Psychiatric Nursing 7th Edition by Norman L. Keltner – Debbie Steele – Test Bank A+

$35.00
Psychiatric Nursing 7th Edition by Norman L. Keltner – Debbie Steele – Test Bank A+

Psychiatric Nursing 7th Edition by Norman L. Keltner – Debbie Steele – Test Bank A+

$35.00
Psychiatric Nursing 7th Edition by Norman L. Keltner – Debbie Steele – Test Bank A+
  1. The patient says, “I know I’m very sick right now, but I trust that God will make me better.” Based on this statement, the nurse can assess the patient’s spirituality as being based in:
a.theism.
b.humanism.
c.behaviorism.
d.existentialism.

ANS: A

Theism is the only model that suggests that people are inextricably tied to a transcendent being. This view provides hope for a better future. None of the other views have this basis.

DIF: Cognitive level: Understanding REF: pp. 58-59

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. The spouse of a psychiatric patient says, “This mental illness should not have happened. I tried to teach the importance of professing faith in God and getting converts, but my partner rejected them. Those practices keep me well. It’s the only way to live.” The nurse can assess that the spouse is demonstrating:
a.atheism.
b.humanism.
c.agnosticism.
d.sick religiosity.

ANS: D

Sick religiosity is marked by a lack of openness to other possibilities, a sense of exclusiveness, and absolutism. The scenario does not give evidence of any of the other options.

DIF: Cognitive level: Understanding REF: p. 59

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. A depressed patient expresses feelings of hopelessness, helplessness, and powerlessness. The patient’s spiritual distress is related to an inability to:
a.find meaning and hope through choices.
b.develop wisdom in the face of adversity.
c.draw strength from a higher power.
d.live by higher principles.

ANS: A

Although individuals cannot always choose their circumstances, they always have a choice of attitudes toward their experiences. Without finding meaning, individuals develop hopelessness. None of the other options relates directly to hopelessness.

DIF: Cognitive level: Applying REF: p. 59

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. A patient says, “I know I need religion in my life, but I don’t know how to find God. I feel I have been abandoned.” The nurse should assess for a childhood history of:
a.recurrent losses.
b.overindulgence.
c.lack of nurturing.
d.poor school performance.

ANS: C

Loder has hypothesized that early developmental experiences set the stage for later spiritual dynamics. Inadequate nurturing may result in lack of establishment of trust. Later, spiritual issues of abandonment and shame might surface. None of the other options have been advanced as explanations for feelings of abandonment by God.

DIF: Cognitive level: Understanding REF: p. 59

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. A group of nurses disagrees about whether or not to make spirituality a part of the assessment. Which statement provides a compelling argument in favor of including spiritual assessment?
a.Research clearly demonstrates that spiritual interventions by nurses are a cost-effective practice.
b.Accrediting organizations regard spiritual care as a patient right.
c.Spirituality is better addressed by nurses than by clergy.
d.Prayer consistently improves mental health outcomes.

ANS: B

There is a lack of agreement as to whether or not spiritual care should be a legitimate concern of nurses, despite a large body of research evidence citing its advantages to patients. Among the major deterrents to including spiritual care is the concern that already overburdened nurses will not find time to perform the assessment. It should be noted, however, that when an accrediting body considers a facet of care to be a right of patients, it will look for evidence of attention to that right. A spiritual assessment documented in the medical record provides such evidence. The other options are of lesser importance when weighed against the standards set by an accrediting agency.

DIF: Cognitive level: Analyzing REF: pp. 59-60 TOP: Nursing process: Planning

MSC: NCLEX: Psychosocial Integrity

  1. Which statement by a mentally ill patient best exemplifies sick religiosity?
a.“Suicide will result in eternal damnation for your soul.”
b.“Your illness has nothing to do with insufficient faith.”
c.“Questioning God is a common reaction to illness.”
d.“Your illness is not related to sin.”

ANS: A

Sick religiosity is marked by a lack of openness to other possibilities, a sense of exclusiveness, and absolutism. The correct option best exemplifies this thinking. The other options are supportive of the patient’s spirituality.

