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Full file at http://testbank360.eu/solution-manual-mental-health-nursing-6th-edition-karen-lee-fontaine

ROAD Assessment:

Critical Thinking Assessment Answers

SUGGESTED ANSWERS

Following are suggested answers to the Critical Thinking questions that form the “A”

(assessment) in the ROAD acronym. The Critical Thinking questions are found at the end of

Chapters 8, 11, 12, 13, 14, 15, 16, 17, 21, and 22.

All ROAD material was contributed by Susan Siwinski-Hebel, RN, MSN.

CHAPTER 8 ANSWERS TO ROAD TO CRITICAL THINKING

ASSESSMENT (TEXT PAGE 160)

1. SUGGESTED ANSWER: You would assess: A) Ann’s feelings and thoughts about her

new role as a mother; B) the routines of activity and sleep for Ann since the birth of her

daughter; and C) her perceived ability to establish new routines. These include healthy

nutrition and activity, and protection of rhythms of activity and sleep. You might ask about

the breastfeeding routine, how her sleep was affected, and what support systems were in

place to assist her in managing and adapting to her new role as a mother. You would ask

what difficulties Ann perceived or experienced as she strove to adapt and cope with her new

role. Educating clients in these matters includes teaching them about the course of illness

and how to recognize symptoms of the onset of illness.

SOURCE: Swann, A. & Ginsberg, D. (2004, August 15). CME Certified Symposium

Monograph. An Expert Review of Clinical Challenges in Psychiatry and Neurology: Special

Needs of Women with Bipolar Disorder. Sponsored by Intelly Medical Communications and

1


supported through a grant funded by GlaxoSmithKline, pp. 1–12. Retrieved March 6, 2006,

from http://mblcommunications.com/proceed/proceed_08_2004.pdf.

2. SUGGESTED ANSWER: Ann is experiencing paranoid and persecutory delusions. Her

reference to being under investigation by the CIA and her involvement in the Challenger

incident are examples of the delusions.

3. SUGGESTED ANSWER: It is important to determine if, in addition to the paranoid and

persecutory delusions, there are any associated safety risks for Ann or others. Safety is

always the first consideration in mental health assessments. You could ask questions such as:

What types of actions do you think about taking when you have those thoughts? When you

have that kind of thought, do you ever think about harming yourself or engaging in

behaviors that could be harmful to yourself? Others? What sort of pressure do you feel to act

upon your thoughts? Would you be able to let me know if you were having an increase in

those thoughts?

4. SUGGESTED ANSWER: Ann is displaying phase 2, the transition phase. The best nursing

response is to not match anger with anger; keep talking; set limits and give directions;

negotiate compromise; explore consequences; and get help. Specifically: You may use any

combination of the following interventions identified within Chapter 8: Seek out the client

and provide an opportunity to discuss what transpired between her and the other client.

Provide comfort and reassure the client’s safety. After listening and reassuring, refocus the

conversation to another topic to provide distraction from the troubling thoughts. Determine

whether there was a behavior that triggered the delusion. Focus on the underlying feelings,

since unexpressed feelings can trigger delusions. Identify beliefs that may be self-harmful or

harmful to others to protect the client and others from acting out behaviors that may be

2


harmful. Encourage clients to verbalize delusions to caregivers before impulsively acting on

them. Do not attempt to reason, argue, or challenge the delusion because that would put the

client on the defensive. Do not attempt to logically explain the delusion. Once triggers have

been identified, assist the client in problem-solving ways to avoid or eliminate stressors that

precipitate delusions. Offer recreational and diversional activities that require attention and

skill to provide temporary relief from disturbing delusions.

5. SUGGESTED ANSWER: Intramuscular lorazepam (Ativan) is frequently used for the

immediate control of psychotic disruptive behavior.

Develop a Care Plan

Nursing Diagnosis: Altered thought process related to persecutory and paranoid delusions

Outcome: Ann will report improved self-restraint of disruption in thoughts during interactions

with others.

Intervention Rationale Goal

Provide an opportunity for

Ann to discuss her delusions.

Delusions are frightening and

discussion may lessen the fear.

Ann shares her delusional

thoughts.

Discourage long narrations

about the delusions.

Lengthy discussions may

reinforce her disordered

thinking.

Ann talks about subjects other

than her delusions.

Implement a stance of

reasonable doubt concerning

the delusions during

Gently present the fact that

you do not perceive the

delusion as reality.

3


interactions with Ann. “I

understand that you believe

the CIA is trying to

assassinate you and that it is a

frightening experience to have

those thoughts. However, I

find those thoughts hard to

believe based upon the

information I have available.”

Assist Ann to try to connect

the false beliefs to incidents

and events that increase

feelings of fear, anxiety,

and/or insecurity.

Unexpressed feelings can

trigger delusions.

Ann identifies the triggers of

the delusion.

Provide Ann with assistance in

her efforts to verbalize

feelings of fear, anxiety,

and/or insecurity.

Unexpressed feelings can

trigger delusions.

Ann verbalizes her feelings.

Introduce and encourage

engagement in distracting

activities.

This creates an alternative to

constantly focusing on the

fixed belief.

Instruct Ann on thought-

interrupting techniques such

Increases awareness of

feelings that get converted

Ann utilizes techniques to

4


as snapping a rubber band on

her wrist or rubbing a penny

she keeps in her pocket.

into illogical thoughts. interrupt illogical thoughts.

Provide positive feedback for

improvement as it is noticed.

This reinforces positive

changes.

Nursing Diagnosis: Potential for violence directed at others related to fear and suspicious,

paranoid delusions Outcome: Ann will not harm others.


Encourage Ann to talk about

feelings rather than acting

upon perceptions and feelings.

This reinforces socially

acceptable and safe behavior.

Ann discusses feelings.

Reinforce that talking is a

manner in which she can

maintain her self-control.

This reinforces health and

nondestructive behavior.

Ann remains in control of her

behavior.

Explore issues and events in

the milieu or in daily life that

trigger anxiety, fear, and

suspiciousness.

Recognizing triggers improves

self-control.

Ann identifies usual triggers.

Offer information to correct

misperceptions Ann may

develop of interactions and

events taking place around

This reinforces reality to help

Ann interpret what is actually

happening.

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her.

Respect personal space and

avoid physical contact during

times of increased fear,

paranoia, and/or anxiety.

Close proximity and touch

may frighten Ann during these

times.

Ann’s anxiety and agitation is

maintained at a manageable

level.



1. SUGGESTED ANSWER: Steve identified the following physical symptoms: heart racing;

hollowness; altered perceptions of breathing; sweating; alterations in communication process

(blocking), stammering, and hyperverbal; Steve identified these cognitive symptoms:

magnification, irrational thoughts, and altered self-perceptions.

2. SUGGESTED ANSWER: Adolescents with anxiety disorder often perform poorly in

school and have difficulty with social interactions. Since adolescence is a stage of

development when the importance of what others think is heightened, an adolescent with

anxiety disorder, like Steve, would find the high school years even more difficult than others

in his peer group. Symptoms of anxiety disorder include an increased concern about the

opinion of others in regard to personal behavior and performance.

