ch13.doc

[Osborn] chapter 13

Learning Outcomes [Number and Title] Learning Outcome 1 Discuss conceptual foundations that inform psychosocial nursing.Learning Outcome 2 Define the characteristics of a therapeutic nurse–patient relationship.Learning Outcome 3 Utilize culturally competent principles of therapeutic communication for

the care of patients and significant others.Learning Outcome 4 Apply the principles of teaching and learning to the care of patients and

significant others.Learning Outcome 5 Identify the dimensions of crisis and the nursing actions that promote

adaptive coping.Learning Outcome 6 Discuss the impact of illness and hospitalization on patients and

significant others.Learning Outcome 7 Compare and contrast the psychodynamics of anxiety, frustration, anger,

depression, and loss and grief.Learning Outcome8 Utilize the nursing process for patients experiencing loss and grief,

anxiety, depression, and anger.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for PracticeCopyright 2010 by Pearson Education, Inc.

1. A patient tells the nurse that she needs help bathing even though she independently walks in the room and accesses personal belongings without assistance. The nurse realizes this patient is demonstrating which of the following ego defense mechanisms?

1. Regression2. Projection3. Sublimation4. Compensation

Correct Answer: Regression

Rationale: Regression is a mechanism whereby a person returns to a time and level of less demanding functioning. The patient, who is independent, is asking for help with the basic care task of bathing. Projection occurs when individuals acknowledge their own shortcomings by blaming others or the environment for their behavior. Sublimation describes a person who avoids acting in an unacceptable way by substituting acceptable behavior. Compensation describes a person who overcomes a deficit by overachieving in a more comfortable area.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Psychosocial IntegrityLO: 1


2. The daughter of an ill patient tells the nurse that her father would not be so sick if she had spent more time with him over the years. The nurse realizes the daughter is exhibiting which of the following cognitive distortions?

1. Personalization2. Selective abstraction3. Overgeneralization4. Magnification

Correct Answer: Personalization

Rationale: Personalization is when external events are attributed to oneself without any evidence to support the causal relationship. The daughter believes that visiting her father would have prevented the illness. Selective abstraction is the conceptualization of a situation while ignoring contradictory information. Overgeneralization is taking specific information and generalizing it broadly to unrelated situations. Magnification is seeing something as far more important than it is.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Psychosocial Integrity LO: 1


3. A patient with a history of multiple childhood illnesses tells the nurse that she dislikes doctors and hospitals because “nothing good ever happens in a hospital.” The nurse’s understanding of cognitive concepts helps him realize this patient’s comment demonstrates:

1. A cognitive triad.2. Selective abstraction.3. Dichotomous thinking.4. Minimization.

Correct Answer: Cognitive triad.

Rationale: The cognitive triad is a group of three negative recurring patterns of thought that influence people to see themselves as inadequate, negatively misinterpret an experience, and view the future in a negative way. The patient had many childhood illnesses and may have experienced at an early age that hospitals and doctors mean illness, and therefore a bad experience. Selective abstraction occurs when a situation is conceptualized while ignoring contradictory information. In dichotomous thinking, experiences are categorized with all-or-nothing reasoning. Minimization is seeing something as far less important than it is.



4. A student nurse is having difficulty establishing relationships with patients. Which of the following should this student be counseled to do?

1. Develop self-awareness to focus on being helpful to patients.2. Study cognitive theory.3. Review the concepts of caring.4. Focus on the purpose of a therapeutic alliance.

Correct Answer: Develop self-awareness to focus on being helpful to patients.

Rationale: One aspect of the nurse−patient relationship is that of the nurse’s self-awareness. The nurse needs to be responsible to expand insight into her own personality. The theorist Peplau explains that a basic task of nursing education should be the development of each nurse as a person who wants to nurse patients in a helpful way. The nurse should be encouraged to develop a helpful nature to her personality. Cognitive theory does not assist with the development of the nurse−patient relationship. The concepts of caring might assist the nurse, but will not help with the nurse’s personality development. A therapeutic alliance is when the nurse and patient work together to reach mutually agreed-upon goals.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Psychosocial IntegrityLO: 2


5. While changing a patient’s abdominal dressing, the nurse talks about aspects of wound care, the need to check the skin, and the protection of the wound from infection or injury. The nurse and patient are currently in the _________ phase of the nurse−patient relationship.

