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Chapter 1. The Nurse Psychotherapist and a Framework for Practice - TB

Terms in this set (29)

The nurses new job description at the generalist level of practice reflects the definition of psychiatricmental
health nursing and the PsychiatricMental Health Nursing Standards of Practice (ANA, APNA, ISPN). In which of the following areas might the nurse plan programs and intervention to fulfill employment expectations?

Select all that apply:
1. Stress management strategies
2. Early diagnosis of psychiatric disorders
3. Parenting classes for new parents
4. Family and group psychotherapy
5. Medication teaching for anti-anxiety medications
Correct Answer: 1,3,4,5

Rationale 1: Stress management strategies address health, wellness, and care of mental health problems and
are appropriate for psychiatricmental health nursing at the generalist level of practice.

Rationale 2: Early diagnosis of psychiatric disorders is generally not consistent with the definition or
practice of psychiatricmental health nursing especially at the generalist level.

Rationale 3: Parenting classes for new parents provide teaching that is consistent with the prevention of
mental health problems and is consistent with psychiatricmental health nursing at the generalist level of
practice.

Rationale 4: Family and group psychotherapy is consistent at the advanced practice registered nurse level but
not the generalist level.

Rationale 5: Medication teaching for anti-anxiety medications promotes quality of care for persons with
psychiatric disorders and is vital for psychiatricmental health nursing practice at the generalist level of practice.
The nurse is serving on a committee charged with reviewing the roles and responsibilities of the nurses on the psychiatric unit. Which publication should the nurse bring to the first meeting?

1. Diagnostic and Statistical Manual of Mental Disorders
2. American Nurses Credentialing Center certification requirements
3. American Nurses Association, Code of Ethics
4. PsychiatricMental Health Nursing Standards of Practice
Correct Answer: 4

Rationale 4: The PsychiatricMental Health Nursing Standards of Practice delineates psychiatricmental health
nursing roles and functions and serves as guidelines for providing quality care. The Diagnostic and Statistical
Manual of Mental Disorders is used by the mental health care team, particularly the psychiatrist, to diagnose clients with mental disorders and is not specific to nursing care issues. The Code of Ethics helps to clarify right and wrong actions by the nurse, but does not clarify roles and nursing care actions. Certification requirements outline steps toward certification that acknowledge knowledge and expertise, but do not delineate roles and responsibilities.
The psychiatricmental health nurse reflecting on professional role activities is referred to the standards of professional performance by a colleague. To which organization should the nurse look for guidance?

1. North American Nursing Diagnosis Association
2. American Nurses Credentialing Center
3. National League for Nursing
4. American Nurses Association
Correct Answer: 4

Rationale 4: The American Nurses Association will be the best resource as professional performance is
addressed in standards 715 of ANAs PsychiatricMental Health Nursing Standards of Practice. The National
League for Nursing primarily addresses nursing education, while the American Nurses Association Credentialing Center focuses on certification. The North American Nursing Diagnosis Association develops a classification system for nursing diagnoses.
The psychiatricmental health nurse is working with the new graduate nurse who is orienting to the psychiatric unit. Which comment by the new graduate indicates further clarification of the generalist-nursing role is
needed?

1. I would feel better if you would look at my documentation that addresses progress toward treatment goals.
2. I will spend time each day evaluating the effectiveness of the therapeutic milieu.
3. I am a little nervous about conducting psychotherapy with clients.
4. I am doing some reading on how to incorporate complementary interventions into treatment plans.
Correct Answer: 3

Rationale 3: The intent to conduct psychotherapy with clients is not consistent with the role of the nurse at the generalist level of practice as outlined in the PsychiatricMental Health Nursing Standards of Practice and
indicates a need for role clarification. Evaluation of the therapeutic milieu, documenting progress toward
treatment goals, and incorporating complementary interventions are consistent with the roles of the
psychiatricmental health nurse practicing at the generalist level.
The client on the psychiatric unit is asking questions about prevention of sexually transmitted diseases. Given the PsychiatricMental Health Nursing Standards of Practice, which action would be most appropriate for the nurse to take at this time?

1. Consult with the mental health care team.
2. Teach safer sexual practices.
3. Investigate the questions in individual psychotherapy.
4. Notify the attending psychiatrist.
Correct Answer: 2

Rationale 2: The psychiatricmental health nurse employs strategies to promote health and a safe environment
and teaches safer sexual practices to the client who is asking for the information. Notifying the psychiatrist and consulting with the mental health care team is not necessary as health teaching is within the independent
practice of the RN. Conducting individual psychotherapy is not within the practice standards for the generalist
nurse.
The client asks the nurse if certain changes can be made in the unit milieu. Which action by the nurse indicates understanding of the nursing role in the therapeutic milieu?