3. SUGGESTED ANSWER: (a) Alcohol tends to relax inhibitions in social behaviors and

initially mutes the physical sensations of anxiety. Specifically, alcohol has an effect upon

these neurotransmitters:

Dopamine—Alcohol acts on the nucleus accumbens to release dopamine and produces a

rewarding effect. This action increases feelings of motivation and reinforces the

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consumption of more alcohol.

GABA—Alcohol generates an inhibitory effect that produces sedation and relaxation in

direct contrast to the physical sensations of anxiety.

Serotonin—Alcohol may cause additional dopamine release as it attaches to serotonin

receptors. It increases the rewarding effects associated with increased dopamine levels.

(b) The nurse should assess his prescribed medications to verify that he was not prescribed

any benzodiazepines, which would create a significant depressant effect when combined

with alcohol.

4. SUGGESTED ANSWER: (a) Steve coped by excusing himself and physically removing

himself from the group. He did not return to the same group of people.

(b) Separating himself allowed him to regroup and realign his thinking and perceptions;

however, he would go to a new person with whom he had never conversed, and the same

scenario was repeated once again.

(c) It would be helpful to explore the automatic cognitive thoughts that were generated

within the group. Assist Steve to realistically evaluate the thoughts. Explore and role play

thought processes in which he could cognitively establish realistic perceptions of the social

situation.

Develop a Care Plan

Nursing Diagnosis: Ineffective individual coping related to an increase in negative cognitive

distortions that arise during social situations

Outcome: Steve will report improved interactions with others.

7



Provide Steve with

information on the definition

of cognitive distortions and

their relationship to feelings of

anxiety.

Client education is the

precursor to problem solving.

Steve verbalizes an

understanding of cognitive

distortions.

Assist Steve in identifying the

types of cognitive distortions

he experiences in social

interactions.

Insight into the problem

precedes change.

Steve accurately identifies his

personal cognitive distortions.

Implement social skills

training:

Social skills training

empowers clients to manage

their lives more effectively.

Steve engages in social skills

training and exhibits fewer

cognitive distortions.a. Role play with Steve a

social interaction, stopping

to process negative

cognitive distortions that

arise.

b. Provide positive feedback

for Steve’s efforts to

perform the exercise.

c. Provide corrective

feedback on how the

8


process could be

improved.

Encourage Steve to practice

the skills in public, social, and

work settings.

Reinforcement in real-life

situations will improve the use

of social skills.

Steve practices the skills and

reports back on the process.

Nursing Diagnosis: Alteration in self-esteem related to ineffective management of stress that is

experienced during social situations and evidenced by the verbalized need to be perceived as

intelligent, knowledgeable, and credible

Outcome: Steve will utilize stress-reducing techniques.


Educate Steve on the

maladaptive neurobiological

effects of alcohol use and the

resultant physical and

cognitive experiences of

anxiety with ongoing alcohol

use.

Understanding the relationship

between alcohol use and

anxiety may help Steve limit

his use of alcohol.

Steve decreases his use of

alcohol.

Encourage Steve to prioritize

areas of value and importance

in his life.

Setting priorities will help

Steve focus his attention and

energy.

Steve identifies priorities.

Support Steve in setting and This will help Steve adjust his Steve achieves goals.

9


working to accomplish

achievable, realistic goals in

his personal, work, and social

life.

idealized expectations to those

that are more realistic.

Role play the practice of

counteracting negative

thoughts with positive

thoughts.

Affirmations quiet the mind

and set the expectation for

positive experiences.

Steve verbalizes fewer

negative thoughts.

Practice with Steve the

process of imagining himself

engaging in social interactions

confidently, successfully,

while managing any anxiety

that arises.

Practice and positive imagery

lead to a change in behavior.

Steve verbalizes effective

coping with his anxiety.

Encourage Steve to pursue a

form of physical exercise.

Exercise helps limit the

experience of anxiety.

Steve participates regularly in

an exercise program.



1. SUGGESTED ANSWER: Additional assessment for the presence of major depressive

disorder would be indicated. Major depression is often a primary problem, with an eating

disorder existing as a secondary problem. The eating disorder becomes superimposed onto

an untreated major depression. Jessica mentions an inability to cope with her feelings of

10


anger, fear, and loneliness. She is unable to find any understanding or acceptance of her

feelings through prior methods of coping. She reports feeling tremendous emotional pain

that has no outlet. Furthermore, as her nurse it would be important to assess if this emotional

pain was cascading into other self-destructive behaviors and further attempts to release the

building tension she is verbalizing. Jessica states she currently dissociates from the

emotional pain through purging. It would be important to assess for the presence of any self-

mutilating/injurious behaviors that could be used as an alternative method to dissociate from

the emotional pain:

“Of 236 patients with anorexia, over 60% reported some form of self-injurious behavior,

including skin cutting/burning, hair pulling or severe nail biting, classified as either

impulsive or compulsive.”

SOURCE: Favaro, A. and Santonastaso, P. (2000). Self-injurious behavior in anorexia

nervosa. The Journal of Nervous and Mental Disease. 188(8), pp. 537-42. Abstract retrieved

March 27, 2006 from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?

cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10972574&query_hl=5&itool=pubm

ed_DocSum.

Also, see Chapter 8, page 152, which states that there is a correlation between the incidence

of self-injurious/ mutilating behaviors and eating disorders.

2. SUGGESTED ANSWER: “They experience ego-dystonic behavior, behavior that does not

conform to the person’s thoughts, wishes, and values. Another facet of ego-dystonic

symptoms is that one feels the symptoms are beyond personal control. The person feels

compelled to binge, purge, and fast; feels helpless to stop the behavior; and feels full of self-

11


disgust for continuing the pattern.” (Content to support the answer is in Chapter 12 of the

text, pages 276, 277.)

3. SUGGESTED ANSWER: In the videos, Jessica exhibits the following cognitive distortions

and defense mechanisms. The transcript of the video clips appears before the answers.

First Segment

“Yeah. No matter how thin I got, I was never going to be perfect enough. I was never

going to be thin enough. I looked in the mirror and I saw something completely different

than reality. And even as the scale went—as the numbers on the scale went down, the

image in the mirror got bigger.”

Cognitive distortion: Overgeneralization—Jessica exhibits the cognitive distortion of

overgeneralization (and a paradoxical dilemma*) as evidenced by her statements that convey

a fixed belief in her need to achieve perfection. Consequently, she could never realize this

goal unless she was also able to achieve her idealized and indefinable weight, which she

equated with acceptable physical appearance. This continuous circle of thought was

perplexing and reinforced further self-destructive thinking that she would never be able to

achieve the idealized weight, and therefore would never be perfect or good enough.

(*NOTE: Student may not be able to identify the paradoxical dilemma, but this creates a

discussion point between student and nursing faculty to reinforce the inherent control issues

among those with eating disorders. These faulty patterns of thinking are predictors of

failure, self-fulfilling prophecies, and ultimately reinforce ongoing destructive behavior

patterns.)

Defense Mechanism: Denial—Jessica also exhibits the defense mechanism of denial, as

12


evidenced by her rejection of the reality of the decrease in pounds on the scale. She was

unable to realistically acknowledge her weight and instead saw herself as heavier in physical

appearance.

Second Segment

“My weight fluctuated a lot. It fluctuated between about 100 and 110. But during all of

those fluctuations, I just—my weight could never be low enough for me, and one little tick

up on the scale meant total failure for that week for me.”