1. Working2. Orientation3. Termination4. Caring

Correct Answer: Working

Rationale: The working phase of the nurse−patient relationship describes the participation of the patient and nurse in interventions to achieve mutually agreed-upon goals. Most patient education occurs during this phase. The orientation phase is the first phase of the relationship in which introductions occur and the trusting relationship begins to develop. The termination phase describes the time during which the nurse and patient review what has occurred during the working phase and the progress of goal achievement. There is not a caring phase within the nurse−patient relationship.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Psychosocial IntegrityLO: 2


6. A patient tells the nurse that he is “happy to see” her because she “helps me and gets me what I need” when the other nurses do not. The nurse realizes the patient is describing the interpersonal competence theme of:

1. Going the extra mile.2. Translating.3. Getting to know you.4. Establishing trust.

Correct Answer: Going the extra mile.

Rationale: The patient is comparing the current nurse with others who do not “get him what he needs.” This is a description of the nurse “going the extra mile.” Translating describes the nurse being able to understand what a patient is describing or needing. In the “getting to know you” phase, the nurse takes the time to communicate with patients in an effort to understand their needs and goals. Trust is established when the nurse portrays nonjudgmental behavior and accepts the patient as a unique individual.

Cognitive Level: AnalyzingNursing Process: EvaluationClient Need: Psychosocial IntegrityLO: 2


7. Prior to assessing a patient from a different culture, which of the following should the nurse do to ensure cultural competence?

1. Review the patient’s culture to ensure cultural awareness.2. Find another nurse who knows the patient’s native language.3. Conduct the assessment as any other assessment would be done.4. Leave the assessment to be done by another nurse.

Correct Answer: Review the patient’s culture to ensure cultural awareness.

Rationale: To provide the best care for the patient, the nurse should review information about the patient’s culture to ensure awareness. As nurses enter into therapeutic relationships, they do so with persons of diverse beliefs and values. These beliefs and values are born from cultural and subcultural socialization. Nurses are expected to be culturally sensitive and competent, continually striving to provide culturally appropriate care to patients and families. The nurse should not seek another nurse to do the assessment or negate the fact that the patient is from another culture. The nurse should not leave the assessment for another nurse to complete.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Psychosocial IntegrityLO: 3


8. While conducting an assessment, the nurse asks the patient to explain more about the type of pain she is experiencing. The nurse is utilizing which of the following therapeutic communication techniques?

1. Exploring2. Focusing3. Accepting4. Offering self

Correct Answer: Exploring

Rationale: The nurse uses the exploring technique to delve deeper into a subject, as when the nurse asks the patient to explain more about the type of pain. Focusing is a technique that helps when a patient moves quickly between topics. Accepting is when the nurse conveys an attitude of reception and regard that is characterized by head nodding and eye contact. Offering self describes the nurse making herself available to the patient by either sitting or staying with the patient.



9. A patient tells the nurse that he thinks he has cancer because every other male family member was diagnosed with cancer at the same age. The nurse tells the patient that “everything will be all right.” the nurse’s response exemplifies the nontherapeutic technique of:

1. Giving reassurance.2. Agreeing.3. Giving advice.4. Probing.

Correct Answer: Giving reassurance

Rationale: The nurse provided the nontherapeutic technique of giving reassurance, which indicates to the patient that there is no cause for anxiety, and devalues the patient’s feelings. It would have been better for the nurse to ask the patient to “discuss that a bit further.” The nurse is not agreeing with the patient’s idea, is not giving the patient advice, nor is the nurse probing for more information.



10. The nurse is planning to instruct a patient on the anatomy of the heart so that he will understand what type of surgery he needs. The best teaching strategy for the nurse to use would be:

1. Discussion with printed materials.2. Role modeling.3. Demonstration.4. Self-discovery.

Correct Answer: Discussion with printed materials.

