relationships c. Psychosexual theory
b. Classical conditioning theory d. Behaviorism theory

 

 

ANS:  A

The theory of interpersonal relationships recognizes the anxiety and depression as resulting from unmet interpersonal security needs. Behaviorism and classical conditioning theories do not apply. A psychosexual formulation would focus on uncovering unconscious material that relates to the patient problem.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 24 | Page 34 (Table 2-6)         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A psychotherapist works with an anxious, dependent patient. Which strategy is most consistent with psychoanalytic psychotherapy?
a. Identifying the patient’s strengths and assets
b. Praising the patient for describing feelings of isolation
c. Focusing on feelings developed by the patient toward the therapist
d. Providing psychoeducation and emphasizing medication adherence

 

 

ANS:  C

Positive or negative feelings of the patient toward the therapist indicate transference. Transference is a psychoanalytic concept that can be used to explore previously unresolved conflicts. The distracters relate to biological therapy and supportive psychotherapy. Use of psychoeducational materials is a common “homework” assignment used in cognitive therapy.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 21-22 | Page 34 (Table 2-6)    TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A person says, “I was the only survivor in a small plane crash. Three business associates died. I got depressed and saw a counselor twice a week for 4 weeks. We talked about my feelings related to being a survivor, and I’m better now.” Which type of therapy was used?
a. Milieu therapy c. Behavior modification
b. Psychoanalysis d. Interpersonal psychotherapy

 

 

ANS:  D

Interpersonal psychotherapy returned the patient to his former level of functioning by helping him come to terms with the loss of friends and guilt over being a survivor. Milieu therapy refers to environmental therapy. Psychoanalysis would call for a long period of exploration of unconscious material. Behavior modification would focus on changing a behavior rather than helping the patient understand what is going on in his life.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 24-25 | Page 34 (Table 2-6)    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which technique is most applicable to aversion therapy?
a. Punishment c. Role modeling
b. Desensitization d. Positive reinforcement

 

 

ANS:  A

Aversion therapy is akin to punishment.  Aversive techniques include pairing of a maladaptive behavior with a noxious stimulus, punishment, and avoidance training.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 28          TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient says to the nurse, “My father has been dead for over 10 years, but talking to you is almost as comforting as the talks he and I had when I was a child.”  Which term applies to the patient’s comment?
a. Superego c. Reality testing
b. Transference d. Counter-transference

 

 

ANS:  B

Transference refers to feelings a patient has toward the health care workers that were originally held toward significant others in his or her life. Counter-transference refers to unconscious feelings that the health care worker has toward the patient.  The superego represents the moral component of personality; it seeks perfection.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22     TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A college student received an invitation to attend the wedding of a close friend who lives across the country. The student is afraid of flying. Which type of therapy would be most helpful for this patient?
a. Psychoanalysis c. Systematic desensitization
b. Milieu therapy d. Short-term dynamic therapy

 

 

ANS:  C

Systematic desensitization is a type of therapy aimed at extinguishing a specific behavior, such as the fear of flying. Psychoanalysis and short-term dynamic therapy seek to uncover conflicts. Milieu therapy involves environmental factors.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 27-28     TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient would benefit from therapy in which peers as well as staff have a voice in determining patients’ privileges and psychoeducational topics. Which approach would be best?
a. Milieu therapy c. Short-term dynamic therapy
b. Cognitive therapy d. Systematic desensitization

 

 

ANS:  A

Milieu therapy is based on the idea that all members of the environment contribute to the planning and functioning of the setting. The distracters are individual therapies that do not fit the description.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 33          TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient repeatedly stated, “I’m stupid.” Which statement by that patient would show progress resulting from cognitive behavioral therapy?
a. “Sometimes I do stupid things.”
b. “Things always go wrong for me.”
c. “I always fail when I try new things.”
d. “I’m disappointed in my lack of ability.”

 

 

ANS:  A

“I’m stupid” is a cognitive distortion. A more rational thought is “Sometimes I do stupid things.” The latter thinking promotes emotional self-control. The distracters reflect irrational or distorted thinking. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 29-31 (Table 2-5)                   TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient says, “All my life I’ve been surrounded by stupidity.  Everything I buy breaks because the entire American workforce is incompetent.”  This patient is experiencing a:
a. self-esteem deficit. c. deficit in motivation.
b. cognitive distortion. d. deficit in love and belonging.

 

 

ANS:  B

Automatic thoughts, or cognitive distortions, are irrational and lead to false assumptions and misinterpretations.  See related audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 29-31 (Table 2-5)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient is fearful of riding on elevators.  The therapist first rides an escalator with the patient.  The therapist and patient then stand in an elevator with the door open for five minutes and later with the elevator door closed for five minutes.  Which technique has the therapist used?
a. Classic psychoanalytic therapy c. Rational emotive therapy
b. Systematic desensitization d. Biofeedback

 

 

ANS:  B

Systematic desensitization is a form of behavior modification therapy that involves the development of behavior tasks customized to the patient’s specific fears.  These tasks are presented to the patient while using learned relaxation techniques. The patient is incrementally exposed to the fear.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 28          TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient says, “I always feel good when I wear a size 2 petite.”  Which type of cognitive distortion is evident?
a. Disqualifying the positive c. Catastrophizing
b. Overgeneralization d. Personalization

 

 

ANS:  B

Automatic thoughts, or cognitive distortions, are irrational and lead to false assumptions and misinterpretations.  The stem offers an example of overgeneralization.  See related audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 29-31 (Table 2-5)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which comment best indicates a patient is self-actualized?
a. “I have succeeded despite a world filled with evil.”
b. “I have a plan for my life.  If I follow it, everything will be fine.”
c. “I’m successful because I work hard.  No one has ever given me anything.”
d. “My favorite leisure is walking on the beach, hearing soft sounds of rolling waves.”