Cognitive Distortions: Magnification and Dichotomous Thinking—Jessica exhibits

magnification and dichotomous thinking by her statements conveying a fixed belief that an

increase in weight, revealed by a minute increase in pounds on the scale, was symbolic of

her inability to have self-control and consequently meant that she was a failure at that point

in her life.

Third Segment

“And then at night I would usually—and during this whole time, I was completely

fixated on what my next meal would be, on counting calories in my head, on feeling my

body to make sure I hadn’t gained any weight in the past hour, on looking around to see

how other people were judging me, what other people were thinking of me, internalizing

all that. Any criticism I got became immediately internalized and sort of ammunition

against me.”

Cognitive Distortion: Personalization—Jessica’s statements convey a fixed belief that

nonverbal behavior of others meant they were appraising her qualities as a person and her

overall worthiness. Negative interpretations of these encounters became the faulty logic

13


behind Jessica’s unending self-criticism.

Defense Mechanism: Sublimation—Jessica’s displaced the emotional energy stimulated by

her feelings of self-disgust and self-reproach into activities that she perceived as being

within her control, such as her choice of food, intake of calories, and vigilance in

interpersonal interactions.

4. SUGGESTED ANSWER: Jessica says in the video:

“My family life was great growing up, but my sister was sort of the one who needed a lot

of attention because she suffered from depression—severe, severe depression—when we

were growing up. So I sort of had to be the happy child and I had to be the one who had

it all put together, who there were never any problems with. So then when there were

problems in my life, when my life got bumpy or I got lonely or I got scared or I felt out of

control, I didn’t want to go to people and ask for help because I didn’t want to sort of

burden them with one more thing. And that got to be a habit, and this whole like people-

pleaser mode of operation got to be a habit, so that by the time I was in the middle of my

eating disorder, or before even starting it, I really had no idea who I was. I’d spent so

long operating by other people’s expectations and what I perceived as other people’s

expectations of me, that I had no idea who I was. And therefore, if I failed to meet the

expectations, I was a failure.”

It is important to assess the family dynamics within Jessica’s family of origin. This includes

Jessica’s level of satisfaction with individual family member relationships, her perceived

ability to verbalize her needs, and/or her perception of problems within the family system.

Typically, when there is a family member with an active eating disorder, additional

14


assessment reveals that there may be altered patterns of family cohesion and unsatisfying

emotional bonding. Usually a pattern of enmeshed family systems is seen in which everyone

becomes concerned and involved with the eating behavior of one family member (see

Chapter 12 text, page 270). However, in Jessica’s family of origin, it appears that her family

may have functioned somewhere along a continuum of disengaged to separated emotional

bonding in their relationship with her. This is supported by Jessica’s statement that there was

an increased focus or attention given to Jessica’s sister as she struggled with episodes of

depression. Jessica may have functioned within her family system with a high degree of

independence and need to develop self-sufficiency as the family struggled to cope with her

sister’s illness. During your interactions with Jessica, the following communication

techniques would reinforce your efforts to utilize effective communication, further facilitate

your nurse– client relationship, and contribute to the gathering of pertinent assessment data:

1. Validating Perceptions: The technique of validating perceptions would be formulated as,

“It sounds like you thought you had to be independent and self-sufficient while you were

growing up. Is that true?” Another option would be: “It sounds like you didn’t verbalize any

of the personal feelings or struggles that you experienced while you were growing up in

hopes that your perceived ‘perfect adjustment’ could make your family more happy. Is that

true?”

2. Restatement: An example of this technique would be formulated as, “As a child you

weren’t able to ask your parents for help. You wanted to shield them from any additional

emotional pain.” Another option would be: “You thought you could increase your parents’

happiness by hiding your fears, worries, and anxieties.”

Develop a Care Plan

15


Nursing Diagnosis: Body image disturbance related to delusional perception of body in

anorexia

Outcome: Jessica will verbalize more accurate rather than inaccurate perceptions of her body

image at the conclusion of her outpatient therapy sessions.


Explore situations that elicit

feelings of anxiety and/or

loneliness and how these

feelings are translated into acts

of self-control.

Linking negative feelings to

purging is the first step in

developing new behaviors.

Jessica verbalizes how purging

is an attempt to cope with

negative feelings.

Assist Jessica in identifying

underlying fears, such as a

fear of rejection, that are

closely tied to the

competitiveness of her

professional career.

Help Jessica make the

connection between her career

and how this may have been

transformed into a fear of

gaining weight.

Jessica identifies fears and

relates these to her eating

disorder.

Suggest that Jessica write a

list of the pros and cons of her

eating disorder.

Identifying pros and cons is an

early part of the problem-

solving process.

Jessica develops the list.

Gently assist Jessica in

identifying the secondary

gains of her eating disorder.

Moving unconscious

secondary gains to conscious

awareness increases the

Jessica identifies secondary

gains and develops a plan to

get these needs met in another

16


Problem-solve ways to get

these needs met in a more

appropriate manner.

likelihood that these needs can

be met in healthier ways.

way.

Assign the therapeutic

exercise of recording a body

image diary in which Jessica

describes situations that

provoke concerns over her

appearance, her body image

beliefs, and the effect of these

beliefs on her mood and

behavior.

Jessica needs to make the

conscious connection of how

fears foster certain feelings

and behaviors.

Jessica keeps a daily body

image diary.

Educate Jessica on how

distorted thinking becomes

maladaptive.

Automatic thoughts about her

weight and self-worth need to

be brought to conscious

awareness before they can be

modified.

Jessica identifies negative,

automatic thinking patterns.

During interactions, provide

feedback and encourage

Jessica to reframe negative

automatic thoughts into

positive affirmations.

Positive affirmations

contribute to a positive sense

of self-worth.

Jessica verbalizes fewer

negative thoughts and

consciously verbalizes

positive affirmations.

Nursing Diagnosis: Chronic low self-esteem related to striving to please others to obtain

17


acceptance

Outcome: Jessica will verbalize increased satisfaction with self at the conclusion of her

outpatient therapy sessions.


Discuss Jessica’s self-

valuation while reinforcing

that she is worthy as a person

who possesses both

weaknesses and strengths.

The reality is that each person

is a combination of strengths

and limitations. Accurate

perception contributes to a

positive self-esteem.

Jessica identifies strengths and

limitations.

Explore with Jessica the

consequences of evaluating

one’s worth based on the need

to please other people.

This helps build an internal

locus of control related to self-

worth.

Jessica verbalizes an improved

self-worth.

Encourage Jessica to discuss

her experience of growing up

as her family struggled with

her sister’s depression.

This helps bring the pursuit

toward perfectionism into

conscious awareness.

Jessica verbalizes the

connection between her

experiences as a youth and her

eating disorder.

Encourage Jessica to make

autonomous decisions.

This promotes feelings of

control.

Jessica makes appropriate

decisions.

Provide positive

reinforcement for situations in

which Jessica makes

Positive reinforcement helps

support new behaviors.

Jessica continues to make

appropriate decisions.

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independent decisions.