DIF: Cognitive level: Understanding REF: p. 59

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

  1. A patient diagnosed with schizophrenia says, “I am a reincarnation of Jesus. I can raise the dead.” The most qualified person for the nurse to refer the patient would be a:
a.psychiatric nurse clinician.
b.professional chaplain.
c.clinical psychologist.
d.community minister.

ANS: B

A professional chaplain holds a ministerial degree and has had a year of special study in ministering to individuals with spiritual concerns related to health problems. The other professionals have less knowledge and experience in dealing with the dual problems of mental illness and spiritual concerns.

DIF: Cognitive level: Understanding REF: p. 62

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

  1. A nurse provides spiritual care for a patient awaiting a liver transplant. The nurse should anticipate that the patient’s most likely response will be:
a.consideration of issues related to own mortality.
b.devaluation of prayer and organized religion.
c.misinterpretation of medical information.
d.clinical depression.

ANS: A

Although each of the options is possible, the most likely response is thinking about what the illness means in terms of lifespan, quality of life, and other mortality issues. The other responses are pathologic and are not seen as frequently.

DIF: Cognitive level: Analyzing REF: p. 61 TOP: Nursing process: Planning

MSC: NCLEX: Psychosocial Integrity

  1. An African-American caregiver says, “Both of my parents have dementia. I find it so difficult to care for them because of their disabilities. I get depressed and hopeless thinking about it. Can you give me any suggestions for coping?” Before making suggestions, the nurse should assess:
a.the parents’ stage of dementia.
b.the caregiver’s religious ideology.
c.whether or not the parents’ medications are helping.
d.if financial resources are sufficient to provide a health care aide.

ANS: B

Serious illness of loved ones often presents difficult dilemmas and problems in adjustment for caregivers. It is known that religious activities are important coping mechanisms for many African-American caregivers of older adults. The correct answer is the only option directly concerned with caretaker coping. The foci of the other options are on the parents.

DIF: Cognitive level: Applying REF: p. 58

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. A patient diagnosed with schizophrenia, paranoid type, has been suspicious of staff since admission. The patient visits with a chaplain but then tells the nurse, “Don’t send any more preachers.” What is the most likely reason for the patient’s reaction?
a.Hostility
b.Distractibility
c.Inability to trust
d.Inability to find meaning in suffering

ANS: C

Individuals with paranoid schizophrenia often have an inability to trust. Inability to trust may be related to inadequate nurturing in infancy and to later difficulty recognizing a connection with God. The other options are less clearly related to issues of paranoia and trust.

DIF: Cognitive level: Understanding REF: pp. 59, 61 TOP: Nursing process: Evaluation

MSC: NCLEX: Psychosocial Integrity

  1. A patient tells the nurse, “I make decisions each day that have a positive effect on my life.” This statement is most closely related to the spiritual construct of:
a.making meaning through choices.
b.a presence that orders the world.
c.higher purpose and principles.
d.higher power and achievement.

ANS: A

Frankl advocated that humans find meaning when they commit themselves to something beyond themselves. Making meaningful choices improves an individual’s mental health. The constructs mentioned in the other options have less to do with the individual’s decision making described in the scenario.

DIF: Cognitive level: Understanding REF: p. 59

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. A patient moans, “God wants me to suffer, but I don’t know why. I feel like an outcast. I should have never been born.” Which nursing diagnosis applies?
a.Potential for enhanced spiritual well-being
b.Disturbed personal identity
c.Spiritual distress
d.Powerlessness

ANS: C

Defining characteristics for the nursing diagnosis of spiritual distress are present. They include concern with the meaning of life, anger toward God, questioning the meaning of suffering, conflict about beliefs, and questions about the morality of the therapeutic regimen. Spiritual distress is more applicable to the patient’s comments than the other diagnoses.

DIF: Cognitive level: Analyzing REF: p. 60

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. A patient diagnosed with schizophrenia complains of demon voices coming through the television. Which statement by the nurse providing spiritual care would be most comforting to the patient?
a.“Rest assured that God will fill your heart with peace.”
b.“I am concerned about your spiritual distress.”
c.“God will hold you in the palm of His hand.”
d.“God knows your every thought.”