Rationale: The patient is in need of cognitive knowledge about the anatomy of the heart. The teaching strategy that supports cognitive learning is discussion with printed materials. Role modeling is a strategy for affective learning. Demonstration and self-discovery are strategies to support psychomotor learning.

Cognitive Level: ApplyingNursing Process: LearningClient Need: Psychosocial IntegrityLO: 4


11. A patient tells the nurse that he will not learn how to give himself insulin injections because he gave his father insulin injections and “he died anyway.” To facilitate this patient’s learning, the nurse’s best action would be to:

1. Talk with the patient about his father’s illness and how the insulin injections will help him control his own illness.

2. Ask the patient if he prefers to read about how to provide the injections.3. Leave a needleless syringe at the patient’s bedside for him to practice with.4. Provide a diagram of body areas where insulin injections should be given.

Correct Answer: Talk with the patient about his father’s illness and how the insulin injections will help him control his own illness.

Rationale: The nurse should talk with the patient about his father’s illness and how the injections will help with the control of his own illness. The patient has experience with providing injections but has an attitude or belief about insulin and the role it plays in diabetes management. The patient needs affective learning, or learning that involves changing an attitude, value, or feeling. The nurse should not ignore the patient’s statement by asking if he prefers written instructions on how to provide injections. Leaving a needleless syringe at the bedside for the patient to practice or providing a diagram of body areas where insulin injections should be given would not support the patient’s need for affective learning.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Psychosocial IntegrityLO: 4


12. The nurse has instructed a patient on the home use of a machine to treat sleep apnea. Which of the following would indicate that the patient understands the instructions?

1. Patient demonstrates the use of the machine and the application of the mask.2. Patient points to the instructions.3. Patient says, “I know how to do it.”4. Patient looks to her husband and says, “Do you have any questions?”

Correct Answer: Patient demonstrates the use of the machine and the application of the mask.

Rationale: The nurse is attempting to evaluate the success of instruction. The best way for the nurse to assess the patient’s learning is to have the patient demonstrate the use of the machine and the application of the mask. Pointing to the instructions does not ensure learning of the process or materials. Stating, “I know how to do it” may or may not be sufficient to assess that learning has taken place. Asking her husband if he has any questions would indicate that the patient is not clear on the use of the equipment.

Cognitive Level: AnalyzingNursing Process: EvaluationClient Need: Psychosocial IntegrityLO: 4


13. A patient undergoing chemotherapy tells the nurse that his wife lost her job and now they do not have any health insurance. The patient has no way of paying for the treatments and tells the nurse that he is going home to die. Which of the following can the nurse do to help with this patient’s crisis?

1. Ask the patient if the wife has been offered a continuation of health care benefits from her previous employer that would cover the costs of chemotherapy.

2. Find out if the chemotherapy can be billed at a later time, once the wife has other employment.3. Contact the health care provider and document that the patient is unable to pay for ongoing

treatment.4. Suggest that the patient visit an emergency room for care because they cannot deny him

treatment.

Correct Answer: Ask the patient if the wife has been offered a continuation of health care benefits from her previous employer that would cover the costs of chemotherapy.

Rationale: The problem of lack of health insurance has initiated a crisis for the patient. Since the problem is already identified, the nurse and patient can move quickly into developing an initial plan of care that, in this case, would be for the patient to find out if his wife has been offered continuation of health care benefits from the previous employer. Postbilling for the chemotherapy is not an option. The nurse should not contact the health care provider and document that the patient is unable to pay for ongoing treatment. It would be inappropriate for the nurse to suggest that the patient go to an emergency room for care.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Psychosocial IntegrityLO: 5


14. The daughter of a patient tells the nurse that her mother was sitting at the kitchen table and then went totally limp and was disoriented. Currently, the daughter is pacing in the emergency room cubicle and continues to try to arouse her mother. Which of the following should the nurse do?