1. SUGGESTED ANSWER: In the video Josh states:

“Cyclical, very cyclical. Sometimes I’ll be really high and manic and I’ll get so much

done. I’ll clean, I’ll cook, I’ll organize my papers. I’m up to 2 or 3 in the morning

organizing my papers and making labels for things—just that bad. But then the reverse

happens and I come down. For every high there’s a low. You’re really low—can’t get out

of bed, don’t shower, don’t shave. I just feel terrible about the world. To manage that,

which is much easier to manage than the thoughts, I just realize that I have to ride them

through at the cyclical and hopefully the meds keep them balanced. But whether I’m high

or whether I’m low, I have to realize they—you have to realize they’re temporary.”

Josh’s affect is appropriate (to the nature of the interview session) and stable without

euphoria. In general, his affectual expression is somewhat blunted. During exacerbations of

his illness he reports having had mixed mood features, experiencing a range of moods from

euphoria with increased energy to depression with decreased motivation.

2. SUGGESTED ANSWER: In the video Josh says:

“. . .But before that I just could not really—I had other jobs, but my goal back then was

to get off my meds, right? When I was off my meds I couldn’t function in the workplace. I

was delusional, I was argumentative, I was hysterically laughing. There’s a point,

though, when you get off the meds where you’re hyper and you’re high and you’re manic

and you can do anything, or at least you think you can. But what always sucks is when

19


you realize you can’t and you’re still manic and you get very depressed afterwards.”

Josh talks about the struggle he has had in not wanting to subdue experiences of euphoria, in

wanting to function without a reliance upon medications, and, consequently, resisting

adherence to a medication regimen. He concedes that the ramifications of not taking his

medications have been unacceptable as he experiences cycling between manic and

depressive phases. Josh is able to recognize the effects of medication noncompliance as

being too great a concession, as he is unable to function in the workplace. He is able to

recognize that when he is noncompliant he has a lack of concentration and altered and

irrational thought processes.

3. SUGGESTED ANSWER: Josh says in the video:

“Well, I have talents but I don’t really explore them. People tell me I’m affable and—

what’s the word?—personable. I don’t really know anything else about me.” (How do

you feel now in terms of your struggle with self-acceptance and being able to accept

others?) “I wish it had happened 10, 15 years ago. It’s just too late for it to happen to be

—to happen.” (How would it be different if it had happened 10 or 15 years ago?)“I

would have had that amount of time to more enjoy my life. My parents say—my

grandmother used to say, you live to 120 and die a fool. And she also used to say, Man

plans and God laughs. That’s about the size of it, really. And again,—nobody’s perfect.

Ease up, you know?” (Does it upset you that some of those dreams or those ideas that

you had for yourself earlier on, becoming an architect. . .) “Archeologist.” (Oh, I’m

sorry, becoming an archeologist or maybe studying physics like Albert Einstein. Did

any of those—did having those dreams and not fulfilling them—did that . . .?)

00:18:30 “For years it caused problems in me. I tried finishing school so many times. I

20


just couldn’t make it through, so I just gave up. And that was the biggest thing to accept

about myself, really. For the longest time I couldn’t believe that there was a life after

school, without school. . . .” (What do you imagine for your future now?) “Well, I’ll

tell you, I spoke to my dad the other day. I said, ‘Dad, do you honestly see me raising a

family?’ He surprised me and he said yes. But the only problem is, I wouldn’t be able to

provide for them, like adequate shelter, housing, food, clothes, doctor’s visits. So I

probably won’t have a family. A wife maybe or a steady girlfriend maybe. I’d like to see

about that one. I’ll never have a career. I’ll have a job probably most of my life. That

was the big key to rehabilitation or what they call therapy—we work. They’re going to

keep the loonies on the path, so to speak. Put them to work, put them to work, put them to

work. So throughout the problems that I’ve had, I’ve always had a job, but I wasn’t too

happy with them. Now I seem to be doing all right.”

Josh has some difficulty verbalizing his personal strengths and weaknesses. He is unclear at

this time about his self-identity. He has struggled with issues of social acceptance, feeling

that others have not accepted him for his own character and personality and that others have

wanted him to change. He has also struggled in identifying a purpose in his life and

achieving self-satisfaction.

4. SUGGESTED ANSWER: Josh has been presenting with an increase in depressive

symptoms and was recently prescribed an antidepressant; however, he is not concurrently

taking any type of mood stabilizer. This information causes you to make an inquiry about

his medication regimen based upon knowledge that, “People with a history of bipolar

disorder who are in the depressive phase and prescribed only an antidepressant are at high

risk for switching to a manic episode. For that reason, mood stabilizers are always

21


prescribed at the same time.” (Content taken from text, page 307.)

5. SUGGESTED ANSWER: Additional assessment is warranted at this time to determine if

Josh’s body is getting ready to cycle into a manic phase. Listening, observing, and

interacting with Josh further would help to determine if the rate and pressure of his

statements during your interaction are precursors to his cycling into a manic phase or an

eagerness to share his recent activities. In addition to his affect, mood, and verbalizations,

your assessment should also explore his perception of his energy levels as cued by his report

of a lack of sleep in the past 48 hours. For those with bipolar disorder, lack of sleep can

trigger a manic episode. Last, you will need to further assess alterations to his activities of

daily living such as bathing, grooming, and nutrition.

Develop a Care Plan

Nursing Diagnosis: Impaired social interaction related to inappropriate behavior during unstable

mood states

Outcome: Josh will verbalize an awareness of interaction behaviors in social and group

situations that are appropriate and inappropriate.


Set limits on unacceptable

group behavior and explain to

Josh what is expected and

consequences if limits are

disregarded.

Josh needs to understand

expectations and consequences

in order to modify his

behavior.

Josh verbalizes an

understanding of expectations

and consequences.

22


Assist Josh in talking about

his perceptions of social and

group interactions during PHP

and in his daily life.

Misperceptions need to be

corrected before appropriate

behavior can occur.

Josh verbalizes his

perceptions.

Explore with Josh how acting

upon his perceptions without

validating them can create

unsatisfactory social

experiences.

Education about social process

will help Josh modify his

behavior.

Josh validates his perceptions

with others during

interactions.

Avoid arguing or discounting

Josh’s efforts to defend an

appropriate behavior.

Power struggles are not

productive to problem solving.

Arguments do not occur.

Provide positive

reinforcement for behaviors

that are socially acceptable

and reflect efforts to improve

social interactions.

Positive reinforcement helps

solidify new behaviors.

Josh acknowledges his efforts

to change his behavior.

Support Josh in identifying

positive self-attributes,

recognizing accomplishments,

and experiencing pleasure

from achievement.


qualities, which improves self-

esteem.

Josh verbalizes his strengths in

social interactions.

Nursing Diagnosis: Sleep pattern disturbance related to insomnia or hyperactivity

23


Outcome: Within 3 days of taking a prescribed sleeping medication, Josh will sleep 4 to 6 hours

without awakening.

Interventions Rationale Goal

Continue to assess Josh’s sleep

patterns.

Baseline and changes should

be documented.

Josh reports his sleep patterns

each morning.

Assess for increased

hyperactivity during the day,

such as increasing restlessness,

pacing, fine tremors, slurred

speech, or an appearance of

increasing tiredness.

When the manic state

intensifies, sleep problems

worsen.

Manic state is stable or

improves.

Incorporate periods of

relaxation during the day.

Josh may be tired from

disrupted sleep and thus need

rest periods to avoid

exhaustion.