ANS: B

The correct answer shows compassion and caring on the part of the nurse and contributes to trust building. The nurse has offered concerns, which reassures the individual that he or she will not be abandoned. The other options each include abstract concepts that are difficult for someone who thinks concretely to interpret correctly. They might even be frightening to patients who think concretely.

DIF: Cognitive level: Analyzing REF: pp. 59, 61

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

  1. A patient with major depression shows the nurse a passage in the Bible and says, “How do you think this verse relates to me?” The nurse is unfamiliar with the verse and unsure how to respond. Select the nurse’s best action.
a.Ask the patient, “What do you think the verse means?”
b.Invite professional clergy to join the dialogue with the patient.
c.Explain to the patient, “I’m not familiar with that passage. It would be better for me not to comment.”
d.Say to the patient, “Would you bring that up in the group session? You can get input from several people about what the verse means.”

ANS: B

The correct answer shows that the nurse recognizes personal limits but remains engaged in the interaction with the patient. The distracters reject the patient’s concerns.

DIF: Cognitive level: Applying REF: p. 62

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

  1. On the admission papers, a patient checked the box labeled “No religious affiliation.” What meaning can the nurse draw from this information? The patient:
a.is not religious.
b.is probably monotheistic.
c.has conventional religious values.
d.is probably experiencing spiritual distress.

ANS: B

The correct answer is consistent with the beliefs of 80% of Americans: there is one Supreme Being. The distracters offer misinformation and misinterpretation about the meaning of “No religious affiliation.”

DIF: Cognitive level: Understanding REF: p. 58

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. What is the predominant religious tradition in the United States?
a.Christian
b.Buddhist
c.Muslim
d.Jewish

ANS: A

Christians compose 78% of Americans.

DIF: Cognitive level: Understanding REF: p. 58

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

  1. A patient says, “I am a Christian.” The nurse understands that Christianity includes which groups? Select all that apply.
a.Judaism
b.Mormonism
c.Buddhism
d.Catholicism
e.Greek Orthodox

ANS: B, D, E

Christianity accounts for 78% of the U.S. population and includes Protestant, Mormon, Catholic, and some orthodox groups. Judaism and Buddhism are not Christian religions.

DIF: Cognitive level: Understanding REF: p. 58

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. A new nurse asks the mentor, “How can I help meet patients’ spiritual needs?” Select the mentor’s best responses. “Patients have reported that what they want most is for a spiritual care provider to (select all that apply):
a.be authentic.”
b.be respectful.”
c.demonstrate caring.”
d.speak slowly and concretely.”
e.provide answers to theological questions.”

ANS: A, B, C, D

The needs elicited from patients (authenticity, caring, respect) can be seen as caregiver behaviors that enhance trust formation. The need to speak slowly and in concrete terms is important for patients with thought disorders who have cognitive problems that make comprehension slower and abstraction difficult to understand.

DIF: Cognitive level: Understanding REF: p. 61

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

  1. What information about a patient’s perceptions and values would the nurse obtain by using questions from the HOPE tool? Select all that apply.
a.Healthy spirituality versus sick religiosity
b.That which gives the patient hope and meaning in life
c.Important personal spiritual practices
d.Role of religion in the patient’s life
e.Sources of strength and comfort

ANS: B, C, D, E

The HOPE questions gather information about sources of hope, strength, comfort, meaning, peace, love, and connection; the role of organized religion for the patient; personal spirituality and practices; and effects on medical care and end-of-life decisions.

