Nurse's Role in Psychiatric Settings Practice Exam/Test (1-10)

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Situation: A., age 15, is admitted to the unit for chronic psychiatric patients. This unit uses a token economy system as its treatment modality.

1. A token economy system is based on the principles of:

a) psychoanalytic theory
b) psychosocial theory
c) behavior modification theory
d) interpersonal theory

2. The success of a token economy system depends on:

a) consistency of all staff members in rewarding targeted behaviors
b) redemption of tokens for concrete rewards, such as candy, soda, or other snacks
c) setting behavioral goals high enough to motivate the patient
d) flexibility of staff members in allowing for slippage when the patient is having a difficult day

3. A."s treatment plan states that he will receive one token for making his bed each morning. After 2 weeks, the nurse reports that A. has not earned any tokens for making his bed. The nurse suggests that:

a) the goal remain the same; he will earn a token when he makes his bed
b) an attempt to motivate A. should be made by offering him two tokens for making his bed
c) the goal should be changed to a one-token penalty when his bed is not made
d) the goal should be modified to reflect more attainable goals at this time

4. A staff member reports that A. may be receiving tokens from other patients who feel sorry for him. Which strategy will control such donations?

a) keep an accurate account of all tokens earned and spent
b) use special, personalized tokens for A
c) penalize the other patients for giving tokens to A
d) penalize A. for accepting tokens from others

Situation: D., an 8 year old girl, is admitted to the pediatrics unit after an emergency appendectomy. Parental visits are permitted around the clock, but the nurses are concerned about Mrs. M.'s overprotective behavior. Mrs. M. is almost constantly at her daughter's side, feeding her, bathing her, and talking baby talk to her. She refuses to let D. walk and keeps her in bed to rest and regain her strength.

5. D. has a slightly elevated temperature, and the nurse notes some lung congestion. The best approach to enlist Mrs. M.'s cooperation in D.'s ambulation is to say:

a) you are not helping D. get better by keeping her in bed. She needs to move around to clear her lungs
b) the physician has told you that D. needs to walk around and get some exercise. Don't you want her to get better?
c) I want D. to get out of bed at least three times a day. Will you help me?
d) D. needs to move around more because her lungs are getting congested. Let's walk her down the hall and back

6. Mrs. M. does not allow D. to do anything for herself. When Mr. M. visits, staff members overhear the parents arguing about Mrs. M.'s babying behavior. Mr. M. asks the nurse if this behavior is normal. How should the nurse respond?

a) of course it's normal. Your daughter had emergency surgery, and your wife is anxious
b) I wouldn't be too concerned at this point. Your wife is in a crisis right now
c) I'd like to learn more about how your wife cares for D. at home
d) do you think it's normal to be so overprotective?

7. Mr. M. asks the nurse to speak with his wife about her over-protectiveness. He says that he has tried everything and that his wife refuses to change. The most appropriate intervention is to:

a) talk to Mrs. M. about her parenting behaviors
b) provide Mr. M. with a referral for family therapy
c) suggest that Mr. M. discuss the problem with D.'s physician
d) ask D. about her relationship with her parents


Situation: After D. is discharged from the hospital, Mr. and Mrs. M. decide to consult a clinical nurse specialist in family therapy.

8. During their initial visit, Mr. and Mrs. M. are asked to complete a chart of their family relationships and history through several generations. That chart is called:

a) a family tree
b) a genogram
c) a sociogram
d) mapping

9. The nurse therapist will use the chart to identify:

a) multigenerational transmission of presenting signs and symptoms
b) signs and symptoms related to the position of siblings within the family
c) family roles and responsibilities
d) family support systems

10. When the nurse therapist suggests that Mr. and Mrs. M. bring their daughter with them to the next therapy session. Mrs. M. states, "D. is too young to understand all this. Why should she be involved?" How should the nurse reply?

a) D. may not understand everything we say, but she's part of the problem and should be included
b) it sounds to me like you are trying to protect D. once again
c) perhaps we should ask D. whether or not she wants to be included in our sessions
d) you've brought up an important issue. Let's discuss why the whole family should attend.



ANSWERS AND RATIONALE

1) C
- a token economy system uses the principle of reward from the behavior modification theory. Tokens are used to reinforce desired behaviors based on the belief that all behavior is learned. The psychoanalytic theory, which focuses on understanding the unconscious psyche, and the psychosocial and interpersonal theories, which focus on underlying personality development, are not based on reward systems

2) A
- the success of a token economy depends on the full cooperation and coordination of the staff members. Behaviorists have found that consistent rewards produce desired outcomes. All staff members must be knowledgeable about the treatment plan and consistently reward the patient's performance of targeted behaviors. Inconsistent rewards and flexibility are countertherapeutic and encourage manipulation, resistance, and noncompliance. Tokens should be redeemable for items desired by a particular patient. Although food can be used, free time, walks, library privileges, and especially praise are better reinforcers than tangible items, particularly for teenage patient. Even though the ultimate goal of behavior modification may be extinction (stoppage) of a behavior, beginning goals should be set at a level low enough so that the patient can successfully meet the goal at least part of the time and receive a reinforcer. If this does not occur, the patient will become frustrated and stop trying to change his behavior.