Josh takes relaxation breaks.



1. SUGGESTED ANSWER: Larry was able to function without noticeable differences from

other children before his symptoms set in. From what he says about creating fictional

baseball players, he had an active imagination and spent time in his imaginary world. This is

not unusual for children, so this behavior was probably not questioned. His symptoms first

appeared when he was in seventh grade, but they were not severe enough to impact his

24


academic or social life significantly.

2. SUGGESTED ANSWER: Larry’s primary education was obtained at a private boys’

school. When his first symptoms began to appear during seventh grade, he would have been

focused upon developing social relationships with those of his same gender. Behavior such

as isolation or withdrawal that he may have displayed as early symptoms of his pending

illness would have created barriers to overcome as he strove to complete the developmental

tasks of his age group. In addition, if his symptoms interfered with his attention span and

concentration, he may have also struggled with goal achievement and learning activities.

3. SUGGESTED ANSWER: Adverse effects related to tardive dyskinesia include buccal

movements, facial tics (eyebrows), grimacing, and lip-licking from dry mouth. NOTE: Hand

flapping seen at one point during the interview is not a characteristic of tardive dyskinesia.

4. SUGGESTED ANSWER: Larry presents during the interview with characteristics that

correlate with the presence of negative symptoms associated with schizophrenia, such as

decreased, slowed psychomotor movements, alogia (limited speech), and, at times,

difficulties with conversation. He has a blunted, restricted affect with limited range of

emotional expression. He also displays some delays in memory recall and alterations to

fluidity of social interaction.

5. SUGGESTED ANSWER: Larry’s attention span is intact, but he has delays in recall of

long-term memory. His conversation is halting as he searches for the term “tardive

dyskinesia” to describe the adverse reaction he has experienced related to the use of

psychotropic medications.

6. SUGGESTED ANSWER: Larry’s ability to initiate and complete routine activities of daily

25


living prior to starting his workday is a measurement of the success he has achieved.

Frequently, people diagnosed with schizophrenia struggle with the things that others might

overlook as unquestionable tasks of everyday life. Because of the negative symptoms of

schizophrenia, particularly avolution (lack of motivation), the ability to engage and perform

self-care is a struggle. In addition, his adherence to a daily medication regimen is a

confirmation of Larry’s successful illness management. Difficulties in establishing a

medication routine as well as the tendency to discontinue medication therapy when

problematic symptoms have subsided often are factors contributing to relapse for people

diagnosed with schizophrenia.

Develop a Care Plan

Nursing Diagnosis: Risk for injury related to medication side effects of extrapyramidal

symptoms and/or tardive dyskinesia

Outcome: Larry will remain free of adverse reactions from prescribed psychotropic medication

regimen.


Educate Larry on the side

effects and/or adverse

reactions of his prescribed

antipsychotic agents.

Education is the basis for

informed decisions and

knowing when to contact the

physician.

Larry verbalizes an

understanding of his

medications.

Reinforce the use of sugarless

candy, gum, ice, or water as

well as practicing good oral

These alleviate the discomfort

of a dry mouth.

Larry verbalizes

understanding of self-care

practices he can implement to

26


hygiene. reduce side effects.

Continue ongoing assessment

for dystonias.

These side effects may occur

at any time.

Monitor for early signs of

tardive

Tardive dyskinesia may be

avoided if caught

dyskinesia. Notify physician if

these occur.

in the very early stages. Since

tardive dyskinesia is usually

nonreversible, prevention is

the key intervention.

Collaborate with

physician/treatment team to

consider prescribing

antiparkinsonian drug.

If Larry experiences

extrapyramidal side effects,

adjunctive medications may

lessen the EPS effects.

Provide Larry with clear,

concise written medication

sheets.

Written information reinforces

client education.

Provide Larry with positive

feedback for adherence to

medication regimen.

Positive feedback reinforces

behavior.

Larry takes his medication as

ordered.

Nursing Diagnosis: Social isolation related to past difficulty in interactions with others as

evidenced by withdrawal, preoccupation with his own thoughts, and negative reaction by others

to his social behavior

27


Outcome: Larry will participate in sessions provided through his outpatient psychosocial

rehabilitation program.


Provide brief, frequent

contacts.

Intense, lengthy sessions may

frighten Larry.

Larry remains calm when

interacting with staff.

During interaction, convey a

respectful, objective, and

accepting attitude.

Larry is considered to be

“different” by many people.

He deserves respect and care

from his treatment team.

Larry verbalizes increased

trust in the staff. Larry

remains calm.

Provide extra personal space

during interactions and remain

cautious with the use of touch.

Close proximity and touch

may frighten individuals with

paranoid ideation.

Remind Larry of outpatient

program schedule.

This increases orientation. Larry attends the outpatient

program.

Discuss with Larry the signs

of increasing anxiety and

techniques to self-interruptthe

anxious response.

This will help Larry increase

his internal locus of control.

Larry identifies and manages

his anxiety.

Collaborate with treatment

team to discuss an intervention

to excuse Larry and offer an

exit strategy in response to

If Larry is unable to manage

his anxiety when interacting

with others, helping him out

of the immediate social

Larry leaves the situation

when his anxiety becomes

unmanageable.

28


increased anxiety during a

group session.

situation may prevent a panic

attack.

In a group format, practice

social communication skills.

It is easier to learn social

behavior in a social setting

with peer modeling.

Larry’s level of social

interaction improves.

Provide recognition for

Larry’s interactions with

others.


behavioral change.

Larry continues to interact

with other people.



1. SUGGESTED ANSWER: In the video, the interviewer asks Chris:

“One of the things that people often wonder is, why did this kid start to drink at age 12?

And then what led to this career where he kept drinking more and more and more and

eventually into drugs over time? How do you understand that for yourself? Chris: “How

do I understand why I started drinking? You know, it’s tough to say. Peer pressure, part

of the—maybe the sexual abuse I endured. I really don’t know, it’s tough to tell. I think

it’s a combination of both.”

Chris indicates that the impetus behind his substance abuse “career” was twofold. He makes

a specific reference to an experience of sexual abuse that necessitates further assessment for

an untreated posttraumatic stress disorder (PTSD). Therefore, this information warrants

conducting a dual-diagnosis assessment. Research data shows that the comorbidity of PTSD

with substance abuse disorders ranges from 22% to 43%. In addition, assessment for a dual

29


diagnosis of major depression and substance abuse would also be indicated. Research data

indicates that the comorbidity of major depression with nicotine, alcohol, and drug abuse

ranges from 32% to 54% percent.

(Support for answer taken from Chapter 15, page 379.)

2. SUGGESTED ANSWER: Chris says in the video:

“All my friends, they were able to drink socially, drink what I call normally. Me, when I

drank, I couldn’t just drink socially and have a couple of beers or a couple of drinks. I’d

have to drink until I blacked out, until I couldn’t drink any more. A normal day for me

would be to drink a case of beer, where my friends would just have a six-pack. I just

drank to get drunk and ease my feelings and pain that I had inside from other issues I

was dealing with. . . . They were able to what I call drink successfully, normally—be able

to go out and have a couple of beers. I thought, what’s normal about going out and

having a couple of beers? It’s a waste of money. You should go out and drink to get

drunk. . .”