1. The nurse refers the clients requests to the psychiatric social worker.
2. The nurse discusses the desired changes with the client.
3. The nurse refers the clients requests to the psychosocial rehabilitation worker.
4. The nurse instructs the client that no changes can be made.
Correct Answer: 2

Rationale 2: The psychiatricmental health nurse has major responsibility for the milieu; therefore, it is
appropriate to discuss requested changes in order to gather information regarding the effectiveness of the
milieu. The psychiatric social worker identifies community resources and may perform counseling. It is nontherapeutic
to instruct the client that no changes can be made before gathering data in relation to the clients requests. The psychosocial rehabilitation worker teaches day-to-day skills for living and may provide case management services.
The nurse assesses that the mental health client has problems choosing productive, safe leisure activities. Which member of the mental health team should the nurse consult with?

1. Recreational therapist
2. Occupational therapist
3. Attending psychiatrist
4. Clinical psychologist
Correct Answer: 1

Rationale 1: The recreational therapist plans and guides recreational activities to provide socialization, healthful recreation, and desirable interpersonal and intrapsychic experiences and will be the member of the healthcare team to take the lead in the implementation of this portion of the treatment plan. While all members of the team work together, the psychiatrist is responsible for the diagnosis and treatment of the mental illness. The occupational therapist teaches self-help activities and helps prepare the client for employment. The clinical psychologists foci are psychotherapy, behavior modification, and psychological testing.
Upon arrival on the psychiatric unit this morning, which activity should be the nurses focus? The nurse should do which of the following?

1. Review psychological testing results for all clients.
2. Schedule the individual therapy sessions for all clients.
3. Identify community resources for clients to be discharged this morning.
4. Assess each client for whom the nurse will be providing care.
Correct Answer: 4

Rationale 4: The nurse is responsible for implementing the nursing process and nursing care for clients. The psychiatric social worker has major responsibility for the identification of post-discharge community resources. The clinical psychologists primary foci are psychotherapy and psychological testing.
Due to a staff members absence, the nurse is reviewing staff assignments for the day. Which task can the nurse delegate to the psychosocial rehabilitation worker?

1. Conflict resolution teaching to a small group of clients
2. Comparison of physicians orders with the medication records
3. Routine medication administration to a stable client
4. Assessment of a long-term client
Correct Answer: 1

Rationale 1: The psychiatric rehabilitation worker teaches clients practical, day-to-day skills for living in the community, which might include conflict resolution. Medication administration, comparison of physician orders with medication records, and assessment fall within the nursing role and cannot be delegated.
The clients treatment plan includes teaching related to possible side effects of psychotropic medications. Which member of the mental health team should plan to implement the teaching?

1. The psychosocial rehabilitation worker
2. The primary therapist
3. The psychiatrist
4. The nurse
Correct Answer: 4

Rationale 4: The nurse is responsible for the nursing care of the client including medication administration and teaching. While the psychiatrist may also do some teaching, he/she is primarily responsible for the diagnosis and medication prescription. The primary therapist is most likely a clinical psychologist or psychiatric social worker who would not have the educational preparation or license consistent with medication teaching. The psychosocial rehabilitation worker is an unlicensed member of the team and would not have the role of
medication teaching.
The mental health team nurse is having some role issues regarding how best to facilitate client progress toward therapeutic goals. What is the priority action by the nurse in order to aid the team as they assist the client?

1. Acknowledge the diversity of the mental health team.
2. Recognize that conflict is natural and expected.
3. Determine personal values, biases, and goals.
4. Attend all mental health team meetings.
Correct Answer: 3

Rationale 3: The priority nursing action is to determine personal values, biases, and goals; these, especially if out of the awareness of the nurse, may be a factor in team dynamics. Acknowledging the diversity of the team, recognizing that conflict is natural, and attending all mental health team meetings are appropriate actions, but not the priority.
The nurse reflecting on the nursing role within the mental health team, understands that the main purpose of delivering care using a multidisciplinary team is to do which of the following?

