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CHAPTER 2CONCEPTS OF PSYCHIATRIC CARE: THERAPEUTIC MODELS
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.
|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.
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.
According to psychoanalytic theory, the personality is almost completely formed by 5 years of age.
|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.
|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.
The development of orally focused habits such as smoking and nail-biting are associated with fixation at the oral stage of development in Freuds theories of the stages of psychosexual growth and development.
|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.
|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.
|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.
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.
|a.||make certain the client suffers some appropriate consequences for this action|
|b.||report this clients 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 clients age-appropriate behavior.
|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.
|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.
|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.
|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.
|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.
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 ones self down, and searching.
|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.
|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.
|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.
|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 Bowlbys attachment theory and has spurred a plethora of clinical and scholarly contributions that transformed researchers and clinicians perceptions of early child-parent interactions.
|a.||angelic and demonic||c.||good boy and bad boy|
|b.||respondent and operant||d.||past oriented and future oriented|
|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.
|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.
A fixed-ratio schedule is used in industry when a workers 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.
|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.
|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.||Lets 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.
|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.
|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 Parkinsons disease and depression, it is believed that the dopamine systems are hypoactive and, therefore, medications in those conditions increase dopamine availability to the body.
|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.
|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.
|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.
|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.
|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.
|a.||level of mental health||c.||spiritual dimension|
|b.||interactions with others||d.||ability to care for self|
Orems model is a self-care model. Clients are assessed in terms of their self-care agencies. Nursing interventions are planned to maximize the clients ability to care for self. Specific nursing actions include actions to provide assistance to clients unable to meet their health-related self-care needs.
|a.||is learned||c.||is unconscious|
|b.||has meaning||d.||is sexually oriented|
According to Freud, everything a person does has meaning.
|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.
|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.
|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 ones self, self-care agency.
|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.
|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.
|b.||eating disorders||d.||personality disorders|
Alterations in the serotonerginic system function along with NE have been implicated in the pathogenesis of depressive syndrome.
|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.
Resilience is the capacity to recover or adjust to stressful or life-threatening situations.
|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.
|a.||Im having a difficult time concentrating on my course work.|
|b.||All of my teachers think Im hopeless because I did poorly on the last exam.|
|c.||School is going well. I received an A on the last exam.|
|d.||Id like to apply for graduate school when I complete the undergraduate program.|
|e.||My classmates dont want to study with me.|
|f.||Im going to try my best in school this semester.|
ANS: A, B, E
Cognitive distortions are characterized by statements
|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.
CHAPTER 20THE CLIENT EXHIBITING AGGRESSION, HOSTILITY, AND VIOLENCE
|b.||female nurses||d.||male nurses and doctors|
According to Fernandez, male nurses and doctors are at the greatest risk for physical assault. Receptionists are at lowest risk.
|a.||anxiety disorders||c.||personality disorders|
|b.||psychotic disorders||d.||substance abuse disorders|
Aggressive and violent behaviors are more common in clients experiencing psychotic disorders. These individuals are out of touch with reality and may be responding to auditory hallucinations. Clients who are paranoid may have delusions that others are out to harm them, and they may respond to nursing staff based on the belief that they are protecting themselves.
|a.||biochemical theories||c.||psychodynamic theories|
|b.||social learning theories||d.||neuroendocrine theories|
Social learning theory views aggression as a learned response that is based on the assumption that role modeling, identification, and human interactions shape learning and behavior. Aggression is believed to be learned through observation and imitation.
|a.||frontal lobe||c.||occipital lobe|
|b.||temporal lobe||d.||parietal lobe|
Contemporary neurophysiologic studies suggest that the temporal lobes of the brain are linked to aggressive and violent behaviors. EEGs of the brains of violent criminals have revealed left hemispheric (temporal lobe) abnormalities.
|a.||is a recent occurrence|
|b.||has decreased in the past 10 years|
|c.||has long been minimized and neglected|
|d.||has been a major topic of research since the early 20th century|
The prevalence and nature of a clients aggression and violence in health care has long been minimized and neglected. Client aggression occurs more often than client violence with a substantial number of psychiatric nurses being threatened. Today, more concern is placed on client aggression and violence perhaps because of the serious morbidity for clients and staff.
|a.||The incidence of client aggression and violence is equal.|
|b.||Client aggression occurs more often than client violence.|
|c.||Client violence occurs more often than client aggression.|
|d.||Clients very seldom demonstrate aggression and violence.|
Client aggression occurs more often than client violence. Aggressive behaviors are those that are marked by combativeness readiness, driving forceful energy, or initiative. Violence is the act of kicking, spitting, beating, grabbing, choking, pushing, forcing sex, or using a weapon.
|a.||52% for physical assault and 57% for physical threat|
|b.||61% for physical assault and 79% for physical threat|
|c.||75% for physical assault and 80% for physical threat|
|d.||92% for physical assault and 97% for physical threat|
According to the study, respondents reported a 1-year prevalence rate of 92% for physical assault and a 97% for physical threat. Additionally, 66% of the respondents reported verbal abuse at least once per shift.
