Chapter 03: Relevant Theories and Therapies for Nursing Practice

Question 1

A parent says, “My 2-year-old child refuses toilet training and shouts “No!” when given directions. What do you think is wrong?” Select the nurse’s best reply.

a. “Your child needs firmer control. It is important to set limits now.”
b. “This is normal for your child’s age. The child is striving for independence.”
c. “There may be developmental problems. Most children are toilet trained by age 2.”
d. “Some undesirable attitudes are developing. A child psychologist can help you develop a plan.”

Answer 1

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

Question 2

A 26-month-old displays negative behaviour, refuses toilet training, and often says, “No!” Which stage of psychosexual development is evident?

a. Oral
b. Anal
c. Phallic
d. Genital

Answer 2

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

Question 3

A 26-month-old displays negative behaviour, refuses toilet training, and often says, “No!” Which psychosocial crisis is evident?

a. Trust versus mistrust
b. Initiative versus guilt
c. Industry versus inferiority
d. Autonomy versus shame and doubt

Answer 3

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

Question 4

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

a. Id
b. Ego
c. Superego
d. Preconscious

Answer 4

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

Question 5

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

a. Id
b. Ego
c. Superego
d. Preconscious

Answer 5

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

Question 6

A nurse supports a parent for praising a child behaving in a helpful way. When this child behaves with politeness and helpfulness in adulthood, which feeling will most likely result?

a. Guilt
b. Anxiety
c. Humility
d. Self-esteem

Answer 6

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

Question 7

An adult says, “I never know the answers,” and “My opinion doesn’t count.” Which psychosocial crisis was unsuccessfully resolved for this adult?

a. Initiative versus guilt
b. Trust versus mistrust
c. Autonomy versus shame and doubt
d. Generativity versus self-absorption

Answer 7

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

Question 8

Which patient statement would lead the nurse to suspect unsuccessful completion of the developmental task of infancy?

a. “I have very warm and close friendships.”
b. “I’m afraid to allow anyone to really get to know me.”
c. “I’m always absolutely right, so don’t bother saying more.”
d. “I’m ashamed that I didn’t do things correctly in the first place.”

Answer 8

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

Question 9

A patient is suspicious and frequently manipulates others. To which psychosexual stage do these traits relate?

a. Oral
b. Anal
c. Phallic
d. Genital

Answer 9

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

Question 10

Which stage of psychosexual development is most relevant to the patient that expresses a desire to be cared for by others and often behaves in a helpless fashion?

a. Latency
b. Phallic
c. Anal
d. Oral

Answer 10

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

Question 11

A nurse listens to a group of recent retirees. One says, “I volunteer with Meals on Wheels, coach teen sports, and do church visitation.” Another laughs and says, “I’m too busy taking care of myself to volunteer to help others.” Which developmental task do these statements contrast?

a. Trust and mistrust
b. Intimacy and isolation
c. Industry and inferiority
d. Generativity and self-absorption

Answer 11

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

Question 12

Although ego defence mechanisms and security operations are mainly unconscious and designed to relieve anxiety, the major difference is which of the following?

a. Defence mechanisms are intrapsychic and not observable.
b. Defence mechanisms cause arrested personal development.
c. Security operations are masterminded by the id and superego.
d. Security operations address interpersonal relationship activities.

Answer 12

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

Question 13

A student nurse says, “I don’t need to interact with my patients. I learn what I need to know by observation.” An instructor can best interpret the nursing implications of Sullivan’s theory to this student by responding with which of the following?

a. “Interactions are required in order to help you develop therapeutic communication skills.”
b. “Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills.”
c. “Observing patient interactions will help you formulate priority nursing diagnoses and appropriate interventions.”
d. “It is important to pay attention to patients’ behavioural changes because these signify adjustments in personality.”

Answer 13

ANS: B
The nurse’s role includes educating patients and assisting them in developing effective interpersonal relationships. Mutuality, respect for the patient, unconditional acceptance, and empathy are cornerstones of Sullivan’s theory. The nurse who does not interact with the patient cannot demonstrate these cornerstones. Observations provide only objective data. Priority nursing diagnoses usually cannot be accurately established without subjective data from the patient. The other distracters relate to Maslow and behavioural theory. This item relates to an audience response question.