1. Maximize the efficiency of the health care team with each team member learning from the others.
2. Increase the opportunity for interpersonal interaction among the client, family, and team members.
3. Facilitate the case management process by delivering care using a multidisciplinary health care team.
4. Make the best use of the different abilities of mental health team members in order to facilitate client progress.
Correct Answer: 4

Rationale 4: The purpose of partnering and collaborating with other disciplines is to make the best use of the different abilities of mental health team members in order to facilitate client progress toward therapeutic goals. While client-centered interpersonal interaction within a therapeutic relationship is a vital piece of the treatment plan, interpersonal interaction unto itself may not be the needed focus. Facilitating the case management process and maximizing efficiency of the health care team are not primary purposes of a team approach. All care must be focused on the clients and their needs.
Observation of the behavior of the mental health team seems to indicate that one team member is primarily interested in client progress as a measure of their knowledge and expertise. Given the nurses knowledge of game theories, this team member might be functioning as which of the following?

1. Rivalist
2. Leader
3. Enabler
4. Maximizer
Correct Answer: 4

Rationale 4: The maximizer is one who is primarily interested only in his or her own gain. A rivalist would be a person whose primary interest is defeating other team members. An enabler is one who facilitates the continuation of what are usually inappropriate behaviors in others and usually not associated with game theory. A leader would function more in the role of a cooperator, one who is interested in helping both themselves and their partners.
The nurse is planning activities to enhance collaboration within the mental health care team. Which activities will be helpful toward this goal?

Select all that apply.
1. Identification of ways to minimize diversity among team members
2. Discussion of decisions that require team unity
3. Identification of ways to ignore individual power bases
4. Review of interpersonal communication skills
5. Discussion of decisions that can be made autonomously
Correct Answer: 2,5

Rationale 2: Discussion of decisions that require team unity. Unity should be balanced with autonomy. Identification of parameters for nursing collaboration would be useful toward the goal.

Rationale 5: Discussion of decisions that can be made autonomously. Unity should be balanced with autonomy. Collaboration is not required for all decisions.
The nurse is admitting a client to the psychiatric unit. Which nursing action is correct?

1. Instruct the client that all information gathered during the assessment will be shared with the mental health
team.
2. Alert the client that the psychiatrist will do all the intake assessment to maximize the efficiency of the team.
3. Discuss with the client information that is to be shared with family members and the mental health team.
4. Instruct the client that the mental health team will decide what the client needs to do in treatment.
Correct Answer: 3

Rationale 3: Discussing with the client information that is to be shared with family members and the mental
health team is an action that promotes a partnership with the client and enhances effectiveness of treatment. The nurse should communicate to the client that decisions related to the sharing of information would take into
consideration any agreement regarding disclosure that exists between the nurse and the client and how the receiving party will use the information in the clients best interest. Not all information is significant to the clients reason for treatment. The nurse should communicate circumstances where significant information will be shared. In the spirit of collaboration, the mental health team should involve the client. This assures that clients are informed consumers of mental health services. While the psychiatrist will assess the client from the medical perspective, the nurse must assess the clients responses to the mental disorder in order to plan appropriate nursing care.
The correct response of the nurse who is asked if Florence Nightingale had any impact on the role of the nurse in psychiatricmental health nursing should be which of the following?

1. No, Nightingale focused her ideas on nursing education rather than direct client care.
2. Yes, Nightingale was among the first to note that the influence of nurses has psychological components.
3. No, Nightingale emphasized the physical environment for healing.
4. Yes, Nightingale developed the idea of the therapeutic relationship.
Correct Answer: 2

Rationale 2: Although it is true that in the context of her time Nightingale emphasized the physical environment, she did have an impact on psychiatricmental health nursing. Nightingale was among the first to
note that the influence of nurses on their clients goes beyond physical care and has psychological and social
components; hence, the value of making her famous evening rounds to say goodnight. Nightingale focused her
ideas on both direct client care and nursing education. Hildegard Peplau is credited with theory related to the
therapeutic nurseclient relationship.
The nurse planning a brief presentation about the first American psychiatric nurse will research which of the
following?

1. Hildegard Peplau
2. Harriet Bailey
3. Linda Richards
4. Gwen Tudor (Will)
Correct Answer: 3

Rationale 3: Linda Richards, the first American psychiatric nurse, opened the first American school for psychiatric nurses and spent a significant part of her career developing better nursing care in psychiatric hospitals. Hildegard Peplau developed the first systematic theoretic framework in psychiatric nursing. Harriet Bailey wrote the first psychiatric nursing text, Nursing Mental Diseases. Gwen Tudor (Will) was the first nurse to publish an article in the journal Psychiatry. While the last three nurses made significant contributions, the title of first American psychiatric nurse, falls to Linda Richards.
The nurse is reflecting on psychiatric nursing care in the 19th century. Which nursing diagnosis is most
consistent with the focus of psychiatric nursing care during the 19th century?