(a) The statements “what’s normal about going out and having a couple of beers? It’s a

waste of money. You should go out and drink to get drunk...” are examples of minimization

and rationalization. He minimizes the significance of his behavior by defining normal

behavior as consuming more than “a couple of beers.” He also rationalizes his behavior by

equating the value of spent money with the achievement of a completely inebriated state.

(b) The indictors that confirm the presence of Chris’s substance (alcohol) dependence are

substantiated by the following data (according to DSM-IV-TR criteria):

A maladaptive pattern of substance use, manifested by three (or more) of the following,

30


occurring at any time in the same 12-month period:

1. Tolerance: a need for increasing amounts of the drug—Chris states that unlike his

friends’ intake of a six-pack a day, he would consume a case of beer.

2. Withdrawal

3. The substance is often taken in larger amounts or over a longer period than was

intended—Chris indicates that he would drink until he blacked out or couldn’t drink

anymore.

4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

5. A great deal of time is spent in activities necessary to obtain the substance—Chris says

that the purpose of going out was not for the socializing, but instead for getting drunk.

6. Important social, occupational, or recreational activities are given up or reduced.

7. The substance use is continued despite knowledge of having a persistent or recurrent

physical or psychological problem that is likely to have been caused or exacerbated by

the substance. (Support for this answer taken from Chapter 15, page 377).


“My parents—when I was young, they really didn’t know. I was able to hide it. I’d come

in; normally they’d be in bed. I’d come in at my curfew; they’d be sleeping; I’d go right

to bed. But as it—you know, sophomore, junior in high school, they knew I was drinking,

but they didn’t think I had a problem. They thought, hey, there’s a lot of kids drinking;

they’re just experimenting. Hopefully nothing will come of it and he won’t have a

problem or anything. They just thought it was a phase I was going through.”

31


Chris’s parents may have denied and/or rationalized the early preadolescent and adolescent

behaviors he exhibited. Despite the extensive family history, his parents were unable to

recognize the potentially destructive pattern Chris was developing. When Chris states that

they “didn’t think I had a problem. They thought, hey, there’s a lot of kids drinking; they’re

just experimenting,” he is speaking about the rationalization he believes his parents used to

cope with his behavior. Furthermore, his parents may have been repeating learned patterns

of co-dependent behavior from within their own family of origin, as Chris identified within

the text that “... Alcohol abuse is prevalent all over my family—my father’s sister, my

mother’s father, my father’s mother, many of my father’s uncles. So it’s all over my

family.”


“The drinking and the drugging led to infidelity with my wife. I was having an affair on

my wife and I thought, you know, this was slick and slack (?), you get away with it. And

finally when I was in rehab, she confronted me about it. And I still denied it in rehab

until I went to a halfway house, and I came clean when I was there and I told her about

it. And I felt awful about it, but I’m lucky she forgave me and accepted me back. But it

caused me to do things that normally I wouldn’t do.”

(a) When a person is under the influence of cocaine they have a tendency to do things that

they wouldn’t usually do. The action of the cocaine upon the central nervous system is as a

stimulant that relaxes inhibitions, increases sexual fantasies, and increases sexual desire.

Cocaine is associated with hypersexuality. Seventy percent of males report a strong link

between cocaine use and a variety of sexual acting-out behaviors.

32


(b) Further assessment would be indicated to determine if Chris had been exposed to any

additional health risks, specifically STIs and/or AIDS. Consequently, the nature of decreased

sexual inhibition associated with cocaine use and the possibility of multiple sexual partners

not only would place Chris at risk, but also place his wife at risk. The topic of testing for

STIs and/or AIDS would be warranted in this situation. (Answers supported by page 407 in

Chapter 15.)


“Oh, yeah. I mean, right now I’m up to about 200 pounds. About 2 years ago I was down

to about 160 pounds. I was about 40 pounds lighter. I wasn’t eating. I just looked really

thin and I didn’t look right. . .”

Table 15.2, “Physiological Complications from Alcohol Dependence,” on page 381 of the

text can be used as a reference.

Develop a Care Plan

Nursing Diagnosis: Readiness for enhanced knowledge of substance-related disorder

Outcome: Chris will maintain sobriety and a substance-free lifestyle.


Educate Chris on the

neurophysiological aspects of

addiction.

Accurate knowledge is a

critical part of recovery.

Chris verbalizes an accurate

understanding of the

neurophysiological aspects of

his disease.

Reinforce the mandatory Recovery is a lifelong, day-to- Chris verbalizes the need to

33


lifestyle he must follow,

which excludes any

consumption of alcohol.

day process. refrain from the use of alcohol

or drugs.

Encourage Chris to work

toward developing an internal

locus of control.

The responsibility for

recovery is on Chris.

Chris verbalizes an improved

internal locus of control.

Explore situations and events

that exist as real or potential

stressors in Chris’s life and

problem-solve ways to cope.

The inability to cope with

stressors may contribute to

relapse.

Chris identifies stressors and

coping mechanisms.

Explore the support and level

of involvement his family has

in his sobriety.

The family may need support

to give up any enabling

behaviors.

Family members verbalize

support of Chris in his

recovery.

Reinforce ongoing connection

and with his AA group or

SMART Recovery group.

This enhances and maintains

motivation to abstain.

Chris participates in self-help

relationship groups.

Nursing Diagnosis: Risk for ineffective coping related to risk for relapse

Outcome: Chris develops strategies to prevent relapse.


Assist Chris in identifying

ways to resolve situations that

generate anger, fear, or other

Out-of-control feelings may

increase the risk for relapse.

Chris describes plans for

minimizing the impact of

34


emotions that are difficult to

manage.

stressors.

Discuss the need to avoid

triggers to relapse: people,

places, and specific activities.

This is the first step in relapse

prevention.

Chris identifies personal

triggers.

Discuss the conscious act of

changing his attitude when he

is confronted with self-

limiting, devaluing, or

negative feelings that

triggered his use of substances

in the past.

This helps Chris anticipate and

plan for problem situations.

Chris implements strategies.

Assist Chris in identifying

recreation/ leisure activities

that do not involve alcohol or

drug use.

This helps him find activities

he can substitute for his

former substance-related

activities.

Chris formulates a list of

possible alternative activities.

Reinforce any ability Chris

has to see himself as capable

of steering the course

An internal locus of control

will prevent feelings of

powerlessness or

victimization.

Chris verbalizes an internal

locus of control of his life.



35


1. SUGGESTED ANSWER: The interviewer asks Kylie on the video:

“Are there times when you’re with another person one on one or in a social situation

where you feel alone even though you’re not?” Kylie: “Most of this revolves around

whether I’m in a secure relationship or not. And because I’m in a secure relationship it

seems my world is normal.”

(a) Self-mutilation, suicide threats, and attempted suicide are maladaptive responses to

intense pain or an attempt to relieve the sense of emptiness that an individual with borderline

personality experiences. These acts help the person to regain reassurance that he or she is

alive and can feel pain. Physically self-damaging actions, such as cutting or burning, may be

precipitated by threats of separation from others, by rejection, or by feelings of despair. Self-

mutilation is a “severity” marker for the disorder, and those who self-mutilate are at higher

risk for suicide. (Support for this answer taken from Chapter 16, page 430.)

