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CHAPTER 2—CONCEPTS OF PSYCHIATRIC CARE: THERAPEUTIC MODELS
1. A psychoanalytically oriented colleague tells you that the behavior of a client you are assigned to work with is driven by a strong thanatos. This client is most likely exhibiting which of the following behaviors?
a. aggression c. social isolation
b. intrusiveness d. sexual behaviors
The psychoanalytic theory assumes that humans have two primary drives or forces: eros, or the drive toward life, and thanatos, which is the drive toward death. Thanatos is expressed as aggression or hate.
2. A client is informed by his family that they could not go on vacation because the cost of his mental health care prevented the family from having enough money for a vacation. Which of the following responses by the client would be the best example of the superego at work?
a. refusing further care c. getting angry at the family
b. having feelings of guilt d. ignoring this statement
The superego is the conscience that rewards moral behavior and punishes actions that are not acceptable by creating guilt. An overly strict superego may lead to extremes of guilt and anxiety.
3. A client is thinking about suing the hospital and the doctor, even though he begins to admit to the nurse that his failure to comply with the treatment regimen may have caused his problems. He begins to share that he feels guilty about these thoughts of suing although he believes the hospital and doctor will settle out of court and he needs the money. The nurse understands that according to psychoanalytic theory, two parts of the client’s personality or two drives are warring. What drive or part of the client’s mind will mediate if the client is to come to a healthy decision?
a. id c. libido
b. ego d. superego
The superego is the part of the client that is feeling guilty. It is the conscience. The id is the aggressive and sexual drive, which operates on the pleasure principle to reduce tension. The ego mediates between the drives, forces, or conflicts of the id and the superego.
4. The mother of a teenager asks the nurse at what age a child’s personality is completely formed. A nurse applying psychoanalytic theory to this question would answer that the personality is almost completely formed by what age?
a. 5 c. 18
b. 8 d. 21
According to psychoanalytic theory, the personality is almost completely formed by 5 years of age.
5. The nurse is working with a young adult client who has been in an automobile accident and is fully conscious but seems to have little recall of the event. The client’s spouse asks the nurse why the client is not able to recall the event. The best answer by the nurse would be that the client is:
a. in a state of denial c. repressing details of the event
b. suffering from a concussion d. suppressing details of the event
Repression is an unconscious process whereby unwanted, unacceptable, and/or painful memories are filed in the unconscious part of the mind. Repression is the first line of defense against such memories.
6. You determine that one of your assigned clients is using defense mechanisms, some of which are sublimation and projection. You realize that these defense mechanisms, sublimation and projection, are allowing the client to:
a. use other people in a way that is not healthy for them or for the client
b. postpone dealing with problems in an unhealthy way for a long period of time
c. keep unpleasant thoughts in the preconscious mind instead of the conscious mind
d. discharge some of the energy needed to keep unwanted thoughts out of awareness
It takes energy to keep unwanted thoughts out of the conscious mind. Energy cannot be contained indefinitely. Some defense mechanisms such as reaction formation, projection, and sublimation allow for the energy to be discharged.
7. The nurse assesses an adult client who admits to being a nail-biter when the nurse observes extreme shortness and unevenness of the client’s nails. The nurse recalls that people who bite their nails are said to be fixated at which of the following stages in Freud’s stages of psychosexual growth and development?
a. oral c. genital
b. latency d. prepuberty
The development of orally focused habits such as smoking and nail-biting are associated with fixation at the oral stage of development in Freud’s theories of the stages of psychosexual growth and development.
8. The nursing instructor advises students who are learning how to communicate with clients with mental health problems not to ask questions beginning with “Why did you…” for which of the following reasons?
a. It is an approach of authority.
b. It hurts the trusting relationship.
c. Often a person cannot identify unconscious motivation.
d. The question makes the person feel like a child being parented.
Often the person cannot identify the motivation for his behavior because it is unconscious. There are more acceptable techniques to foster communication.
9. When you are working with a client who is very anxious and is using a defense mechanism, which of the following approaches would be best?
a. Advise the client to stop using the defense mechanism.
b. Discuss the defense mechanism and whether it is helpful or not.
c. Help the client identify some ways to reduce anxiety before other interventions.
d. Have the client weigh the advantages and disadvantages of the defense mechanism.
Anxiety needs to be reduced before the defenses can be disengaged. Do not take away defense mechanisms until there are other ways to deal with anxiety.
