Chapter 3

Question 1

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

Answer 1

ANS: A
These negative behaviors are typical of a child around the age of 2 years whose developmental task is to develop autonomy. The incorrect options indicate the child’s behavior is abnormal.

Question 2

2. A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, “No!” when given directions. Using Freud’s stages of psychosexual development, a nurse would assess the child’s behavior is based on which stage?
   a. Oral
   b. Anal
   c. Phallic
   d. Genital

Answer 2

ANS: B
In Freud’s stages of psychosexual development, 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 13 and 20 years.

Question 3

3. A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, “No!” when given direction. The nurse’s counseling with the parent should be based on the premise that the child is engaged in which of Erikson’s psychosocial crises?
   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 is related 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, and Industry versus Inferiority is the crisis of the 6- to 12-year-old child.

Question 4

4. A 4-year-old child grabs toys from siblings, saying, “I want that toy now!” The siblings cry, and the child’s parent becomes upset with the behavior. Using the Freudian theory, a nurse can interpret the child’s behavior as a product of impulses originating in the:
   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 behavior and weighs the consequences of the action, perhaps determining that taking the toy is not worth the parent’s wrath. The superego would oppose the impulsive behavior as “not nice.” The preconscious is a level of awareness.

Question 5

5. The parent of a 4-year-old rewards and praises the child for helping a younger sibling, being polite, and using good manners. A nurse supports the use of praise because, according to the Freudian theory, these qualities will likely be internalized and become part of the child’s:
   a. id.
   b. ego.
   c. superego.
   d. preconscious.

Answer 5

ANS: C
In the Freudian theory, the superego contains the “thou shalts” or moral standards internalized from interactions with significant others. Praise fosters internalization of desirable behaviors. 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 easily retrieved with conscious effort.

Question 6

6. A nurse supports parental praise of a child who is behaving in a helpful way. When the individual behaves with politeness and helpfulness in adulthood, which feeling will most likely result?
   a. Guilt
   b. Anxiety
   c. Loneliness
   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. The other options are incorrect; each represents a negative feeling.

Question 7

7. A patient comments, “I never know the right answer” and “My opinion is not important.” Using Erikson’s theory, which psychosocial crisis did the patient have difficulty resolving?
   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 is not being successfully met. 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

8. Which patient statement would lead a nurse to suspect that the developmental task of infancy was not successfully completed?
   a. “I have very warm and close friendships.”
   b. “I’m afraid to let anyone really get to know me.”
   c. “I am always right and confident about my decisions.”
   d. “I’m ashamed that I didn’t do it correctly in the first place.”

Answer 8

ANS: B
According to Erikson, the developmental task of infancy is the development of trust. The patient’s statement that he or she is afraid of becoming acquainted with others clearly shows a lack of ability to trust other people. Having warm and close friendships suggests the developmental task of infancy was successfully completed. Believing one is always right suggests rigidity rather than mistrust. Feelings of shame suggest failure to resolve the crisis of Initiative versus Guilt.

Question 9

9. A nurse assesses that a patient is suspicious and frequently manipulates others. Using the Freudian theory, these traits are related to which psychosexual stage?
   a. Oral
   b. Anal
   c. Phallic
   d. Genital

Answer 9

ANS: A
According to Freud, each of the behaviors mentioned develops 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, and a strong sense of personal identity.

Question 10

10. An adult expresses the wish to be taken care of and often behaves in a helpless fashion. This adult has needs related to which of Freud’s stages of psychosexual development?
    a. Latency
    b. Phallic
    c. Anal
    d. Oral

Answer 10

ANS: D
According to Freud, fixation at the oral stage sometimes produces dependent infantile behaviors in adults. Latency fixations often result in a 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.

Question 11

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. I don’t have time to help others.” These comments contrast which developmental tasks?
    a. Trust versus Mistrust
    b. Industry versus Inferiority
    c. Intimacy versus Isolation
    d. Generativity versus 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. The developmental crisis of Trust versus Mistrust would show a contrast between relating to others in a trusting fashion and being suspicious and lacking trust. Failure to negotiate the developmental crisis of Industry versus Inferiority would result in a sense of inferiority or difficulty learning and working as opposed to the ability to work competently. Behaviors that would be contrasted in the crisis of Intimacy versus Isolation would be emotional isolation and the ability to love and commit to oneself.

Question 12

12. Cognitive therapy was provided for a patient who frequently said, “I’m stupid.” Which statement by the patient indicates the therapy was effective?
    a. “I’m disappointed in my lack of ability.”
    b. “I always fail when I try new things.”
    c. “Things always go wrong for me.”
    d. “Sometimes I do stupid things.”