Question 14

A nurse consistently encourages a patient to do his or her own activities of daily living (ADLs). If the patient is unable to complete an activity, the nurse helps until the patient is once again independent. This nurse’s practice is most influenced by which theorist?

a. Betty Neuman
b. Patricia Benner
c. Dorothea Orem
d. Joyce Travelbee

Answer 14

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

Question 15

A nurse uses Maslow’s hierarchy of needs to plan care for a patient with mental illness. Which problem will receive priority?

a. The patient refuses to eat or bathe.
b. The patient reports feelings of alienation from family.
c. The patient is reluctant to participate in unit social activities.
d. The patient is unaware of medication action and adverse effects.

Answer 15

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

Question 16

Operant conditioning is part of the treatment plan to encourage speech in a child who is nearly mute. Which technique applies?

a. Encourage the child to observe others talking.
b. Include the child in small group activities.
c. Give the child a small treat for speaking.
d. Teach the child relaxation techniques.

Answer 16

ANS: C
Operant conditioning involves giving positive reinforcement for a desired behaviour. Treats are rewards and reinforce speech through positive reinforcement.

Question 17

The parent of a child diagnosed with schizophrenia tearfully asks the nurse, “What could I have done differently to prevent this illness?” Select the nurse’s best response.

a. “Although schizophrenia results from impaired family relationships, try not to feel guilty. No one can predict how a child will respond to parental guidance.”
b. “Schizophrenia is a biological illness resulting from changes in how the brain and nervous system function. You are not to blame for your child’s illness.”
c. “There is still hope. Changing your parenting style can help your child learn to cope effectively with the environment.”
d. “Most mental illnesses result from genetic inheritance. Your genes are more at fault than your parenting.”

Answer 17

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

Question 18

A nurse influenced by Peplau’s interpersonal theory works with an anxious, withdrawn patient. Interventions should focus on which of the following?

a. Rewarding desired behaviours
b. Use of own capacities
c. Changing the patient’s self-concept
d. Administering medications to relieve anxiety

Answer 18

ANS: B
The nurse–patient relationship is structured to provide a model for adaptive interpersonal relationships that can be generalized to others. The theory centres on helping the patient learn to use his or her capacities to live more productively. The distracters apply to theories of cognitive, behavioural, and biological therapy.

Question 19

A patient had psychotherapy weekly for 5 months. The therapist used free association, dream analysis, and facilitated transference to help the patient understand conflicts and foster change. Select the term that applies to this method.

a. Rational-emotive behaviour therapy
b. Psychodynamic therapy
c. Cognitive-behavioural therapy
d. Operant conditioning

Answer 19

ANS: B

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

Question 20

Consider this comment from a therapist: “The patient is homosexual but has kept this preference secret. Severe anxiety and depression occur when the patient anticipates family reactions to this sexual orientation.” Which perspective is evident in the speaker?

a. Theory of interpersonal relationships
b. Classical conditioning theory
c. Psychosexual theory
d. Behaviourism theory

Answer 20

ANS: A
The theory of interpersonal relationships recognizes the anxiety and depression as that which arises from social insecurity or that prevents biological needs from being satisfied. Behaviourism and classical conditioning theories do not apply. A psychosexual formulation would focus on uncovering unconscious material that relates to the patient problem.

Question 21

A psychotherapist works with an anxious, dependent patient. Which strategy is most consistent with psychoanalytic psychotherapy?

a. Identifying the patient’s strengths and assets
b. Praising the patient for describing feelings of isolation
c. Focusing on feelings developed by the patient toward the therapist
d. Providing psychoeducation and emphasizing medication adherence

Answer 21

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

Question 22

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

a. Milieu therapy
b. Psychoanalysis
c. Behaviour modification
d. Interpersonal psychotherapy

Answer 22

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

Question 23

Which technique is most applicable to aversion therapy?

a. Punishment
b. Desensitization
c. Role modeling
d. Positive reinforcement

Answer 23

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

Question 24

A patient says to the nurse, “My father has been dead for over 10 years, but talking to you is almost as comforting as the talks he and I had when I was a child.” Which term applies to the patient’s comment?