|a.||providing a safe environment for self, clients, and others|
|b.||administering a prescribed medication to address the clients behavior|
|c.||exploring with the client reasons for the hostility, aggression, or violence|
|d.||assisting the client to develop alternative methods for expressing feelings|
The priority nursing intervention with a client who is potentially hostile, aggressive, or violent is to provide a safe environment for client, self, and others. The other interventions are all important and will be initiated, but safety is always the priority.
|a.||Hostility will probably increase.|
|b.||Hostility will probably decrease.|
|c.||Hostility will remain unchanged.|
|d.||Hostility will progress to violence.|
Assessment of a client who is moving toward recovery and recognizes the hostility would most likely reveal that the hostility is decreased.
|a.||women are violent more often than men|
|b.||men are violent more often than women|
|c.||there is no gender difference in terms of violence|
|d.||women use more physical aggression than men|
The research suggests that there is no gender difference in terms of violence between men and women with psychiatric disorders. Most researchers suggest that there is an overlap in the expression of violence and in the factors that contribute to its emergence in men and women, specifically psychosis and behavioral disturbances.
The client is most likely experiencing agitation. Agitation is a state of increased mental and motor activity. Clients exhibiting agitated states are often verbally and physically threatening and can become abruptly violent.
|a.||Erik Erikson||c.||Sigmund Freud|
|b.||Dorothea Orem||d.||Abraham Maslow|
According to Freud, aggression is a basic drive (like thirst). From birth to death the person possesses two conflicting instincts. One instinct is a life instinct (eros) that encourages a person to grow and survive. The second instinct is a death instinct (thanatos) that drives the person to redirect the death instinct or self-destructiveness from self to others.
|a.||across all age groups|
|b.||most often with adolescents with juvenile records|
|c.||less often with elderly clients experiencing dementia|
|d.||most often with children who have developmental disorders|
Violent behavior can occur across all age groups. Research has documented acts of violence on pediatric units, adolescent units, adult units, and in geriatric settings.
|a.||anywhere||c.||in any outpatient clinic|
|b.||in the emergency room||d.||on the inpatient psychiatric unit|
Workplace violence can occur anywhere. Incidents have been documented on psychiatric units, emergency rooms, and basically any area of the hospital or clinic. Violence may be initiated by a client, family member, friend, or staff member.
|a.||ignore the client|
|b.||yell back at the client|
|c.||speak calmly and softly|
|d.||tell the client the behavior is childish|
If a client becomes angry and begins to use profane language in a very loud tone, the nurses best response is to speak calmly and softly to the client. Ignoring the client, yelling at the client, or telling the client his behavior is childish will only escalate the situation.
|a.||Take the weapon away from the client.|
|b.||Have security take the weapon away from the client.|
|c.||Ask the client to place the weapon on a desk or on the floor.|
|d.||Ignore the fact that the client has a weapon and continue to provide care.|
If you walk into an examination room and see a client with a weapon, you should ask the client to place the weapon on a desk or on the floor. You should never ignore the weapon. Neither you nor any other staff member should approach the client in an attempt to take the weapon.
|a.||provide a safe working environment|
|b.||screen any client seeking service from the facility|
|c.||install metal detectors at the entrance of the hospital|
|d.||hire twice the number of security guards to assure safety|
The major responsibility of an employer is to provide a safe working environment for the employees. This can be accomplished by providing security to escort staff to parking lots at night. Employers should also provide training to all staff on the proper procedures to use during situations of aggression, hostility, and violence.
|a.||loud noises||d.||helpful and pleasant staff|
|b.||long waiting periods||e.||poor environmental design|
|c.||ignoring a clients request||f.||speaking calmly and softly|
ANS: A, B, C, E
Research has shown that common causes of workplace violence include loud noises, long waiting periods, ignoring a clients request, poor environmental design, crowdedness, and access to firearms. Other contributing factors are inadequately or inappropriately trained security or staff and lack of administrative support for zero tolerance of violence in the workplace. Speaking calmly and softly to a client and staff who are helpful and pleasant may reduce the potential for violence.
ANS: A, B, D, E, F
Hostile clients may demonstrate rudeness, sarcasm, faultfinding, physical violence, or verbal threats. Hostile clients do not exhibit kindness.
|a.||Use common sense.|
|b.||Use active listening.|
|c.||Give suggestions, not orders.|
|d.||Be concerned about personal safety.|
|e.||Avoid using threatening body language.|
|f.||Remain calm and convey being in control.|
ANS: A, B, C, D, E, F
All of the above are correct interventions to implement in an attempt to de-escalate a potentially violent situation.
|b.||visiting hours||e.||client transport|
|c.||bathing hours||f.||during change of shifts|
ANS: A, C, E
Data from several studies exploring risk for violence in inpatient psychiatric facilities have found violence occurred during high activity and interaction with clients such as mealtimes, client transport, and bathing hours. During periods of visiting hours, nursing reports, or change of shifts there is less interaction between staff members and clients and a reduced possibility of violence.
|a.||It is a response to a threat.|
|b.||It never results in violence.|
|c.||It is always an inappropriate act.|
|d.||It is a response to invasion of privacy.|
|e.||It demonstrates a basic character flaw.|
|f.||It is an atte
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