 

 

ANS:  D

The self-actualized personality is associated with high productivity and enjoyment of life.  Self-actualized persons experience pleasure in being alone and an ability to reflect on events.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 31-32 (Box 2-1)                                TOP:              Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse and patient discuss a problem the patient has kept secret for many years.  Afterward the patient says, “I feel so relieved that I finally told somebody.”  Which term best describes the patient’s feeling?
a. Catharsis c. Cognitive distortion
b. Superego d. Counter-transference

 

 

ANS:  A

Freud initially used talk therapy, known as the cathartic method. Today we refer to catharsis as “getting things off our chests.”  The superego represents the moral component of personality.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 20          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which patient is the best candidate for brief psychodynamic therapy?
a. An accountant with a loving family and successful career who was involved in a short extramarital affair
b. An adult with a long history of major depression who was charged with driving under the influence (DUI)
c. A woman with a history of borderline personality disorder who recently cut both wrists
d. An adult male recently diagnosed with anorexia nervosa

 

 

ANS:  A

The best candidates for psychodynamic therapy are relatively healthy and well-functioning individuals, sometimes referred to as the “worried well,” who have a clearly circumscribed area of difficulty and are intelligent, psychologically minded, and well-motivated for change. Patients with psychosis, severe depression, borderline personality disorders, and severe character disorders are not appropriate candidates for this type of treatment.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 21-22     TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A patient states, “I’m starting cognitive-behavioral therapy. What can I expect from the sessions?” Which responses by the nurse would be appropriate? Select all that apply.
a. “The therapist will be active and questioning.”
b. “You will be given some homework assignments.”
c. “The therapist will ask you to describe your dreams.”
d. “The therapist will help you look at your ideas and beliefs about yourself.”
e. “The goal is to increase subjectivity about thoughts that govern your behavior.”

 

 

ANS:  A, B, D

Cognitive therapists are active rather than passive during therapy sessions because they help patients reality-test their thinking. Homework assignments are given and completed outside the therapy sessions. Homework is usually discussed at the next therapy session. The goal of cognitive therapy is to assist the patient in identifying inaccurate cognitions and in reality- testing and formulating new, accurate cognitions. One distracter applies to psychoanalysis. Increasing subjectivity is not desirable.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 29-31 | Page 34 (Table 2-6)    TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which comments by an elderly person best indicate successful completion of the developmental task? Select all that apply.
a. “I am proud of my children’s successes in life.”
b. “I should have given to community charities more often.”
c. “My relationship with my father made life more difficult for me.”
d. “My experiences in the war helped me appreciate the meaning of life.”
e. “I often wonder what would have happened if I had chosen a different career.”

 

 

ANS:  A, D

The developmental crisis for an elderly person relates to integrity versus despair. Pride in one’s offspring indicates a sense of fulfillment. Recognition of the wisdom gained from difficult experiences (such as being in a war) indicates a sense of integrity. Blaming and regret indicate despair and unsuccessful resolution of the crisis.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which comments by an adult best indicate self-actualization? Select all that apply.
a. “I am content with a good book.”
b. “I often wonder if I chose the right career.”
c. “Sometimes I think about how my parents would have handled problems.”
d. “It’s important for our country to provide basic health care services for everyone.”
e. “When I was lost at sea for 2 days, I gained an understanding of what is important.”

 

 

ANS:  A, D, E

Self-actualized persons enjoy privacy, have a sense of democracy, and show positive outcomes associated with peak experiences. Self-doubt, defensiveness, and blaming are not consistent with self-actualization.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 22 | Page 31-32                                 TOP:              Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which activities represent the art of nursing?  Select all that apply.
a. Administering medications on time to a group of patients
b. Listening to a new widow grieve her husband’s death
c. Helping a patient obtain groceries from a food bank
d. Teaching a patient about a new medication
e. Holding the hand of a frightened patient

 

 

ANS:  B, C, E

Peplau described the science and art of professional nursing practice.  The art component of nursing consists of the care, compassion, and advocacy nurses provide to enhance patient comfort and well-being. The science component of nursing involves the application of knowledge to understand a broad range of human problems and psychosocial phenomena, intervening to relieve patients’ suffering and promote growth.  See related audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 24-25     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

 

Chapter 16: Trauma, Stressor-Related, and Dissociative Disorders

 

MULTIPLE CHOICE

 

  1. A nurse works with a patient diagnosed with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care?
a. Trigger flashbacks intentionally in order to help the patient learn to cope with them.
b. Explain that the physical symptoms are related to the psychological state.
c. Encourage repression of memories associated with the traumatic event.
d. Support “numbing” as a temporary way to manage intolerable feelings.