a. Superego
b. Transference
c. Reality testing
d. Counter-transference

Answer 24

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

Question 25

A college student received an invitation to attend the wedding of a close friend who lives across the country. The student is afraid of flying. Which type of therapy would be most helpful for this patient?

a. Psychoanalysis
b. Milieu therapy
c. Systematic desensitization
d. Short-term dynamic therapy

Answer 25

ANS: C
Systematic desensitization is a type of therapy aimed at extinguishing a specific behaviour, such as those associated with a fear of flying. Psychoanalysis and short-term dynamic therapy seek to uncover conflicts. Milieu therapy involves environmental factors.

Question 26

Which approach would be best to provide therapy in which peers as well as staff have a voice in determining patients’ privileges and psychoeducational topics?

a. Milieu therapy
b. Cognitive therapy
c. Short-term dynamic therapy
d. Systematic desensitization

Answer 26

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

Question 27

A patient repeatedly stated, “I’m stupid.” Which statement by that patient would show progress resulting from cognitive behavioural therapy?

a. “Sometimes I do stupid things.”
b. “Things always go wrong for me.”
c. “I always fail when I try new things.”
d. “I’m disappointed in my lack of ability.”

Answer 27

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

Question 28

A patient says, “All my life I’ve been surrounded by stupidity. Everything I buy breaks because the entire American workforce is incompetent.” Which of the following is this patient experiencing?

a. A self-esteem deficit
b. A cognitive distortion
c. A deficit in motivation
d. A deficit in love and belonging

Answer 28

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

Question 29

A patient is fearful of riding on elevators. The therapist first rides an escalator with the patient. The therapist and patient then stand in an elevator with the door open for five minutes and later with the elevator door closed for five minutes. Which technique has the therapist used?

a. Classic psychoanalytic therapy
b. Systematic desensitization
c. Rational emotive therapy
d. Biofeedback

Answer 29

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

Question 30

A patient says, “I always feel good when I wear a size 2 petite.” Which type of cognitive distortion is evident?

a. Disqualifying the positive
b. Overgeneralization
c. Catastrophizing
d. Personalization

Answer 30

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

Question 31

Which comment best indicates a patient is self-actualized?

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

Answer 31

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

Question 32

A nurse and patient discuss a problem the patient has kept secret for many years. Afterward, the patient says, “I feel so relieved that I finally told somebody.” Which term best describes the patient’s feeling?

a. Catharsis
b. Superego
c. Cognitive distortion
d. Counter-transference

Answer 32

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

Question 33

Which patient is the best candidate for brief psychodynamic therapy?

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

Answer 33

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

Question 34

A patient states, “I’m starting cognitive-behavioural therapy. What can I expect from the sessions?” Which responses by the nurse would be appropriate? Select all that apply.

a. “The therapist will be active and questioning.”
b. “You will be given some homework assignments.”
c. “The therapist will ask you to describe your dreams.”
d. “The therapist will help you look at your ideas and beliefs about yourself.”
e. “The goal is to increase subjectivity about thoughts that govern your behaviour.”

Answer 34

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

Question 35

Which comments by an elderly person best indicate successful completion of the developmental task? Select all that apply.

a. “I am proud of my children’s successes in life.”
b. “I should have given to community charities more often.”
c. “My relationship with my father made life more difficult for me.”
d. “My experiences in the war helped me appreciate the meaning of life.”
e. “I often wonder what would have happened if I had chosen a different career.”

Answer 35

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

Question 36

Which comments by an adult best indicate self-actualization? Select all that apply.

a. “I am content with a good book.”
b. “I often wonder if I chose the right career.”
c. “Sometimes I think about how my parents would have handled problems.”
d. “It’s important for our country to provide basic health care services for everyone.”
e. “When I was lost at sea for 2 days, I gained an understanding of what is important.”

Answer 36

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

Question 37

Which activities represent the art of nursing? Select all that apply.

a. Administering medications on time to a group of patients
b. Listening to a new widow grieve her husband’s death
c. Helping a patient obtain groceries from a food bank
d. Teaching a patient about a new medication
e. Holding the hand of a frightened patient

Answer 37

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