DIF: Cognitive level: Understanding REF: p. 61

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

Chapter 07: Models for Working with Psychiatric Patients

MULTIPLE CHOICE

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

ANS: B

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

DIF: Cognitive level: Understanding REF: p. 67 TOP: Nursing process: Planning

MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Understanding REF: p. 67

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: D

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

DIF: Cognitive level: Understanding REF: p. 67

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Understanding REF: p. 67

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Analyzing REF: pp. 67-68

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Analyzing REF: pp. 69-71

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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

ANS: B

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

DIF: Cognitive level: Understanding REF: pp. 70-71

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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

ANS: A

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

DIF: Cognitive level: Understanding REF: 67

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: D

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

DIF: Cognitive level: Understanding REF: p. 67

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: D

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

DIF: Cognitive level: Understanding REF: p. 68

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Analyzing REF: pp. 69-71

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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

ANS: B

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

DIF: Cognitive level: Analyzing REF: pp. 69-71

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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

ANS: B

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

DIF: Cognitive level: Analyzing REF: pp. 69-71

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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

ANS: B

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

DIF: Cognitive level: Understanding REF: pp. 71-72 TOP: Nursing process: Planning

MSC: NCLEX: Health Promotion and Maintenance

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

ANS: A

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

DIF: Cognitive level: Analyzing REF: pp. 71-72 TOP: Nursing process: Planning

MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Applying REF: p. 69

TOP: Nursing process: Implementation MSC: NCLEX: Health Promotion and Maintenance

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

ANS: D

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

DIF: Cognitive level: Analyzing REF: pp. 72-75

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: D

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

DIF: Cognitive level: Analyzing REF: p. 73

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: D

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

DIF: Cognitive level: Understanding REF: pp. 72-73 TOP: Nursing process: Analysis

MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Analyzing REF: pp. 69-71

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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

ANS: A

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

DIF: Cognitive level: Applying REF: pp. 71-72

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Understanding REF: p. 73

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Understanding REF: p. 73

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

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

ANS: C, D, E

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

DIF: Cognitive level: Understanding REF: pp. 67-68

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: D, E, F

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

DIF: Cognitive level: Understanding REF: pp. 67-68

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

Chapter 09: Working with an Individual Patient

MULTIPLE CHOICE

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

ANS: C

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

DIF: Cognitive level: Analyzing REF: p. 84

TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment

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

ANS: A

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

DIF: Cognitive level: Understanding REF: p. 85 TOP: Nursing process: Evaluation

MSC: NCLEX: Safe, Effective Care Environment

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

ANS: D

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

DIF: Cognitive level: Applying REF: p. 85

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Applying REF: pp. 87-88

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Applying REF: p. 86 TOP: Nursing process: Planning

MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Analyzing REF: p. 86

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Applying REF: p. 86

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Applying REF: p. 85

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Understanding REF: p. 87

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: D

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

DIF: Cognitive level: Analyzing REF: p. 86

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Understanding REF: p. 89

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: D

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

DIF: Cognitive level: Applying REF: p. 88

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Analyzing REF: pp. 84-85

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Analyzing REF: p. 85

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Applying REF: p. 93

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Applying REF: p. 86

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Understanding REF: p. 86

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Analyzing REF: p. 87

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Analyzing REF: p. 89

TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment

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

ANS: D

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

DIF: Cognitive level: Applying REF: p. 89

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Understanding REF: p. 90

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Understanding REF: pp. 87-88 TOP: Nursing process: Planning

MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Applying REF: p. 89

TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment

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

ANS: A

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

DIF: Cognitive level: Understanding REF: p. 90

TOP: Nursing process: Assessment MSC: NCLEX: Safe, Effective Care Environment

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

ANS: B

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

DIF: Cognitive level: Understanding REF: p. 91

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Understanding REF: p. 91

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Understanding REF: p. 93 TOP: Nursing process: Planning

MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Analyzing REF: p. 93

TOP: Nursing process: Assessment MSC: NCLEX: Physiologic Integrity

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

ANS: A

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

DIF: Cognitive level: Understanding REF: pp. 92-93

TOP: Nursing process: Outcome Identification

MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Analyzing REF: p. 93

TOP: Nursing process: Outcome Identification/Planning

MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Understanding REF: p. 93

TOP: Nursing process: Outcome Identification/Planning

MSC: NCLEX: Safe, Effective Care Environment

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

ANS: A

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

DIF: Cognitive level: Analyzing REF: p. 93 TOP: Nursing process: Planning

MSC: NCLEX: Safe, Effective Care Environment

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

ANS: A

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

DIF: Cognitive level: Understanding REF: pp. 92-93 TOP: Nursing process: Evaluation