 

 

ANS:  B

Persons with posttraumatic stress disorder often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body’s responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for posttraumatic stress disorder is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 310-311                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who:
a. visit their teenager’s grave daily.
b. return immediately to employment.
c. discuss the accident within the family only.
d. create a scholarship fund at their child’s high school.

 

 

ANS:  D

Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 306-307 | Page 310-313 | Page 312 (Nursing Care Plan 16-1)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. After the sudden death of his wife, a man says, “I can’t live without her…she was my whole life.” Select the nurse’s most therapeutic reply.
a. “Each day will get a little better.”
b. “Her death is a terrible loss for you.”
c. “It’s important to recognize that she is no longer suffering.”
d. “Your friends will help you cope with this change in your life.”

 

 

ANS:  B

Adjustment disorders may be associated with grief. A statement that validates a bereaved person’s loss is more helpful than false reassurances and clichés. It signifies understanding.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 310-311                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, “If you had given him your undivided attention, he would still be alive.”  How should the nurse analyze this behavior?
a. The comment suggests potential allegations of malpractice.
b. In some cultures, grief is expressed solely through anger.
c. Anger is an expected emotion in an adjustment disorder.
d. The patient had ambivalent feelings about her husband.

 

 

ANS:  C

Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 310-311                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, “He would still be alive if you had given him your undivided attention.” Select the nurse’s best intervention.
a. Say to the wife, “I understand you are feeling upset. I will stay with you until your family comes.”
b. Say to the wife, “Your husband’s heart was so severely damaged that it could no longer pump.”
c. Say to the wife, “I will call the health care provider to discuss this matter with you.”
d. Hold the wife’s hand in silence until the family arrives.

 

 

ANS:  A

The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 310-311 | Page 312 (Nursing Care Plan 16-1)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child’s parents have adapted to their loss? The parents:
a. visit their child’s grave daily.
b. maintain their child’s room as the child left it 2 years ago.
c. keep a place set for the dead child at the family dinner table.
d. throw flowers on the lake at each anniversary date of the accident.

 

 

ANS:  D

Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 306-307 | Page 310-313 | Page 312 (Nursing Care Plan 16-1)

TOP:   Nursing Process: Evaluation           MSC:  Client Needs: Psychosocial Integrity

 

  1. A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse’s most therapeutic response.
a. “Are you taking your medications the way they are prescribed?”
b. “This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?”
c. “I’m worried about how much you are crying. Your grief over your husband’s death has gone on too long.”
d. “The unexpected death of your husband is very painful. I’m glad you are able to talk about your feelings.”

 

 

ANS:  D

The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurse’s priority intervention is to form a therapeutic alliance and support the patient’s expression of feelings. Crying at 2 weeks after his death is expected and normal.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 310-313                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which scenario demonstrates a dissociative fugue?
a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing.
b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them.
c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of “blackouts” despite not drinking.
d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

 

 

ANS:  A

The patient in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from one’s body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are “lost” to the patient (blackouts).  See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 317        TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is:
a. risk for self-harm. c. memory impairment.
b. cognitive function. d. condition of self-esteem.

 

 

ANS:  A

Assessments that relate to patient safety take priority. Patients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self-injury. The other options are important assessments but rank below safety. Treatment motivation, while an important consideration, is not necessarily a part of the nursing assessment.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 317-319                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A patient states, “I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school.” This scenario is most suggestive of which health problem?
a. Acute stress disorder
b. Dissociative amnesia
c. Depersonalization disorder
d. Disinhibited social engagement disorder

 

 

ANS:  C

Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 318-319 (Table 16-1)             TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. The unlicensed assistive personnel (UAP) says to the nurse, “That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?”  Select the nurse’s best reply.
a. “Spend as much time with her as you can and ask questions about her life.”
b. “Use short, simple sentences and keep the environment calm and protective.”
c. “Provide more information about her past to reduce the mysteries that are causing anxiety.”
d. “Structure her time with activities to keep her busy, stimulated, and regaining concentration.”

 

 

ANS:  B

Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in patients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the patient should only gradually be given information about her past. Asking questions that require recall that the patient does not possess will only add frustration. Quiet, undemanding activities should be provided as the patient tolerates them and should be balanced with rest periods; the patient’s time should not be loaded with demanding or stimulating activities.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 318-320 (Table 16-2)             TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with depersonalization disorder tells the nurse, “It’s starting again. I feel as though I’m going to float away.” Which intervention would be most appropriate at this point?
a. Notify the health care provider of this change in the patient’s behavior.
b. Engage the patient in a physical activity such as exercise.
c. Isolate the patient until the sensation has diminished.
d. Administer a PRN dose of anti-anxiety medication.