10. One of your colleagues is basing his work with clients on the theories of Erikson. When explaining personality development, your colleague would say that personality is:
a. almost totally inherited
b. developed over the life span
c. completely developed by age 5
d. a result of experiences before age 18
Erik Erikson identified 8 stages of psychosocial development and believed that personality development continues over the life span.
11. Erikson saw the major task of life as:
a. trust c. reproduction
b. identity d. self-actualization
According to Erik Erikson, the task of identity is seen as the major task of life. All previous tasks are fundamental to self-discovery, and all adult tasks are predicated on comfortable resolution of identity.
12. A young adult on the psychiatric ward asks a nurse for a date. Although the nurse realizes this is inappropriate and declines, the nurse will also:
a. make certain the client suffers some appropriate consequences for this action
b. report this client’s behavior to the administrator and refuse to work with the client
c. tell the client that this behavior is inappropriate with a professional nurse
d. recognize age-appropriate behavior and advise the client of the professional nature of the relationship
The young adult is seeking a life mate and dealing with the task of intimacy versus isolation. Although it is inappropriate for the nurse in a professional relationship to develop an intimate relationship, the nurse needs to recognize the client’s age-appropriate behavior.
13. A client is discussing some insights gained in therapy in the past and mentions archetypes of anima and animus. The nurse listening to this client realizes that this client received therapy based on the theories of:
a. Albert Ellis c. Carl Jung
b. Eric Berne d. Sigmund Freud
Carl Jung discovered repeated common images he called archetypes. Two of the most popular were those of the anima, or feminine archetype in men, and the animus, the masculine archetype in women.
14. Closely following the beliefs of Harry Stack Sullivan, a psychiatric nurse working with clients would look closely at what Sullivan referred to as the persona, which is best described as the:
a. unconscious c. dark side
b. “I” or “me” d. best friend
The persona is what one is talking about when referring to “I” or “me.” It could also be called self-concept and begins developing in infancy with the idea of “good me” and “bad me.”
15. The main focus of Sullivan’s work was on:
a. insight through gestalt c. interpersonal relationships
b. learned helplessness d. identifying a purpose in life
Harry Stack Sullivan focused on interpersonal relationships. He looked at the development of the self-system, which he called personification. Personification includes all related attitudes, feelings, and concepts about self and another.
16. You are assigned to work with a client who describes a life of feeling isolated and helpless with many fears about dangers in the world. The client frequently demonstrates aggressive behavior or is verbally aggressive. Using Horney’s theories, you would view this aggressive behavior as:
a. a failure to develop a healthy personality
b. incongruent with feeling helpless and isolated
c. a means to protect what little security they have
d. stemming from experiences with an aggressive mother
Karen Horney believed that insecure, anxious children develop personality patterns to help them cope with feelings of isolation and helplessness. They may become aggressive as a means of protecting what little security they have.
17. Applying interpersonal theories in the nurse-client relationship, the most important goal for the nurse and client to set for therapy sessions would be for the client to:
a. identify the causes of failed relationships in the past
b. gain insight into how early relationships shape behavior
c. deal with repressed anger against self and against significant others in his life
d. verbalize a realistic and hopeful perspective of self in relationships with others
In the nurse-client relationship where interpersonal theories are utilized, the client learns to separate past learning from present and to gain a realistic and hopeful perspective of self in relationships with others and society.
18. The nurse is caring for a young child in the hospital. As the child’s visiting parent prepares to leave, the child appears anxious and begins to cry and cling to the parent. Using Bowlby’s stages of separation anxiety to explain the child’s behavior, the child can be said to be in a stage called:
a. anxiety c. despair
b. protest d. detachment
John Bowlby described separation anxiety as a predictable process involving the stages of protest, despair, and detachment. Examples of protest behaviors include increasing anxiety, crying, clinging, throwing one’s self down, and searching.
19. A couple is concerned about the amount of time they must spend away from their infant. Looking at the findings of Bowlby in his work on attachment, you would most help the clients by setting and meeting which one of the following goals?
a. Improve the quality of time and interactions.
b. Leave the child when the child is distracted.
c. Decrease the period of time between separations.
d. Increase the amount of overall time with the child.
John Bowlby found that the amount of time spent with early caregivers is less significant than the quality of time and interactions between the child and caregivers. The nurse should focus on helping the clients to learn to use behaviors that reinforce the child-parent attachment.