(b) The prevailing tone of ongoing nursing assessment questions should convey an attitude

that is nonjudgmental, accepting, and communicates concern about the client’s well-being.

The nurse can transition the assessment by acknowledging a heightened concern that was

raised from a linkage with the client’s past diagnosis of borderline personality disorder.

Furthermore, sharing with Kylie the nurse’s knowledge base that “creates a reasonable

doubt” about the congruency between the character of the marks and the manner in which

they occurred as well as calling upon knowledge that correlates a heightened tendency

toward self-harm during periods of emotional turmoil could be constructive in explaining

the stimulus for specific questions.

(c) “What has been happening for you in your life during the past month? Tell me about

36


how things are going for you and your fiancé. What is your level of satisfaction with your

life in general? How satisfied are you with personal relationships? Has anything happened

within the past month that caused you to feel fear, despair, or hopelessness? Have you had

any thoughts about wanting to end your life? Would you tell me if you were having thoughts

about hurting yourself?”

2. SUGGESTED ANSWER: Kylie says in the video:

“When I get angry, I go from zero to 60 in like zero seconds. And when I’m sad, there’s

no just, oh, that’s sad. It’s like I’m crying. I have to go take a nap because I’m so sad

and wake up fresh. If I’m angry, I need to throw something . . . I get so—jump down

people’s throats so fast that they almost don’t even have time to explain that right away

because they’re so shocked at the change in my behavior. Then weeks or days later, they

say that was really all over nothing. But between the time of the initial confrontation and

the time when the person says, looking back on it, this was totally blown out of

proportion, so much other dirty laundry and issues have come into it that it becomes

damaging.”

The influence of Kylie’s illness causes her to have intense experiences of negative life

events and disappointments. She becomes engulfed with strong, potentially destructive,

feelings. Frequently, these types of experiences will produce intense feelings of anger,

compelling her to discharge overwhelming emotions in a physical manner. Likewise, it is

probably difficult for her to have enduring friendships and/or relationships. It is reasonable

to anticipate that a certain degree of disappointment and unmet expectations will be

experienced as part of human nature and relationships. However, Kylie’s intense response to

relationship conflict coupled with an inability to moderate her behavioral reaction probably

37


causes others to distance themselves from her. In addition, relationships become further

complicated by Kylie’s fears of abandonment and rejection. In many ways her response to

negative life events sets in motion a self-fulfilling prophecy.

3. SUGGESTED ANSWER: The interviewer asks Kylie, “Do you sometimes feel that even

when you aren’t actually alone?”

“Oh yeah. Oh, it makes me sweat, it makes me shake, it makes me dizzy. Sometimes I see

stars. Oh, it’s definitely—I can physically feel it. Sometimes I cry. Sometimes I feel like I

need to throw things or punch things or I have to get the energy out of me somehow.”

Kylie’s physical sensations are a manifestation of anxiety. A person diagnosed with

borderline personality disorder experiences anxiety that is evoked as a response to

difficulties in tolerating and moderating strong feelings. This specific emotion can rapidly

escalate and produce a panic attack. Again, emotions are often labile, and in an effort to

dissipate the intense emotional discomfort, some people inflict harm to their bodies.

4. SUGGESTED ANSWER: It would be reasonable to discuss with Kylie that she and her

fiancé consider counseling/therapy sessions as they prepare for a lifetime commitment.

Exploration and discussion about relationship expectations, management of conflict and

disagreements, as well as healthy and supportive responses to Kylie’s erratic personality

would be warranted in these premarital sessions.

Develop a Care Plan

Nursing Diagnosis: Ineffective coping related to intense, labile affect as evidenced by expressed

thoughts of acting on feelings of anger

Outcome: Kylie will refrain from responding to feelings of anger in ways that are life

38


threatening to self or others.


Explore situations that elicit

feelings of anger.

Specific situations can be used

to personalize the anger

management process.

Kylie identifies triggers to her

anger.

Encourage journal keeping to

record experience of life

events and associated

Journal writing helps track

progress.

Kylie uses the journal for

greater insight.

cognitive interpretation as

well as emotional and

behavioral reactions.

Provide education about anger

management:

This establishes the link

between feelings and

behavior.

Kylie verbalizes an

understanding of anger.

a. Nature and function of

anger.

b. Healthy anger is that

which leads to desirable,

productive change.

c. Unhealthy anger is that

which is too intense and

leads to problems with

39


other people or self-

destructive behavior.

d. Distinguish between the

types of aggression: verbal

and physical.

Assist Kylie in identifying the

presence of signals heralding

anger before it becomes

overwhelming:

Learning early signals may

help Kylie modify her typical

reactions to others.

Kylie is able to “stop before

she reacts” with anger.

a. What are her personal

triggers to anger?

b. What are emotional,

physical, and cognitive

cues she can use as

recognition of escalating

anger?

c. Introduce the practice of

“stopping before you

react.”

Provide instruction on calming

strategies for anger

management:

Interrupting the usual process

of anger escalation will allow

for better control of emotions.

Kylie utilizes calming

strategies.

40


a. Practice controlled

breathing techniques.

b. Utilize distraction or

refocusing—draw, listen

to music, talk to someone,

spend time with a pet, etc.

c. Count backward.

d. Leave the situation.

Educate Kylie about

alternatives to self-mutilation:

Having a variety of other

activities may lessen self-

harmful behavior.

Kylie utilizes other behaviors

that result in decreased self-

harm.

a. Discuss nonharmful

symbolic enactment of

feelings, such as “injure” a

toy, make marks with a

red marker, stroke the skin

with ice, snap a rubber

band on the wrist.

b. Use distraction such as

read a book, watch a

video, call a friend.

c. Engage in physical

41


activity.

d. Use art or writing to

express feelings.

Nursing Diagnosis: Disturbed personal identity related to unmet dependency needs and

depreciation as evidenced by inability to tolerate being alone

Outcome: Kylie will utilize a problem-solving approach when she feels emotionally vulnerable

and threatened.


Clearly communicate the

structure, availability, and

length of time for your nurse–

client relationship.

This will diminish the

intensity of future issues that

may arise with relationship

termination.

Kylie verbalizes an

understanding of the

boundaries of the therapeutic

relationship.

Explore the relationship

between thinking, feeling, and

acting.

This will improve insight into

intrapersonal and interpersonal

processes.

Kylie verbalizes an

understanding of these

relationships.

Assist Kylie in owning

personal feelings rather than

projecting them onto others.

This will deepen insight into

typical problems with other

people.

Kylie verbalizes an

understanding of her own

feelings.

Assist Kylie to identify

alternative ways to relate

without seduction or

This will help Kylie learn

ways to socialize with others

in an effective manner.

Kylie discusses other ways to

interact.

42


intimidation.

Assist Kylie in utilizing a

problem-solving

process when faced with a

conflict or unmet expectation.

With each use of the problem-

solving process, skills

increase.

Kylie actively engages in

problem solving.



1. SUGGESTED ANSWER: The interviewer begins, “How come you got into BD? Do you

remember?”

Ashley:“Oh, suspended too many times.”

Interviewer:“Oh. And how come you were suspended?”

Ashley:“Just arguing, skipping classes.”

Interviewer:“And so you were in all these fights. But how come you got kicked out if

people were picking on you?”

Ashley:“It’s more like I was picking on them.”