Answer 12

ANS: D
“I’m stupid” is a cognitive distortion or irrational thought. A more rational thought is, “Sometimes I do stupid things.” The latter thinking promotes emotional self-control. The incorrect options reflect irrational thinking.

Question 13

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

Answer 13

ANS: A
Sullivan believed that the nurse’s role includes educating patients and assisting them in developing effective interpersonal relationships. Mutuality, respect for the patient, unconditional acceptance, and empathy are cornerstones of Sullivan’s theory. 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 third response pertains to Maslow’s theory. The fourth response pertains to behavioral theory.

Question 14

14. A psychiatric technician says, “Little of what takes place on the behavioral health unit seems to be theory based.” A nurse educates the technician by identifying which common use of Sullivan’s theory?
    a. Structure of the therapeutic milieu of most behavioral health units
    b. Frequent use of restraint and seclusion for behavior modification
    c. Assessment tools based on age-appropriate versus arrested behaviors
    d. Use of the nursing process to determine the best sequence for nursing actions

Answer 14

ANS: A
The structure of the therapeutic environment has, as its foci, an accepting atmosphere and provision of opportunities for practicing interpersonal skills. Both constructs are directly attributable to Sullivan’s theory of interpersonal relationships. Sullivan’s interpersonal theory did not specifically consider the use of restraint or seclusion. Assessment based on the developmental level is associated with Erikson’s theories. The nursing process applies concepts from multiple theories.

Question 15

15. A nurse uses Maslow’s hierarchy of needs to plan care for a psychotic patient. Which problem will receive priority? The patient:
    a. refuses to eat or bathe.
    b. reports feelings of alienation from family.
    c. is reluctant to participate in unit social activities.
    d. needs to be taught about medication action and side effects.

Answer 15

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

Question 16

16. Operant conditioning will be used to encourage speech in a child who is nearly mute. Which technique would a nurse include in the treatment plan?
    a. Ignore the child for using silence.
    b. Have the child observe others talking.
    c. Give the child a small treat for speaking.
    d. Teach the child relaxation techniques, then coax speech.

Answer 16

ANS: C
Operant conditioning involves giving positive reinforcement for a desired behavior. Treats are rewards to reinforce speech. Ignoring the child will not change the behavior. Having the child observe others describes modeling. Teaching relaxation techniques and then coaxing speech is an example of systematic desensitization.

Question 17

17. The parent of a child diagnosed with schizophrenia tearfully asks a nurse, “What could I have done differently to prevent this illness?” Select the nurse’s most caring response.
    a. “Although schizophrenia is caused by impaired family relationships, try not to feel guilty. No one can predict how a child will respond to parental guidance.”
    b. “Most of the damage is done, but there is still hope. Changing your parenting style can help your child learn to cope more effectively with the environment.”
    c. “Schizophrenia is a biological illness with similarities to diabetes and heart disease. You are not to blame for your child’s illness.”
    d. “Most mental illnesses result from genetic inheritance. Your genes are more at fault than your parenting.”

Answer 17

ANS: C
Patients and families need reassurance that the major mental disorders are biological in origin and are not the “fault” of parents. Knowing the biological nature of the disorder relieves feelings of guilt over being responsible for the illness. The incorrect responses are neither wholly accurate nor reassuring; they fall short of being reassuring and place the burden of having faulty genes on the shoulders of the parents.

Question 18

18. A nurse uses Peplau’s interpersonal therapy while working with an anxious, withdrawn patient. Interventions should focus on:
    a. changing the patient’s perceptions about self.
    b. improving the patient’s interactional skills.
    c. using medications to relieve anxiety.
    d. reinforcing specific behaviors.

Answer 18

ANS: B
The nurse-patient relationship is structured to provide a model for adaptive interpersonal relationships that can be generalized to others. Changing the patient’s perceptions about his- or herself would be appropriate for cognitive therapy. Reinforcing specific behaviors would be used in behavioral therapy. Using medications is the focus of biological therapy.

Question 19

19. A patient underwent psychotherapy weekly for 3 years. The therapist used free association, dream analysis, and facilitated transference to help the patient understand unconscious processes and foster personality changes. Which type of therapy was used?
    a. Short-term dynamic psychotherapy
    b. Transactional analysis
    c. Cognitive therapy
    d. Psychoanalysis

Answer 19

ANS: D
The therapy described is traditional psychoanalysis. Short-term dynamic psychotherapy would last less than 1 year. Neither transactional analysis nor cognitive therapy makes use of the techniques described.

Question 20

20. An advanced practice nurse determines a group of patients would benefit from therapy in which peers and interdisciplinary staff all have a voice in determining the level of the patients’ privileges. The nurse would arrange for:
    a. milieu therapy
    b. cognitive therapy
    c. short-term dynamic therapy
    d. systematic desensitization

Answer 20

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 other therapies are all individual therapies that do not fit the description.