MSC: NCLEX: Psychosocial Integrity

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

ANS: D

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

DIF: Cognitive level: Understanding REF: p. 94 TOP: Nursing process: Evaluation

MSC: NCLEX: Safe, Effective Care Environment

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

ANS: A

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

DIF: Cognitive level: Understanding REF: p. 93

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: C

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

DIF: Cognitive level: Analyzing REF: p. 93

TOP: Nursing process: Outcome Identification

MSC: NCLEX: Psychosocial Integrity

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

ANS: A

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

DIF: Cognitive level: Applying REF: p. 91

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Applying REF: p. 89

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: B

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

DIF: Cognitive level: Understanding REF: p. 89

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

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

ANS: A, B, C, D

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

DIF: Cognitive level: Analyzing REF: p. 87

TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment

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

ANS: D, E

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

DIF: Cognitive level: Applying REF: p. 85

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: A, B, C, D, E

This sequence proceeds logically from assessment of the problem to analysis of the problem to determining that change is necessary to testing new behaviors and evaluating their efficacy.

DIF: Cognitive level: Applying REF: pp. 87-88

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

Chapter 11: Working with the Family

MULTIPLE CHOICE

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

ANS: B

Physical and safety needs are given greater importance in Maslow’s hierarchy of needs than other needs.

DIF: Cognitive level: Applying REF: p. 107

TOP: Nursing process: Assessment MSC: NCLEX: 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 that 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.

DIF: Cognitive level: Understanding REF: p. 107

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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

ANS: B

The names and relationships of the patient’s family members constitute the most fundamental information and should be obtained first. Without this, the nurse cannot fully process the other responses.

DIF: Cognitive level: Analyzing REF: p. 108

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

  1. Which information is the nurse most likely to find when assessing the family of a patient with a serious and persistent 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.The stress of living with a mentally ill individual has negatively affected family 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.

DIF: Cognitive level: Understanding REF: p. 108

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. The patient’s parent asks the nurse, “Why do you want to do a family assessment? My child 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

This 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.

DIF: Cognitive level: Applying REF: p. 108

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

  1. An adult diagnosed with paranoid schizophrenia lives with older adult parents. The patient was recently hospitalized with acute psychosis. One parent is very anxious, and the other is ill from all the stress. Select the most applicable nursing diagnosis.
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).

DIF: Cognitive level: Analyzing REF: pp. 108-109

TOP: Nursing process: Assessment MSC: NCLEX: 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.Identify and describe effective coping methods.
b.Describe the stages of the anticipatory grieving process.
c.Recognize the ways dysfunctional communication is expressed in the family.
d.Examine previously unexpressed feelings related to the patient’s sexuality.

ANS: A

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 is experiencing is to focus on identifying and describing ways of coping with the anxiety. The other options are not appropriate at this time.

DIF: Cognitive level: Applying REF: pp. 108-109

TOP: Nursing process: Outcome Identification/Planning

MSC: NCLEX: 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 family assessment?
a.Spouse’s co-dependent 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 too narrow in scope when compared with the correct option.

DIF: Cognitive level: Analyzing REF: pp. 108-109

TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity

  1. A parent is admitted to a chemical dependency treatment unit. The patient’s spouse and adolescent children attend a family session. What is the priority assessment question to ask 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 in both the family of origin and the present family. The other questions are related more to outcome identification and planning intervention, neither of which should be attempted until assessment is complete.

DIF: Cognitive level: Analyzing REF: p. 109

TOP: Nursing process: Assessment MSC: NCLEX: 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.“Do you feel you have adequate resources to survive?”
d.“What is one thing you dislike about this family?”

ANS: B

The correct option asks about resource use in an open, direct fashion. It will give information about choices that the family has made to use other family members or resources in the community. The other questions do not address prior use of resources.