1. Ineffective individual coping
2. Self-care deficit
3. Anxiety
4. Altered thought processes
Correct Answer: 2

Rationale 2: During the 19th century, psychiatric nurses attended mainly to the physical needs of clients and
did not pursue systematic interpersonal work with them. Psychiatric nursing practice was primarily custodial. Nursing care that systematically addresses anxiety, coping, and altered-thought processes did not come about until the mid 20th century.
On which dimension would the nurse most likely focus data collection if the nurse was assessing the client from primarily a 19th century perspective?

1. Spiritual
2. Physical
3. Social
4. Emotional
Correct Answer: 2

Rationale 2: Up until the early to mid-20th century, psychiatric nurses attended primarily to the physical needs
of the clients and did not pursue interpersonal work with them. Psychiatric nursing care during this period emphasized a physical environment that would promote recovery. More holistic care (including emotionalsocial- spiritual dimensions) is a product of more recent history.
The nursing student is asked which historical event was most significant in the development of psychiatric nursing as a specialty and psychotherapeutic roles for nurses. Which response by the nursing student indicates understanding of important events related to development of the psychiatric nursing role?

1. Release of the report Nursing for the Future
2. Passage of the Community Mental Health Centers Act
3. Publication of Commonsense Psychiatry
4. Passage of the National Mental Health Act
Correct Answer: 4

Rationale 4: The National Mental Health Act of 1946 is probably the most significant piece of legislation
affecting the development of psychiatricmental health nursing. Within this act, psychiatric nursing was added to psychiatry, psychology, and social work as a field in which the highest priority became the preparation of
clinically capable persons for positions of leadership. Commonsense Psychiatry, written by Adolf Meyer, had great impact on psychiatry; however, it did not have a noticeable influence on psychiatric nursing. Nursing for the Future eliminated single-focus schools of psychiatric nursing. The Community Mental Health Centers Act of 1963 encouraged the closing of large mental hospitals and further encouraged the trend toward expanded nursing roles at the graduate level.
The nurse is writing a scholarly paper on early nursing leaders who made major contributions to the
development of the multifaceted psychiatric nursing role of today. The nurse should include which of the
following nurses when writing the paper?

Select all that apply.
1. Florence Nightingale
2. Frances Sleeper
3. Linda Richards
4. Gwen Tudor (Will)
5. Hildegard Peplau
Correct Answer: 4,5

Rationale 4: Gwen Tudor (Will). Designed a nursing intervention that demonstrated that nurses can promote
emotional growth in clients and that the psychotherapeutic nursing role can be taught to others.

Rationale 5: Hildegard Peplau. Published Interpersonal Relations in Nursing, the first systematic theoretic
framework in psychiatric nursing, a milestone in the development of the psychiatric nursing roles and practice.
The psychiatric-mental health nurse is planning a personal program of continuing education to better meet the challenges of the future in psychiatric nursing practice. What areas should be included in the nurses plan for continuing education?

Select all that apply.
1. Psychiatric nursing care in nontraditional settings
2. Psychopharmacology
3. Genetic research
4. Psychobiology
5. Physical health of psychiatric clients
Correct Answer: 1,2,3,4,5

Rationale 1: Psychiatric nursing care in nontraditional settings. Settings continue to expand from hospitals
and traditional settings to alternative and nontraditional settings.

Rationale 2: Psychopharmacology. Newer psychopharmacologic agents with fewer side effects continue to
grow.

Rationale 3: Genetic research resulted in significant knowledge related to the genetic basis of inherited mental
disorders that must be integrated into various areas of psychiatric nursing practice.

Rationale 4: Psychobiology. As there has been a knowledge explosion in psychobiology, the greatest challenge
for psychiatric nursing is the integration of psychobiologic knowledge into clinical practice while maintaining a
focus on caring.

Rationale 5: Physical health of psychiatric clients is a sometimes overlooked dimension of care especially among the severely and persistently mentally ill clients living in community settings is a new area of focus and challenge for psychiatric nurses.
While caring for the client with a mental illness, which action by the psychiatricmental health nurse best
indicates use of Hildegard Peplaus nursing theory?

1. Establishing a therapeutic nurse-client relationship
2. Intervening to enhance the clients abilities to perform self-care
3. Assessing clients interactions with their environment
4. Evaluating the effectiveness of the clients coping and adaptation skills
Correct Answer: 1

Rationale 1: Peplau conceptualized the one-to-one nurseclient relationship in which the client can accomplish
developmental tasks and practice healthy behaviors. Dorothea Orem identified the goal of self-care and focused on the clients abilities to perform self-care to maintain life, health, and well-being. Martha Rogers work gave psychiatric nurses a mandate to use holistic principles and to consider human beings and environmental
interactions. Sister Callista Roys adaptation theory related the notion of coping or adapting to stimuli as humans
interact with their environment.
If psychiatric nurses used Orems theory for structuring much of their nursing practice, a major focus area for assessment would be the clients ability to do which of the following?