20. When a child is in the final stages of separation anxiety as described by Bowlby and the primary caregiver returns to the child, the nurse should most likely expect the child to exhibit which of the following behaviors?
a. acting very excited c. clinging to caregiver
b. engaging in a tantrum d. withdrawing from caregiver
The final stage of separation anxiety is detachment in which the child appears listless, apathetic, and socially isolates and withdraws from the caregiver even when the caregiver returns.
21. When the primary caregivers of a hospitalized infant cannot stay in the hospital with the infant, which of the following diagnoses would the nurse most likely include in the care plan?
a. caregiver role strain
b. interrupted family processes
c. risk for impaired parent-infant attachment
d. ineffective therapeutic regimen management
An infant who is hospitalized and left alone by primary caregivers is likely to be at risk of developing attachment disturbances.
22. The systematic study of infant-caregiver attachment behaviors using the Strange Situation protocol was the work of which of the following persons?
a. Mary Ainsworth c. Karen Horney
b. John Bowlby d. Bruno Bettelheim
Mary Ainsworth systematically studied infant-caregiver attachments by means of the Strange Situation protocol. This protocol has provided an empirical template for delineating and measuring John Bowlby’s attachment theory and has spurred a plethora of clinical and scholarly contributions that transformed researchers and clinicians’ perceptions of early child-parent interactions.
23. In his theories, Skinner identified two types of behavior which he referred to as:
a. angelic and demonic c. good boy and bad boy
b. respondent and operant d. past oriented and future oriented
B. F. Skinner identified respondent behavior as occurring when a known and specific stimulus elicits a response and operant behaviors as those that obtain a response or reinforcement from another person or the environment.
24. A client comes to the psychiatric nurse for help with social situations. The client is not comfortable meeting with others. The nurse utilizes the theories of Bandura and Walters. Which of the following interventions by the nurse would most reflect application of Bandura and Walter’s theories and techniques?
a. Ask the client to do the opposite of the expected or desired behavior.
b. Use a gradually increasing schedule of social contact to desensitize the client.
c. Verbally reinforce the client for any attempt to increase socialization behavior.
d. Have the client study a person who is successful at socializing and imitate them.
Albert Bandura and Richard Walters placed emphasis on the role of modeling in learning behaviors. The model can be a person, film, or cartoon. A person can take on new social behaviors quickly when imitating a role model.
25. When working with clients diagnosed with schizophrenia who have been hospitalized several times in the last year after failing to fill their prescriptions, the nurse applies the self-efficacy model. What is the nurse’s primary goal in this case?
a. Making certain a staff member supervises the clients’ taking the medication.
b. Reminding the clients daily through a phone call that the medication is due.
c. Finding a source that will pay for, pick up, and deliver the medication to the clients.
d. Convincing the clients they have the capacity to find a way to get the prescriptions filled.
The primary goal of self-efficacy is to encourage or persuade the clients that they have the capacity to make adaptive behavioral changes in an identified problem area.
26. When trying to reinforce a behavior using behavior modification techniques, the most effective schedule of reinforcement is:
a. fixed-ratio c. fixed-interval
b. variable-ratio d. variable-interval
A fixed-ratio schedule is used in industry when a worker’s pay depends upon the number of units produced or sold. For interval schedules, the reward is based upon the passage of time and not on the amount of behavior change.
27. Beck is best known for his theories about which of the following:
a. behavior modification c. cognitive patterns
b. interpersonal theories d. childhood development
Aaron Beck is one of the best known proponents of cognitive psychology because of his writings on cognitive distortions or thinking errors.
28. You are working with a client who is upset because he believes one of his college classmates does not like him. If you were to apply the theories of Ellis, you would most likely respond:
a. “Describe the feelings that you have toward this classmate.”
b. “Tell me what you have done to cause this classmate not to like you.”
c. “Let’s examine this irrational thought that everyone should like you.”
d. “This is really something that is wrong with her and not with you at all.”
Albert Ellis developed what he referred to as rational emotive therapy. He believed that irrational thoughts cause maladaptive behavior and emotional distress. He identified the thinking that everyone should like you as an irrational thought.