Question 21

21. A nurse psychotherapist works with an anxious, dependent patient. The therapeutic strategy most consistent with the framework of psychoanalytic psychotherapy is:
    a. emphasizing medication compliance.
    b. identifying the patient’s strengths and assets.
    c. offering psychoeducational materials and groups.
    d. focusing on feelings developed by the patient toward the nurse.
    .

Answer 21

ANS: D
Positive or negative feelings of the patient toward the nurse or therapist represent transference. Transference is a psychoanalytic concept that can be used to explore previously unresolved conflicts. Emphasizing medication compliance is more related to biological therapy. Identifying patient strengths and assets would be consistent with supportive psychotherapy. The use of psychoeducational materials is a common “homework” assignment used in cognitive therapy

Question 22

22. A person tells a nurse, “I was the only survivor in a small plane crash, but three business associates died. I got anxious and depressed and saw a counselor three times a week for a month. We talked about my feelings related to being a survivor, and now I’m fine, back to my old self.” Which type of therapy was used?
    a. Milieu therapy
    b. Psychoanalysis
    c. Behavior modification
    d. Interpersonal therapy

Answer 22

ANS: D
Interpersonal therapy returns the patient to the former level of functioning by helping the patient come to terms with the loss of friends and guilt over being a survivor. Milieu therapy refers to environmental therapy. Psychoanalysis calls for a long period of exploration of unconscious material. Behavior modification focuses on changing a behavior rather than helping the patient understand what is going on in his or her life.

Question 23

23. A cognitive strategy a nurse could use to assist a very dependent patient would be to help the patient:
    a. reveal dream content.
    b. take prescribed medications.
    c. examine thoughts about being autonomous.
    d. role model ways to ask for help from others.

Answer 23

ANS: C
Cognitive theory suggests that one’s thought processes are the basis of emotions and behavior. Changing faulty learning makes the development of new adaptive behaviors possible. Revealing dream content would be used in psychoanalytical therapy. Taking prescribed medications is an intervention associated with biological therapy. A dependent patient needs to develop independence.

Question 24

24. A single parent is experiencing feelings of inadequacy related to work and family since one teenaged child ran away several weeks ago. The parent seeks the help of a therapist specializing in cognitive therapy. The psychotherapist who uses cognitive therapy will treat the patient by:
    a. discussing ego states.
    b. focusing on unconscious mental processes.
    c. negatively reinforcing an undesirable behavior.
    d. helping the patient identify and change faulty thinking.

Answer 24

ANS: D
Cognitive therapy emphasizes the importance of changing erroneous ways people think about themselves. Once faulty thinking changes, the individual’s behavior changes. Focusing on unconscious mental processes is a psychoanalytic approach. Negatively reinforcing undesirable behaviors is behavior modification, and discussing ego states relates to transactional analysis.

Question 25

25. A person received an invitation to be in the wedding of a friend who lives across the country. The individual is afraid of flying. What type of therapy should the nurse recommend?
    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 behavior, such as the fear of flying. Psychoanalysis and short-term dynamic therapy are aimed at uncovering conflicts. Milieu therapy involves environmental factors.

Question 26

26. A basic level registered nurse works with patients in a community setting. Which groups should this nurse expect to lead? Select all that apply.
    a. Symptom management
    b. Medication education
    c. Family therapy
    d. Psychotherapy
    e. Self-care

Answer 26

ANS: A, B, E
Symptom management, medication education, and self-care groups represent psychoeducation, a service provided by the basic level registered nurse. Advanced practice registered nurses provide family therapy and psychotherapy.

Question 27

2. A patient states, “I’m starting cognitive behavioral therapy. What can I expect from the sessions?” Which responses by the nurse are appropriate? Select all that apply.
   a. “The therapist will be active and questioning.”
   b. “You may be given homework assignments.”
   c. “The therapist will ask you to describe your dreams.”
   d. “The therapist will help you look at ideas and beliefs you have about yourself.”
   e. “The goal is to increase your subjectivity about thoughts that govern your behavior.”

Answer 27

ANS: A, B, D
Cognitive therapists are active rather than passive during therapy sessions because they help patients to reality test their thinking. Homework assignments are given and completed outside the therapy sessions. Homework is usually discussed at the next therapy session. The goals of cognitive therapy are to assist the patient to identify inaccurate cognitions, to reality test their thinking, and to formulate new, accurate cognitions. Dream describing applies to psychoanalysis, not cognitive behavioral therapy. The desired outcome of cognitive therapy is to assist patients in increasing their objectivity, not subjectivity, about the cognitions that influence behavior.