3) D
- goals should be realistic and attainable by the patient. Initial goals may be set rather low to motivate the patient and allow him to attain some success; lack of success can frustrate and discourage the patient. Goals should be reassessed regularly for their appropriateness. In this case, A. has made no progress after 2 weeks, so his situation should be reevaluated. The reinforcers chosen may not mean enough to A. to motivate him to make his bed; new reinforcers may be necessary. Raising the stakes by offering more tokens for a behavior that has not been attained can lead to manipulation of staff members rather than motivation of the patient. Negative reinforcement usually is reserved to discourage maladaptive behaviors, such as fighting, acting out sexually, or cursing. Rewards are given for desired behaviors, not to penalize patients for nonperformance.

4) B
- a simple, nonpunitive way to end the donations is to reward A. with personalized tokens. He must then redeem his own special tokens, enabling staff members to monitor his behavior. Keeping track of tokens earned and spent by all patients can be an effective way to monitor progress but is a formidable task. Because staff members should encourage positive, helping relationships among patients, penalizing patients for giving or receiving tokens may be misunderstood or misinterpreted

5) D
- the nurse can enlist Mrs. M.'s cooperation by teaching her that inactivity is causing her daughter's lung congestion and by assertively telling her what needs to be done. The nurse's remarks should be made in a positive firm, but nonjudgmental tone. Accusatory responses such as "You're not helping D..." and "Don't you want her to get better?" are likely to be met with defensiveness, not cooperation. These remarks also may shift the focus of the discussion to the mother's behavior rather than of walking D. Asking for Mrs. M.'s help without restating why it is important does not take advantage of the teaching opportunity presented.

6) C
- the nurse is presented with an opportunity to further assess Mrs. M.'s parenting behaviors. To determine whether her behavior is a result of the crisis or evidence of more long-standing family dysfunction the nurse should seek additional data about how Mrs. M. cares for D. at home. Offering false reassurance by telling Mr. M. that his wife's behavior is normal or that he should not worry about it without further exploring his exploring his perception of the event denies his feelings and is nontherapeutic. Asking Mr. M. if he thinks the behavior is normal puts him in an awkward position because he must then take a stand on whether his wife overprotects his child. A more effective approach is to ask Mr. M. how he feels about the behavior, which allows him to express his feelings and provides the nurse with more assessment data.

7) B
- the most appropriate nursing action in this situation is to provide Mr. M. with a referral for family therapy. This decision recognizes that family therapy is a specialized skill requiring careful assessment and analysis and much advanced preparation. Discussing would serve no purpose unless the nurse is prepared to address the problem in ongoing therapy. Suggesting that Mr. M. discuss problem with the physician is nontherapeutic because it avoids answering the question directly.

8) B
- a genogram is a drawing that charts three or more family generations. It identifies family members, dates of birth, occupations, illnesses, significant life event, and relationships. A family tree displays family members and their dates of birth and death but does not usually detail the other areas mentioned. A sociogram is a diagram that helps identify the frequency and direction of messages and communications patterns (how messages are relayed and to whom) between members of a group or family. The therapist uses the sociogram to assess and evaluate these communications patterns. Family mapping is used by a structural family therapist to assess family system characteristics, such as clear, diffuse, or rigid boundaries; subsystems; and conflicts. Boundaries are the rules defining who participates in which subsystem. Family subsystems consist of individuals, pairs, or groups that form as a result of commonalities such as sex, generation, function, or interest. Interventions are directed toward reconstructing the family organization and relationships.

9) A
- the purpose of the genogram is to help the family therapist identify patterns of multigenerational transmission of presenting signs and symptoms. Therapists who follow a systems theory framework believe that signs and symptoms have their roots in earlier generations. A family genogram often can identify patterns that on the surface appear to be isolated in the family seeking treatment. Some family therapists believe that the gender and position of siblings -- for example, oldest daughter or youngest son -- determine personality characteristics that have an impact on relationships with others and adjustments in later life. These therapists focus on the ranking of individuals within the family and are not concerned with a more comprehensive genogram. Neither family roles and responsibilities nor family support systems are designated by the genogram.

10) D
- in responding to Mrs. M., the nurse should attempt to foster trust and cooperation while helping her understand the importance of each member's participation in the family sessions. Showing acceptance of Mrs. M.'s concern by acknowledging "You have brought up an important issue...," allows the matter to be discussed without placing undue focus on D. or Mrs. M. Attacking Mrs. M.'s protectiveness or putting D. in a position against her mother is not helpful.


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