1. Adapt and function to meet various role expectations.
2. Care about self and participate in self-healing.
3. Implement self-care to meet psychosocial needs.
4. Enter into a therapeutic one-to-one relationship with the nurse.
Correct Answer: 3

Rationale 3: Orems theory of self-care identifies universal self-care requisites and categories that encompass
both physical and psychosocial human needs. Orem focuses on abilities to perform self-care to maintain life,
health, and well-being. Peplau conceptualizes the one-to-one nurseclient relationship. Roys adaptation theory identifies modes of human adapting, including the area of role function. Watsons theory of human caring emphasizes self-caring and self-healing.
The psychiatricmental health nurse is asked to develop an intervention for the nursing unit based on Watsons theory of caring. Given this assignment, which intervention is most appropriate for the nurse to implement?

1. One-to-one debriefing sessions each week with individual unit nurses and the unit manager
2. Clarification of values and cultural beliefs that might pose barriers to caring for clients
3. Identification of additional coping skills for new nurses on the unit
4. Discussion of the impact of recent changes in hospital policy on the nursing staff
Correct Answer: 2

Rationale 2: Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding
personal and cultural beliefs that might pose barriers to transpersonal caring. Identification of coping skills for new nurses is consistent with Roys theory of adaptation. Discussion of the impact of change on the nursing staff is consistent with Rogerss theory that considers humans and environmental interactions and change. One-to-one debriefing sessions are more consistent with Peplaus theory; however, this intervention could be used in a variety of theoretical approaches.
The unit manager is consistently advocating for self-awareness among the psychiatricmental health nursing staff in order to promote quality care. From which theoretical base is the unit manager operating?

1. Jean Watsons theory of human caring
2. Dorothea Orems theory of self-care
3. Martha Rogerss principles of homeodynamics
4. Sister Callista Roys adaptation theory
Correct Answer: 1

Rationale 1: Jean Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding personal and cultural beliefs that might pose as barriers to transpersonal caring. Roys adaptation theory (coping and adapting to environmental stimuli), Rogerss principles of homeodynamics (human and environmental interaction), and Orems theory of self-care (matching nursing systems of care with clients levels of self-care functioning) have different emphases.
Upon the clients arrival on the patient care unit, the nurse begins implementation of the nursing process. Of which nursing theorist should the nurses practice be most reflective?

1. Ida Jean Orlando
2. Jean Watson
3. Dorothea Orem
4. Hildegard Peplau
Correct Answer: 4

Rationale 4: Some say that the phases of Peplaus therapeutic nurseclient relationship are ancestors of the phases of the nursing process. While Orem, Watson, and Orlando guide the nurse in areas for assessment, analysis, planning, intervention, evaluation, etc., they do not identify specific phases or steps of the nurseclient interaction process.
The nursing student asks the nurse the reason that knowledge of nursing theories is important. The nurse should respond that nurses use nursing theories to do which of the following?

Select all that apply.
1. Organize assessment data.
2. Generate goals.
3. Evaluate outcomes.
4. Plan interventions.
5. Generate nursing actions.
Correct Answer: 1,2,4,5

Rationale 1: Organize assessment data. Nurses use theories to assist them to organize and think about human
responses and data in meaningful ways.

Rationale 2: Generate goals. Nurses use theories to generate goals that have meaning for clients and reflect
desired outcomes to promote health and well-being.

Rationale 4: Plan interventions. Nurses use theories to plan interventions that address human responses as
they interact with both the internal and external environments.

Rationale 5: Generate nursing actions. Nurses use theories to provide guidance in the focus for nursing
actions that promote health as defined by each theory.
If the nurse is using the nursing theory that has shaped psychiatricmental health most directly, which nursing action is priority?

1. Assessing the clients abilities in areas of self-care
2. Teaching effective coping skills
3. Establishing a therapeutic nurseclient relationship
4. Encouraging the clients sensitivity and caring for self
Correct Answer: 3

Rationale 3: The interpersonal theory of psychiatricmental health nursing and the therapeutic relationship originated by Peplau remains the theory that has shaped psychiatricmental health nursing most directly. While assessing self-care abilities, encouraging sensitivity and caring for self, and teaching effective coping skills are important areas for nursing action, all efforts are supported by a therapeutic nurseclient relationship.
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