 

 

ANS:  B

Helping the patient apply a grounding technique, such as exercise, assists the patient to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the patient. It is not necessary to notify the health care provider.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 319-320 (Table 16-2)             TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience?
a. Limbic system c. Sympathetic nervous system
b. Peripheral nervous system d. Parasympathetic nervous system

 

 

ANS:  C

The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person would experience stress associated with the experience of being in danger. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 306        TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. The gas pedal on a person’s car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this person’s cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol?
a. Weight gain c. Headache
b. Flashbacks d. Diuresis

 

 

ANS:  B

Cortisol is a hormone released in response to stress. Severe dissociation or “mindflight” occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol. The cortisol level may go up or down, so diuresis and/or weight gain may or may not occur. Answering this question correctly requires that the student apply prior learning regarding the effects of cortisol.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 306-307                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse’s highest priority is to screen this soldier for:
a. bipolar disorder. c. depression.
b. schizophrenia. d. dementia.

 

 

ANS:  C

Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 310-316                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurse’s immediate attention?
a. “It’s good to be home. I missed my home, family, and friends.”
b. “I saw my best friend get killed by a roadside bomb. I don’t understand why it wasn’t me.”
c. “Sometimes I think I hear bombs exploding, but it’s just the noise of traffic in my hometown.”
d. “I want to continue my education, but I’m not sure how I will fit in with other college students.”

 

 

ANS:  B

The correct response indicates the soldier is thinking about death and feeling survivor’s guilt.  These emotions may accompany suicidal ideation, which warrants the nurse’s follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 310-317                                 TOP:   Nursing Process: Analysis/Diagnosis

MSC:  Client Needs: Psychosocial Integrity

 

  1. A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). The soldier says, “If there’s a loud noise at night, I get under my bed because I think we’re getting bombed.”  What type of experience has the soldier described?
a. Illusion c. Nightmare
b. Flashback d. Auditory hallucination

 

 

ANS:  B

Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 307 | Page 310-312                TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A soldier returned 3 months ago from Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier?
a. Halloween festival with neighborhood children
b. Singing carols around a Christmas tree
c. A family outing to the seashore
d. Fireworks display on July 4th

 

 

ANS:  D

The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 307 | Page 310-312                TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)?
a. Immediately upon return to the U.S. from Afghanistan
b. Before departing Afghanistan to return to the U.S.
c. One year after returning from Afghanistan
d. Screening should be on-going

 

 

ANS:  D

PTSD can have a very long lag time, months to years. Screening should be on-going.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 310-311                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A soldier in a combat zone tells the nurse, “I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere.  I see something red, and the visions race back to my mind.”  Which phenomenon associated with posttraumatic stress disorder (PTSD) is the soldier describing?
a. Reexperiencing c. Avoidance
b. Hyperarousal d. Psychosis

 

 

ANS:  A

Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event.  This description does not indicate psychosis, hypervigilance, or avoidance.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 310-311                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A soldier who served in a combat zone returned to the U.S. The soldier’s spouse complains to the nurse, “We had planned to start a family, but now he won’t talk about it. He won’t even look at children.”  The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)?
a. Reexperiencing c. Avoidance
b. Hyperarousal d. Psychosis

 

 

ANS:  C

Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individual’s avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 310-311                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A soldier returned home last year after deployment to a war zone. The soldier’s spouse complains, “We were going to start a family, but now he won’t talk about it. He will not look at children. I wonder if we’re going to make it as a couple.”  Select the nurse’s best response.
a. “Posttraumatic stress disorder often changes a person’s sexual functioning.”
b. “I encourage you to continue to participate in social activities where children are present.”
c. “Have you talked with your spouse about these reactions?  Sometimes we just need to confront behavior.”
d. “Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support.”

 

 

ANS:  D

Posttraumatic stress disorder precipitates changes that often lead to divorce. It’s important to provide support to both the veteran and spouse.  Confrontation will not be effective.  While it’s important to provide information, on-going support will be more effective.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 305 | Page 319                        TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which assessment finding best supports dissociative fugue? The patient states:
a. “I cannot recall why I’m living in this town.”
b. “I feel as if I’m living in a fuzzy dream state.”
c. “I feel like different parts of my body are at war.”
d. “I feel very anxious and worried about my problems.”

 

 

ANS:  A

The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.  See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 317-318                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. After major reconstructive surgery, a patient’s wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient?  Dysfunction of the:
a. pons. c. hippocampus.
b. occipital lobe. d. hypothalamus.

 

 

ANS:  C

The scenario presents chronic and potentially debilitating stress.  If arousal continues unabated, neuronal changes occur that alter the neural circuitry of the prefrontal cortex, reducing the size the hippocampus so that memory is impaired.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 306-307                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. Relaxation techniques help patients who have experienced major traumas because they:
a. engage the parasympathetic nervous system.
b. increase sympathetic stimulation.
c. increase the metabolic rate.
d. release hormones.

 

 

ANS:  A

In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 311-312                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity related to:
a. obsessive fears of harming self or others.
b. poor impulse control and lack of self-confidence.
c. depressed mood secondary to nightmares and intrusive thoughts.
d. cognitive distortions associated with unresolved childhood abuse issues.