29. When working with the mother of a young child who is in the later part of Piaget’s sensorimotor stage of development, you would teach the mother to do which of the following things to help the child move out of this stage?
a. play classical music frequently
b. play peek-a-boo and hide and seek
c. read the same book to the child every day
d. reward the child for attempts to use the potty
In the first stage or sensorimotor stage of development from birth to about 2 years of age, the young child appears to think that only objects that can be seen are those that exist. As the child grows in experience, the child develops object permanence. Peek-a-boo and hide-and-seek prepare the child for realizing that things and people are still there even when they cannot be seen.
30. When you administer the atypical antipsychotic agents ordered by the psychiatrist to a client who has schizophrenia, you realize that this medication is most likely to do which of the following things?
a. increase the activity of dopamine
b. decrease the activity of dopamine
c. increase the reuptake of serotonin
d. have no effect on dopamine activity
In schizophrenia and mania, there is hyperactivity of dopaminergic systems that must be tempered or reduced. In Parkinson’s disease and depression, it is believed that the dopamine systems are hypoactive and, therefore, medications in those conditions increase dopamine availability to the body.
31. When giving antipsychotic medication and atypical antipsychotics to clients with a diagnosis of schizophrenia, because of the effect of the medication on a specific neurotransmitter, you would most need to be frequently assessing these clients for:
a. weight loss c. ringing in the ears
b. nausea and vomiting d. fine motor tremors
Dopamine is primarily responsible for fine motor movement, sensory integration, and emotional behavior. These medications reduce dopamine so the client is apt to lose some of the fine motor movement and demonstrate tremors.
32. A client who is experiencing low levels of GABA or fewer GABA receptors is most vulnerable to which of the following disorders?
a. panic disorder c. conversion disorder
b. bipolar disorder d. antisocial personality disorder
A person with low levels of GABA or fewer GABA receptors is more vulnerable to anxiety disorders or panic symptoms/disorders.
33. The latest and most popular theory of mental disorders is that the cause is most likely:
a. a combination of factors
b. genetically and chemically based
c. structural differences in the brain
d. a result of disturbed interpersonal interactions
At the current time, researchers believe that mental disorders are most likely caused by a variety of factors. Some of the factors include structural differences in the brain and disturbed interpersonal interactions. Additionally, genetic propensity and chemical imbalance can be causative factors.
34. You are working with a client who has been playing tennis and has developed tendonitis. Which of the following remarks by the client would indicate function in an integrated way as identified by the theories of Dunn?
a. “What other sport would be less injurious?”
b. “I will use heat on my elbow after playing tennis.”
c. “I will avoid activity and rest my elbow until it is healed.”
d. “An elbow brace will be a help in preventing further damage.”
Integrating involves using energy efficiently, such as taking measures to conserve energy so the physical resources needed to reduce swelling and pain are accessible.
35. Your client has shared a primary appraisal of a wedding he attended. Based on how he describes his experiences at the wedding, the appraisal could fall into any one of the three types of primary appraisal described by Lazarus. Which of the following statements by the client would place it into the benign positive type of appraisal?
a. “It was all right I guess.”
b. “It was very tastefully done.”
c. “I felt real happy even if I felt guilty not taking a present.”
d. “It was a challenge to get there on time, but I did manage it.”
Benign appraisals are events with a genuinely positive appraisal. These events generate feelings of pleasure, joy, and happiness, but the feelings may also be accompanied by guilt or anxiety.
36. When working with clients using Orem’s nursing theories, you would be most interested in helping the clients to maximize their:
a. level of mental health c. spiritual dimension
b. interactions with others d. ability to care for self
Orem’s model is a self-care model. Clients are assessed in terms of their self-care agencies. Nursing interventions are planned to maximize the client’s ability to care for self. Specific nursing actions include actions to provide assistance to client’s unable to meet their health-related self-care needs.
37. A basic assumption of Freud’s psychoanalytic theory is that all behavior:
a. is learned c. is unconscious
b. has meaning d. is sexually oriented
According to Freud, everything a person does has meaning.
38. A nurse who follows the therapeutic approach of Rogers, would most likely be using an approach focused on:
a. reality therapy c. client-centered therapy
b. directive therapy d. psychoanalytic therapy
Carl Rogers focused primarily on empathy, warmth, and genuineness in relating. His form of therapy was coined “client-centered therapy.”