DIF: Cognitive level: Applying REF: p. 108

TOP: Nursing process: Assessment MSC: NCLEX: 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.guidance about parenting at two developmental levels.
b.role-playing opportunities for conflict resolution.
c.formal teaching about problem-solving skills.
d.referral to a family therapist.

ANS: A

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

DIF: Cognitive level: Applying REF: pp. 107-108 TOP: Nursing process: Planning

MSC: NCLEX: 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 should use interventions to assist with the parent’s:
a.denial.
b.grieving.
c.acting out.
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 ability to function, altered family functioning, income, and altered future prospects. Data do not support choosing any of the other options.

DIF: Cognitive level: Understanding REF: pp. 107-108

TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity

  1. Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, “Our child sometimes acts so strangely that we don’t invite friends to the house. Sometimes we don’t get any sleep. We quit taking vacations.” Which nursing diagnosis applies?
a.Impaired parenting
b.Dysfunctional grieving
c.Impaired social interaction
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. Data support the possibility of this diagnosis. Data are insufficient to consider the other diagnoses.

DIF: Cognitive level: Understanding REF: pp. 108-109

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

  1. A family expresses helplessness related to dealing with a mentally ill member’s odd behaviors, mood swings, and argumentativeness. An appropriate nursing intervention for the family would be to:
a.express sympathy.
b.involve local social services.
c.explain symptoms of relapse.
d.role-play problem 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.

DIF: Cognitive level: Applying REF: p. 109

TOP: Nursing process: Implementation MSC: NCLEX: Health Promotion and Maintenance

  1. Parents of a mentally ill teenager say, “We’ve never known anyone who was mentally ill. We have no one to talk to because none of our friends understand the problems.” The nurse’s most helpful intervention would be to:
a.refer the parents to a support group.
b.build their self-esteem as coping parents.
c.teach techniques of therapeutic communication.
d.facilitate achievement of normal developmental tasks.

ANS: A

The need for support can be clearly identified. Referrals are made when working with families whose needs are unmet. A support group such as the National Alliance for the Mentally Ill (NAMI) will provide these parents with the support of others who have had similar experiences and with whom they can share feelings and experiences. The distracters are less relevant.

DIF: Cognitive level: Applying REF: p. 109

TOP: Nursing process: Implementation MSC: NCLEX: Health Promotion and Maintenance

  1. Select the best question 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 other options seek opinions or are closed-ended.

DIF: Cognitive level: Applying REF: pp. 108-109

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

  1. Which scenario best illustrates scapegoating within a family?
a.Messages of aggression are sent by the identified patient to selected family members.
b.Family members project problems of the family onto one particular family member.
c.The identified patient threatens separation 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 family members.

DIF: Cognitive level: Understanding REF: pp. 106-107

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

  1. A parent has become verbally abusive toward the spouse and oldest child since losing a job 6 months ago. 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 individual 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 more than one individual is affected by the stressors.

DIF: Cognitive level: Analyzing REF: p. 107

TOP: Nursing process: Assessment MSC: NCLEX: 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 most appropriate action?
a.Educate the parent about the 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.

DIF: Cognitive level: Applying REF: pp. 108-109

TOP: Nursing process: Implementation MSC: NCLEX: Health Promotion and Maintenance

  1. Which option describes a healthy family?
a.One parent takes care of the children. The other parent earns income and maintains the home.
b.A family has strict boundaries that require members to address problems inside the family.
c.A couple requires their adolescent children to attend church services three 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 that the family is moving through its stages of development. Strict family boundaries or roles interfere with flexibility and the use of outside resources. Adolescents should have some input into deciding their activities.

DIF: Cognitive level: Understanding REF: p. 107

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

MULTIPLE RESPONSE

  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 what to do 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 among family members.
e.Focus on the family rather than on the patient in planning.

ANS: A, B, C, D

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

DIF: Cognitive level: Applying REF: p. 109

TOP: Nursing process: Implementation MSC: NCLEX: 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, age 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 place severe, potentially disabling stress on families. The distracters identify normal milestones in a family’s development.

DIF: Cognitive level: Analyzing REF: pp. 109-110

TOP: Nursing process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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