 

 

ANS:  D

Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 315-319 (Table 16-1)             TOP:   Nursing Process: Analysis/Diagnosis

MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A young adult says, “I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind.  I don’t remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them.”  Which disorders should the nurse suspect based on this history? Select all that apply.
a. Acute stress disorder
b. Depersonalization disorder
c. Generalized anxiety disorder
d. Posttraumatic stress disorder
e. Reactive attachment disorder
f. Disinhibited social engagement disorder

 

 

ANS:  A, B, D

Acute stress disorder, depersonalization disorder, and posttraumatic stress disorder can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patient’s presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 310-311 | Page 313-316         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse.  The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents?  The nurse should recommend:  (select all that apply)
a. conveying empathy and acknowledging the child’s distress.
b. explaining and reinforcing reality to avoid distortions.
c. using a calm manner and low, comforting voice.
d. avoiding repetition in what is said to the child.
e. staying with the child until the anxiety decreases.
f. minimizing opportunities for exercise and play.

 

 

ANS:  A, B, C, E

The child’s symptoms and behavior suggest that he is exhibiting posttraumatic stress disorder. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child’s distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 309-311 (Box 16-1)               TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: (select all that apply)
a. avoids people and places that arouse painful memories.
b. experiences flashbacks or reexperiences the trauma.
c. experiences symptoms suggestive of a heart attack.
d. feels driven to repeat selected ritualistic behaviors.
e. demonstrates hypervigilance or distrusts others.
f. feels detached, estranged, or empty inside.

 

 

ANS:  A, B, C, E, F

These assessment findings are consistent with the symptoms of posttraumatic stress disorder. Ritualistic behaviors are expected in obsessive-compulsive disorder.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 310-312                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)?  Select all that apply.
a. A young adult bungee jumped from a bridge with a best friend.
b. An 8-year-old child watched an R-rated movie with both parents.
c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator.
d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment.
e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

 

 

ANS:  C, D, E

PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individual’s extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 305-307 | Page 310-312         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

Chapter 34: Family Interventions

 

MULTIPLE CHOICE

 

  1. A married couple has two biologic children who live with them as well as a child from the wife’s first marriage. What type of family is evident?
a. Homogeneous c. Blended
b. Extended d. Nuclear

 

 

ANS:  C

A blended family is made up of members from two or more unrelated families. It is not a nuclear family because a stepchild is present. It is not an extended family, because there are only two generations present. Homogeneous is not a family type.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 620        TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A married couple has two children living in the home. Recently, the wife’s mother moved in. This family should be assessed as:
a. nuclear. c. extended.
b. blended. d. alternative.

 

 

ANS:  C

An extended family has members from three or more generations living together. Nuclear family refers to a couple and their children. A blended family is one made up of members from two or more unrelated families. An alternative family can consist of a same-sex couple or an unmarried couple and children.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 620        TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When a nurse assesses a family, which family task has the highest priority for healthy family functioning?
a. Allocation of family resources c. Maintenance of order and authority
b. Physical maintenance and safety d. Reproduction of new family members

 

 

ANS:  B

Physical and safety needs have greater importance in Maslow’s hierarchy than other needs.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 620        TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which documentation of family assessment indicates a healthy and functional family?
a. Members provide mutual support.
b. Power is distributed equally among all members.
c. Members believe there are specific causes for events.
d. Under stress, members turn inward and become enmeshed.

 

 

ANS:  A

Healthy families nurture and support their members, buffer against stress, and provide stability and cohesion. The distracters are unrelated or incorrect.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 620-621                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A 15-year-old is hospitalized after a suicide attempt. This adolescent lives with the mother, stepfather, and several siblings. When performing a family assessment, the nurse must first determine:
a. how the family expresses and manages emotion.
b. names and relationships of the family’s members.
c. the communication patterns between the patient and parents.
d. the meaning that the patient’s suicide attempt has for family members.

 

 

ANS:  B

The identity of the members of the family is the most fundamental information and should be obtained first. Without this, the nurse cannot fully process the other responses.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 627-628                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which information is the nurse most likely to find when assessing the family of a patient with a serious mental illness?
a. The family exhibits many characteristics of dysfunctional families.
b. Several family members have serious problems with their physical health.
c. Power in the family is maintained in the parental dyad and rarely delegated.
d. Stress from living with a mentally ill member has challenged the family’s function.

 

 

ANS:  D

The information almost universally obtained is that the family is under stress associated with having a mentally ill member. This stress lowers the family’s level of functioning in at least one significant way. Stress does not necessarily mean the family has become dysfunctional.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 620-621 | Page 626 | Page 631

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. The parent of an adolescent diagnosed with mental illness asks the nurse, “Why do you want to do a family assessment? My teenager is the patient, not the rest of us.” Select the nurse’s best response.
a. “Family dysfunction might have caused the mental illness.”
b. “Family members provide more accurate information than the patient.”
c. “Family assessment is part of the protocol for care of all patients with mental illness.”
d. “Every family member’s perception of events is different and adds to the total picture.”