39. A common form of treatment on psychiatric inpatient units which focuses on the patient’s environment is known as:
a. milieu therapy c. encounter therapy
b. reality therapy d. client-centered therapy
Milieu therapy is the treatment modality that uses the total physical and social environment to provide psychosocial rehabilitation. The term is sometimes used interchangeably with therapeutic milieu.
40. You are caring for a group of mental health patients, and you base your nursing practice on the belief that your clients should play a major role in their own self-care. These practices stem from the work of:
a. Martha Rogers c. Dorothea Orem
b. Hildegard Peplau d. Ida Jean Orlando
According to Dorothea Orem, people have the ability to perform self-care activities they initiate and perform independently to maintain life, health, and well-being. She coined the term describing the ability to care for one’s self, self-care agency.
41. Dialectical behavior therapy (DBT) was introduced by:
a. B. F. Skinner c. Albert Bandura
b. Sigmund Freud d. Marsha Linehan
In 1987, Marsha Linehan introduced dialectical behavior therapy (DBT). This form of therapy is used to challenge distorted cognitions or schematas that produce enormous anxiety and stress in clients with borderline personality disorder.
42. One of your clients constantly complains of feeling nervous even though his medicines have been administered as prescribed. The doctor orders one sugar tablet between doses of regularly scheduled medications. After taking the sugar tablet, the client states “That pill really worked. I feel much better now.” This is known as the:
a. halo effect c. placebo effect
b. Skinner effect d. behavioral effect
The placebo effect is an attitude of optimistic concern and belief in the efficacy of an intervention. It is one of the best reinforcements nurses can use.
43. Alterations in the seretonergic system or serotonin (5-hydroglyryptamine, 5HT) function along with NE have been implicated in the pathogenesis of:
a. schizophrenia c. depressive syndrome
b. eating disorders d. personality disorders
Alterations in the serotonerginic system function along with NE have been implicated in the pathogenesis of depressive syndrome.
44. The nurse providing care to an alcoholic client administers Antabuse. The administration of Antabuse would be considered which form of behavioral therapy?
a. classic conditioning c. medical conditioning
b. operant conditioning d. cognitive conditioning
Operant conditioning includes use of aversion techniques. One form of aversion therapy includes the use of Antabuse for the treatment of alcohol. Clients who ingest alcohol while on Antabuse will experience several very uncomfortable symptoms.
45. A nurse researcher is conducting a study to determine his client’s capacity to recover or adjust to stressful or life-threatening situations. This ability is known as:
a. coping c. adaptability
b. resilience d. self-efficacy
Resilience is the capacity to recover or adjust to stressful or life-threatening situations.
1. Which of the following are essential features of DBT? Select all that apply.
a. daily individual psychotherapy
b. weekly skills training
c. encouraging and coaching via telephone
d. consultation with client
e. short-term inpatient hospitalization
f. electroconvulsive therapy (ECT)
ANS: B, C
Dialectical Behavior Therapy (DBT) has five essential features which include weekly individual psychotherapy, weekly skills training group, encouragement and coaching via telephone interactions between sessions, consultation with the client, and the development of a treatment environment by the DBT directors and case managers. ECT is not an essential feature of DBT.
2. When interviewing a client, which of the following statements would indicate that the client has distorted cognition? Select all that apply.
a. “I’m having a difficult time concentrating on my course work.”
b. “All of my teachers think I’m hopeless because I did poorly on the last exam.”
c. “School is going well. I received an A on the last exam.”
d. “I’d like to apply for graduate school when I complete the undergraduate program.”
e. “My classmates don’t want to study with me.”
f. “I’m going to try my best in school this semester.”
ANS: A, B, E
Cognitive distortions are characterized by statements
3. A nurse caring for a 9-year-old client would plan care based on the knowledge that according to Sullivan’s theory, clients between the ages of 8 and 11 are in the concrete operational stage. Because of this information, the nurse’s assessment would most likely reveal a client who can do which of the following? Select all that apply.
a. Think scientifically
b. Attained reversibility
c. Demonstrate mature cognitive structures
d. Solve complex verbal problems
e. Solve conservation problems
f. Demonstrate egocentric thought and language
ANS: B, E
Children in the concrete operational stage can solve conservation problems and reversibility is retained. Egocentric thought and language are characteristic of the preoperational period (2 to 7 years). It is not until the stage of formal operations period (11 years to adulthood) that the cognitive structures are mature and the individual is able to think scientifically and solve complex verbal problems.