1. Explain to the daughter that her mother is in the best place to figure out what has happened to cause her to become disoriented.

2. Ask the daughter to have a seat in the waiting room until the doctor has finished examining her mother.

3. Encourage the daughter to return home to wait for information.4. Tell the daughter that being obviously stressed out will not help her mother.

Correct Answer: Explain to the daughter that her mother is in the best place to figure out what has happened to cause her to become disoriented.

Rationale: The daughter is reacting to the sudden change in her mother’s health status. The daughter’s reaction to the event is creating a crisis. The nurse needs to explain to the daughter that the mother is in the best possible place to determine the cause for the change in her health status. The nurse should not ask the daughter to leave her mother by going to the waiting room or returning home. The nurse should also not threaten the daughter by stating that being stressed out will not help her mother.



15. After being hit by an automobile, a patient tells the nurse that he lay on the pavement until the ambulance arrived and was thinking about how his wife would continue to survive without him. Which of the following is the best action by the nurse to help this patient with the crisis?

1. Offer to contact his wife to explain where he is and what his condition is.2. Provide the patient with a telephone so he can contact his wife.3. Tell the patient that once his injuries are stabilized, someone will contact his wife.4. Suggest that the patient should not worry about anything.

Correct Answer: Offer to contact his wife to explain where he is and what his condition is.

Rationale: The patient was a victim of a pedestrian-automobile accident and is concerned about his wife. At the onset of a crisis, the nurse might have to intervene and do some things for the patient that, under different circumstances, the patient could do for himself. While the nurse could provide the patient with a phone for him to call his wife, he may not be in a condition to make the call, and will not be able to provide factual answers to the wife about his condition. The nurse should not make the patient wait to contact his wife by telling him that once he is stabilized, someone will call her. Telling the patient not to worry is dismissive of his concerns.



16. A patient tells the nurse that he is sick and will do whatever he is told to do. The nurse realizes this patient is demonstrating:

1. Sick role behavior.2. Internal locus of control.3. Crisis response.4. Denial.

Correct Answer: Sick role behavior.

Rationale: When individuals become ill and must be hospitalized, they are expected to behave in certain ways and assume a sick role. A sick role is a set of expectations that people who are ill should meet and that society, including caregivers, expects of them. When a person enters the hospital, that person is immediately oriented to hospital rules, regulations, policies, and procedures. It is expected that patients and their families will adhere to these rules. The patient is expected to be cooperative, dependent, and nondemanding. Internal locus of control is the perception that people have control over events that happen in their lives. This patient is not demonstrating denial or a response to a crisis.



17. A male patient, newly diagnosed with prostate cancer, tells the nurse that his wife died a few weeks ago and he does not know how he is going to deal with this new health problem. Which of the following can the nurse do to help this patient?

1. Talk with the patient about his support systems and what he can do to maintain stability.2. Suggest that the patient talk with a spiritual counselor.3. Listen quietly while the patient talks.4. Tell the patient that it seems overwhelming now, but everything is going to work out all right.

Correct Answer: Talk with the patient about his support systems and what he can do to maintain stability.

Rationale: The best approach would be for the nurse to talk with the patient about his support systems and what he can do to maintain autonomy and stability. The patient is experiencing two losses: the loss of his wife and the perceived loss of his health. The patient is still working through the stages of grief and mourning for his wife when he is confronted with a new crisis. Suggesting that the patient talk with a spiritual counselor may or not be appropriate, but it does not immediately address the patient’s concerns. The nurse needs to do more than listen quietly while the patient talks. The nurse should not minimize the patient’s losses by saying that although it is overwhelming now; everything is going to work out all right. The nurse has no way of knowing if this will occur.



18. The wife of a patient tells the nurse that she realizes that her husband’s cancer is in remission but she can’t stop thinking about when he will eventually die and that she can’t seem to be motivated to do anything anymore. The nurse realizes the wife is demonstrating which of the following stages of grief and mourning?