 

 

ANS:  D

The identified patient usually bears most of the family system’s anxiety and may have come to the attention of parents, teachers, or law enforcement because of poor coping skills. The correct response helps the family understand that the opinions of each will be valued. It allows the nurse to assess individual coping and prepares the family for the experience of working together to set goals and solve problems. The other responses are either incorrect or evasive.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 626-627                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. An adult diagnosed with schizophrenia lives with elderly parents.  The patient was recently hospitalized with acute psychosis. One parent is very anxious, and the other is ill because of the stress. Which nursing diagnosis is most applicable to this scenario?
a. Ineffective family coping related to parental role conflict
b. Caregiver role strain related to the stress of chronic illness
c. Impaired parenting related to patient’s repeated hospitalizations
d. Interrupted family processes related to relapse of acute psychosis

 

 

ANS:  B

Caregiver role strain refers to a caregiver’s felt or exhibited difficulty in performing a family caregiver role. In this case, one parent exhibits stress-related illness and the other exhibits increased anxiety. The other nursing diagnoses are not substantiated by the information given and are incorrectly formatted [one nursing diagnosis should not be the etiology for another].

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 629-631 (Box 34-3)               TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Psychosocial Integrity

 

  1. An adult recently diagnosed with AIDS is hospitalized with pneumonia. The patient and family are very anxious. Select the best outcome to add to the plan of care for this family.
a. Describe the stages of the anticipatory grieving process.
b. Identify and describe effective methods for coping with anxiety.
c. Recognize ways dysfunctional communication is expressed in the family.
d. Examine previously unexpressed feelings related to the patient’s sexuality.

 

 

ANS:  B

Desired outcomes might be set for the family as a whole or for individuals within the family. The outcome most closely associated with the anxiety that each member is experiencing is to focus on identifying and describing ways of coping with the anxiety. The other options are not appropriate at this time.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 631-632                                 TOP:   Nursing Process: Outcomes Identification

MSC:  Client Needs: Psychosocial Integrity

 

  1. A parent is admitted to a chemical dependency treatment unit. The patient’s spouse and adolescent children participate in a family session. What is the most important aspect of this family’s assessment?
a. Spouse’s codependent behaviors
b. Interactions among family members
c. Patient’s reaction to the family’s anger
d. Children’s responses to the family sessions

 

 

ANS:  B

Interactions among all family members are the raw material for family problem solving. By observing interactions, the nurse can help the family make its own assessments of strengths and deficits. The other options are narrower in scope when compared with the correct option.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 631-632                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A parent is admitted to a chemical dependency treatment unit. The patient’s spouse and adolescent children attend a family session. Which initial assessment question should the nurse ask of family members?
a. “What changes are most important to you?”
b. “How are feelings expressed in your family?”
c. “What types of family education would benefit your family?”
d. “Can you identify a long-term goal for improved functioning?”

 

 

ANS:  B

It is important to understand family characteristics, particularly in a family under stress. Expression of feelings is an important aspect of assessment of the family’s function (or dysfunction). The distracters relate more to outcome identification and planning interventions, both of which should be delayed until the assessment is complete.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 627-629                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse interviews a homeless parent with two teenage children. To best assess the family’s use of resources, the nurse should ask:
a. “Can you describe a problem your family has successfully resolved?”
b. “What community agencies have you found helpful in the past?”
c. “What aspect of being homeless is most frightening for you?”
d. “Do you feel you have adequate resources to survive?”

 

 

ANS:  B

The correct option asks about use of resources in an open, direct fashion. It will give information about choices the family has made regarding use of resources in the community. The other questions do not address prior use of resources or focus on other aspects of coping.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 620 | Page 631-633                TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Two divorced people plan to marry. The man has a teenager, and the woman has a toddler. This family will benefit most from:
a. role-playing opportunities for conflict resolution regarding discipline.
b. guidance about parenting children at two developmental levels.
c. formal teaching about problem-solving skills.
d. referral to a family therapist.

 

 

ANS:  B

The newly formed family will be coping with tasks associated with the stage of rearing preschool children and teenagers. These stages require different knowledge and skills. There is no evidence of a problem, so the distracters are not indicated.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 620 | Page 624-625 | Page 631                                           TOP:    Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, “Our hopes for our child’s future are ruined. We probably won’t ever have grandchildren.” The nurse will use interventions to assist with:
a. denial. c. acting out.
b. grieving. d. manipulation.

 

 

ANS:  B

Grief is a common reaction to having a family member diagnosed with mental illness. The grief stems from actual or potential losses, such as the family’s ability to function, financial well-being, and altered future. Data do not support choosing any of the other options.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 628-629                                 TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, “Our child acts so strangely that we don’t invite friends to our home. We quit taking vacations. Sometimes we don’t get any sleep.” Which nursing diagnosis best applies?
a. Impaired parenting c. Impaired social interaction
b. Dysfunctional grieving d. Interrupted family processes

 

 

ANS:  D

Interrupted family processes are evident in the face of disruptions in family functioning as a result of having a mentally ill member. Assessment data best support this diagnosis. Data are insufficient to support the other diagnoses.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 629-630 | Page 631 (Box 34-3)

TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Psychosocial Integrity

 

  1. A family expresses helplessness related to dealing with a mentally ill member’s odd behaviors, mood swings, and argumentativeness. An effective nursing intervention for this family would be to:
a. express sympathy for their situation. c. explain symptoms of relapse.
b. involve local social service agencies. d. role-play difficult situations.

 

 

ANS:  D

Helping a family learn to set limits and deal with difficult behaviors can often be accomplished by using role-playing situations, which give family members the opportunity to try new, more effective approaches. The other options would not provide learning opportunities.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 629        TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Parents of a mentally ill teenager say, “We have never known anyone who was mentally ill. We have no one to talk to because none of our friends understand the problems we are facing.”  Select the nurse’s most helpful intervention.
a. Refer the parents to a support group.
b. Build the parents’ self-concept as coping parents.
c. Teach the parents techniques of therapeutic communication.
d. Facilitate achievement of normal developmental tasks of the family.

 

 

ANS:  A

The need for support is evident. Referrals are made when working with families whose needs are unmet. A support group, such as through the National Alliance on Mentally Illness (NAMI), will provide the parents with support of others with similar experiences and with whom they can share feelings and experiences. The distracters are less relevant to providing a network of support.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 633        TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Select the best question for the nurse to ask to assess a family’s ability to cope.
a. “What strengths does your family have?”
b. “Do you think your family copes effectively?”
c. “Describe how you successfully handled one family problem.”
d. “How do you think the current family problem should be resolved?”

 

 

ANS:  C

The correct option is the only statement addressing coping strategies used by the family. The distracters seek opinions or use closed-ended communication techniques.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 627-629                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which scenario best illustrates scapegoating within a family?
a. The identified patient sends messages of aggression to selected family members.
b. Family members project problems of the family onto one particular family member.
c. The identified patient threatens separation from the family to induce feelings of isolation and despair.
d. Family members give the identified patient nonverbal messages that conflict with verbal messages.

 

 

ANS:  B

Scapegoating projects blame for family problems onto a member who is less powerful. The purpose of this projection is to distract from issues or dysfunctional behaviors in the members of the family.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 625 (Table 34-1) | Page 628 (Box 34-2)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A parent became unemployed 6 months ago.  The parent has subsequently been verbally abusive toward the spouse and oldest child. The child ran away twice, and the spouse has become depressed. What is the most appropriate nursing diagnosis for this family?
a. Impaired parenting related to verbal abuse of oldest child
b. Impaired social interaction related to disruption of family bonds
c. Ineffective community coping related to fears about economic stability
d. Disabled family coping related to insecurity secondary to loss of family income

 

 

ANS:  D

Disabled family coping refers to the behavior of a significant family member that disables his or her own capacity as well as another’s capacity to perform tasks essential to adaptation. The distracters are inaccurate because the stressors influence more than one individual.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 629-631 (Box 34-3)               TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A parent says, “My son and I argue constantly since he started using drugs. When I talk to him about not using drugs, he tells me to stay out of his business.”  What is the nurse’s first most appropriate action?
a. Educate the parent about stages of family development.
b. Report the son to law enforcement authorities.
c. Refer the son for substance abuse treatment.
d. Make a referral for family therapy.

 

 

ANS:  D

Family therapy is indicated, and the nurse should provide a referral. Reporting the child to law enforcement would undermine trust and violate confidentiality. The other distracters may occur later.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 620-621                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which scenario best demonstrates a healthy family?
a. One parent takes care of children. The other parent earns income and maintains the home.
b. A family has strict boundaries that require members to address problems within the family.
c. A couple requires their adolescent children to attend church services 3 times a week.
d. A couple renews their marital relationship after their children become adults.

 

 

ANS:  D

Revamping the marital relationship after children move out of the family of origin indicates the family is moving through its stages of development. Strict family boundaries or roles interfere with flexibility and use of outside resources. Adolescents should have some input into deciding their activities.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 623-625                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which comment by a mother during a family therapy session shows evidence of scapegoating?
a. “Our youngest child always starts arguments and upsets everyone else.”
b. “We all express our feelings openly except when we think it might upset my husband.”
c. “Our oldest child knows that my husband and I are doing all we can for the others.”
d. “After my husband has been drinking, I have to get everyone up and ready for school.”

 

 

ANS:  A

Scapegoating is blaming family problems on a member of the family who is not very powerful. The purpose of the blaming is to keep the focus off painful issues and off the blamers themselves. A double-bind message, such as “We all express our feelings openly except when…,” involves giving instructions that are inherently contradictory or that place the person in a no-win situation. “Our oldest child knows that …” is an example of triangulation, wherein a third party is engaged to help stabilize an unstable pair within the family. A child assuming parental responsibilities (e.g., caring for siblings) because a parent fails to do so is an example of enabling.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 625 (Table 34-1) | Page 628 (Box 34-2)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which example of behavior in a family system demonstrates double-bind communication?
a. A mother tells her daughter, “You make me so mad that sometimes I wish I had never had you.”
b. A teenager tells her father, “You are treating me like a baby when you tell me I must be home by 10 PM on a school night.”
c. A son tells his mother, “You worry too much about what might happen.  Nothing has happened yet, so why worry?”
d. A wife tells her husband, “You go ahead with your bowling trip.  Try not to worry about me falling on my crutches while I’m alone at home.”