1. Depression2. Denial3. Anger4. Acceptance

Cognitive Level: Depression

Rationale: The patient’s wife has accepted the patient’s diagnosis and inevitable outcome but is having difficulty continuing with life, which is demonstrative of depression. Denial is not accepting the diagnosis and outcome. Anger is asking “why me” and voicing hostility over the diagnosis and outcome. Acceptance is peacefully accepting the inevitable outcome.



19. A patient who is waiting for a diagnostic test tells the nurse that she is nervous because this test has been “on her mind” for weeks. The nurse realizes that the result of this patient’s ongoing anxiety can lead to:

1. Wear and tear on the body.2. Improved decision-making ability.3. A variety of coping skills.4. Nausea, headache, and dizziness.

Correct Answer: Wear and tear on the body.

Rationale: The patient has been experiencing anxiety for several weeks. The anxiety can become chronic, which leads to dangerous wear and tear on the body. Improved decision-making ability is seen in mild anxiety. A variety of coping skills is also seen in mild anxiety. Nausea, headache, and dizziness are symptoms of severe anxiety.



20. A patient tells the nurse that “she is worthless” and to send in someone “who knows what they are doing.” Which of the following should the nurse do in this situation?

1. Realize the patient is anxious and attempt to calm the patient and find out what the patient needs.2. Tell the patient that there is no one else available and he has to work with her today.3. Leave the room and find someone else to work with the patient.4. Tell the patient that he is not the easiest person in the world to work with, either.

Correct Answer: Realize the patient is anxious and attempt to calm the patient and find out what the patient needs.

Rationale: This patient’s anger should be conceptualized as anxiety. Once the nurse realizes the patient is anxious, she can attempt to calm the patient and find out what the patient needs. The nurse should not respond with feelings of anger or anxiety. Telling the patient there is no one else available, leaving the room, or scolding the patient are not approaches that address the patient’s underlying anxiety.



21. A patient is found sitting on the side of the bed crying and repeating “I can’t take one more thing.” The nurse realizes this patient is most likely demonstrating:

1. Depression.2. Anxiety.3. Frustration.4. Anger.

Correct Answer: Depression.

Rationale: The crying patient is demonstrating depression. Depression is a predictable response to illness and hospitalization and often accompanies loss and grief. Anxiety is an uncomfortable feeling of discomfort, dread, apprehension, and unease; crying is not usually seen with anxiety. Frustration is an emotion that is often seen with anxiety and accompanies the feeling of helplessness and powerlessness. Anger develops as a response to the feelings of powerlessness and helplessness and helps the person feel more in control.



22. A patient who is waiting to go for a diagnostic test that will determine the presence of cancer tells the nurse that she is having difficulty breathing and feels like her heart is pounding out of her chest. To best help this patient, the nurse should:

1. Stay with the patient and provide emotional support.2. Darken the room and let the patient rest quietly alone.3. Encourage the patient to walk around in the room.4. Offer the patient a light snack to eat.

Correct Answer: Stay with the patient and provide emotional support.

Rationale: The patient is demonstrating a panic level of anxiety. In this situation, the nurse should not leave the patient but should provide emotional support. Leaving the patient alone in a darkened room, or encouraging the patient to ambulate or eat, does not provide supportive care to the patient.



23. A patient tells the nurse that he has been having trouble sleeping and it has gotten worse over the last several weeks. The nurse realizes sleep deprivation is most closely associated with which of the following behavioral responses?

1. Anxiety2. Frustration3. Anger4. Loss

Correct Answer: Anxiety

Rationale: Nursing diagnoses for the patient with anxiety include Sleep Deprivation. Sleep deprivation is not typically associated with frustration, anger, or loss.



24. A patient tells the nurse that she has been losing weight and has no appetite or energy to do anything. The nurse believes this patient is demonstrating signs of which of the following behavioral health problems?

1. Depression2. Anxiety3. Frustration4. Anger

Correct Answer: Depression

Rationale: Physical changes seen in depression include weight loss, loss of appetite, and low energy levels. Weight loss, appetite change, and low energy and not typically associated with anxiety, frustration, and anger.



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