 

 

ANS:  D

A double-bind communication is one that is inherently contradictory, that is, a comment that gives conflicting directions. In this case, the wife on crutches suggests that her husband should go bowling but then indicates that she will be at greater risk if he does, which in effect tells him “go ahead” and “don’t do it” at the same time. This remark places the husband in a double bind, a situation in which no acceptable response exists. The distracters are clear, direct communications.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 625 (Table 34-1) | Page 628 (Box 34-2)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. A wife believes her husband is having an affair.  Lately, he has been disinterested in romance and working late. The husband has an important, demanding project at work. The mother asks her teen, “What have you noticed about your father?”  The teen later mentions this to the father, who says, “Tell your mother that I can’t deal with her insecurities right now.”  Which family dynamic is evident?
a. Multigenerational dysfunction c. Enmeshment
b. Triangulation d. Blaming

 

 

ANS:  B

Triangulation is a family dynamic wherein a pair relationship (usually the parents) is under stress and copes by drawing in a third person (usually a child) to align with one or the other members of the pair relationship. Multigenerational dysfunction is any dysfunction that exists within or across multiple generations of a family, such as child abuse or alcoholism. Blaming is distracting attention from one’s own dysfunction or reducing one’s own anxiety by blaming another person. Enmeshment refers to blurred family boundaries or blending together of the thoughts, feelings, or family roles of the individuals so that clear distinctions among members fail to emerge.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 625 (Table 34-1) | Page 628 (Box 34-2)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. A 16-year-old wants to drive, but the parents will not allow it.  A 14-year-old sibling was invited to several sleepovers, but the parents found reasons to deny permission. Both teens are annoyed because the parents buy clothes for them that are more suitable for younger children. The parents say, “We don’t want our kids to grow up too fast.”  Which term best describes this family’s boundaries?
a. Rigid c. Enmeshed
b. Clear d. Differentiated

 

 

ANS:  A

Rigid boundaries are those that do not change or flex with changing circumstances, as indicated here by parents who are reluctant to revise their roles and expectations about their children as the children mature. Enmeshed boundaries are those that have failed to differentiate or develop individually; the family shares roles and thoughts to an excessive degree, without a healthy degree of individuality. Clear boundaries are not enmeshed; they are appropriate and well maintained.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 621-623 | Page 628 (Box 34-2)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A wife believes her husband is having an affair.  Lately, he has been disinterested in romance and working late. The husband has an important, demanding project at work. The mother asks her teen, “What have you noticed about your father?”  The teen later mentions this to the father, who says, “Tell your mother that I can’t deal with her insecurities right now.”  Family therapy should focus on:  (select all that apply)
a. identifying and reducing the cognitive distortion in each parent’s perceptions.
b. confronting the family with the need for honest, direct, assertive communication.
c. helping the parents find ways to cope more effectively with their stress and fears.
d. supporting the teen to redirect the parents when they try to communicate through her.
e. convincing the mother that her fear of an affair is due to her own insecurities and unfounded.
f. helping the husband understand how others might misinterpret the changes in his behavior.

 

 

ANS:  A, C, D, F

Each parent is seeing the other’s behavior in a possibly distorted manner, which the nurse would explore and help the parents correct. The nurse would guide the parents to communicate more effectively, but confrontation would likely be non-therapeutic because it would increase the tension and triangulation. Since fear and anxiety contribute to triangulation, increasing the parent’s coping abilities as well as reducing anxiety and fear would be areas for intervention. Teaching the adolescent how to protect herself from triangulation, when done in conjunction with interventions to help the parents reduce this behavior, would be protective of the adolescent and would assist the parents in their efforts to change this pattern of communication. The nurse has no facts about whether or not the husband is having an affair; therefore, the nurse should not convince the wife that her fear is only due to her insecurities. Her fears may be well-founded. Helping the husband understand how his wife might see the changes in behavior differently can help him to respond helpfully instead of accusing her of being insecure.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 625 (Table 34-1) | Page 628 (Box 34-2)                  TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A parent was recently hospitalized with severe depression.  Family members say, “We’re falling apart. Nobody knows what to expect, who should make decisions, or how to keep the family together.” Which interventions should the nurse use when working with this family? Select all that apply.
a. Help the family set realistic expectations.
b. Provide empathy, acceptance, and support.
c. Empower the family by teaching problem solving.
d. Negotiate role flexibility amongst family members.
e. Focus planning on the family rather than on the patient.

 

 

ANS:  A, B, C, D

The correct answers address expressed needs of the family. The distracter is inappropriate.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 620 | Page 631-632                TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which situations are most likely to place severe, disabling stress on a family? Select all that apply.
a. A parent needs long-term care after sustaining a severe brain injury.
b. The youngest child in a family leaves for college in another state.
c. A spouse is diagnosed with liver failure and needs a transplant.
d. Parents of three children, aged 9, 7, and 2 years, get a divorce.
e. A parent retires after working at the same job for 28 years.

 

 

ANS:  A, C, D

Major illnesses and divorce place severe, potentially disabling stress on families.  The distracters identify normal milestones in a family’s development.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 620 | Page 624                        TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

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