Interviewer:“Oh, you were?”

Ashley:“Yeah, I love to pick on people.” (NOTE: Ashley looks away from Interviewer,

breaking eye contact with her).

Interviewer:“You do?”

43


Ashley:“Well, not slow kids, just kids I don’t like because my brother’s slow.”

Interviewer:“Your brother’s slow so you don’t pick on slow kids?”

Ashley:“Yeah, because I know how it feels. I was slow.”

Overall, Ashley’s nonverbals communicate a prevailing emotional indifference to the

problems she has had at school. Her facial expressions do not convey concern or remorse for

the conflicts she has had at school, yet she does appear sad. Incongruence between her

verbals and nonverbals is noted at one point during the interview when she breaks eye

contact while stating that she “love(s) to pick on people.” Verbally she is supporting a

message of pleasure and indifference to the conflicts at school, yet the broken eye contact

may convey an underlying shame or inability to express how she is really feeling. Ashley

also acknowledges an ability to exercise restraint, avoiding fights with “slow kids.” It seems

as if she is able to apply compassion and concern for children that she identifies with this

label. This compassion may arise from the care and concern she has for her brother, whom

she labels “slow” as well, as the self-identification she has had with being “slow.”

2. SUGGESTED ANSWER: The interview continues:

Ashley:“I have, like, six counselors.”

Interviewer:“Six counselors. Any of them any good?”

Ashley:“No . . . Except when they buy me food and take me to the gym.”

Interviewer:“What’s the best thing that they’ve told you? That they’ve helped you to

learn?”

Ashley:“Nothing. I usually don’t listen to what they say. I just be like, ‘Yeah, Okay.

44


Yeah, sure. All right.’”

Interviewer:“What’s the worst thing you’ve heard?”

Ashley:“Everything.”

Interviewer:“So if the medicine doesn’t work and the counselors aren’t making any sense

—”

Ashley:“Why do I have them?”

Interviewer:“What’s left?”

Ashley:“Nothing. They’re all worthless. They’re not going to help.”

Interviewer:“Well, what do you think might help?”

Ashley:“Nothing.”

Interviewer:“So you think—”

Ashley:“—let me be.”

Interviewer:“Just let you be?”

Ashley:“Yeah, just let me be me.”

Ashley expresses feelings of hopelessness and lack of confidence in being able to change her

behavior. She expresses frustration that the counselors are ineffective and can’t do or offer

anything to make her life change. She identifies immediate, external gratification as the only

source of value in her counseling relationships. The idea of working toward a reward or

outcome is foreign; consequently, this type of thinking is congruent with her diagnosis of

ADHD. In addition to the feelings of hopelessness, Ashley may also be feeling personally

45


worthless in that she states, “They’re all worthless. They’re not going to help . . . Nothing

(will help me) . . . let me be.”

3. SUGGESTED ANSWER:

Interviewer:“How was life different in second grade?”

Ashley:“It was a lot better.”

Interviewer:“How?”

Ashley:“Get to color all day, play games, snack, lunchtime . . . remember those days?”

Ashley recalls life being positive and satisfying when she was in second grade. She tries to

identify and support her recollection of this time in her life by questioning the interviewer

about the interviewer’s ability to evoke the same memory. Through these comments, it may

be that Ashley is conveying that life is too difficult in eighth grade, no longer satisfying, or

that the things she experiences in life now seem hopeless. She is struggling with the reality

of no longer being a child and reminiscing about a time in her life when she considered

herself successful with the tasks of her second-grade life. Further assessment is indicated to

determine if something happened in Ashley’s life during or after second grade. To what, if

any, event(s) does Ashley attribute the change in her school success? In addition to ODD

and ADHD, Ashley could be giving us a clue as to a learning disorder she is experiencing.

Arguing with teachers and a lack of concentration may also be indicators of a learning

disorder. When she references herself as having been “slow,” is she communicating a clue

that she has developmental delays? Are these developmental delays interfering with her

ability to concentrate and demonstrate success in the eighth grade?


46


Interviewer:“Stay home and sleep? . . . Kind of the same way that you feel when you’re not

arguing? Bored, nothing to do? So what do you wish you could do?”

Ashley:“Go back to school.”

Interviewer:“Yeah. Go back to school so you can argue with the teachers some more?”

Ashley:“No, so I can be a good kid, go to college. I want to go to college so bad and be

a veterinarian or a pediatrician.”

Interviewer:“Wow, that takes a lot of college too.”

Ashley:“Yeah.”

(a) Ashley verbalizes her value of pursuing a college education and a career. Consequently,

the careers she has identified provide insight not only about her value of a college education,

but also a value that places an importance upon doing things to help or take care of children

or animals.

(b) “Tell me what interests you about becoming a veterinarian. Tell me what interests you

about becoming a pediatrician. What qualities do you think you have in common with

people who work as veterinarians or pediatricians? Based upon what you said about not

picking on “slow kids,” I hear that you are a person capable of showing concern and

compassion for people. What things do you do now that support your dreams of working

with animals or children? How interested would you be in working with animals and

children right now?”

5. SUGGESTED ANSWER: It is important to assess if Ashley is having or has had any

suicidal thoughts in relation to her feelings of hopelessness and worthlessness. As the

textbook indicates on page 468, “There is some evidence that Strattera (atomoxetine) may

47


increase the risk of suicidal thinking in children and adolescents.”

Develop a Care Plan

Nursing Diagnosis: Risk for self-directed or other-directed violence related to disorganized or

chaotic environment, history of threats of violence toward others, destruction of property of

others, and feelings of hopelessness and worthlessness

Outcome: Ashley will not harm self or others.


Determine suicidal intent,

plan, and available resources

to carry out plan.

This will allow for protection

of the client during times of

suicidal crisis.

Ashley remains safe.

Support efforts to talk about

her thoughts and feelings.

This will help to minimize

acting out of feelings.

Ashley discusses feelings.

Encourage Ashley to keep a

“pictorial” anger notebook.

She has difficulty finding

words to express her feelings,

so a pictorial notebook will be

beneficial.

Ashley uses pictorial notebook

to discuss feelings.

Provide positive feedback for

attempts to conform to

expectations to control anger.

This provides input and

reinforces new behaviors.

Ashley acknowledges

feedback.

Nursing Diagnosis: Self-esteem disturbance related to low achievement in school, an inability

to conform to expectations of parents and teachers, and rejection from peers and adults

48


Outcome: Ashley will acknowledge personal strengths.


If negative or destructive

behavior occurs during

therapeutic relationship,

communicate that it is her

behavior that is unacceptable,

not her as a person.

Provides feedback as well as

unconditional positive regard.

Ashley acknowledges

feedback.

Assist Ashley to identify

positive aspects of self, such

as compassion and care for

children and animals, concern

for “slow” kids, etc.

Increases insight into self-

worth.

Ashley verbalizes positive

qualities.

Assist Ashley to identify

problematic behaviors.

Identification of problems

precedes the use of the

problem-solving process.

Ashley identifies behaviors

that alienate others.

Assist Ashley in problem-

solving ways to interact more

effectively with others.

Problem-solving will

contribute to an internal locus

of control.

Ashley actively engages in

problem-solving process.

Explore the feasibility of and

arrange, as appropriate,

opportunities for Ashley to

This builds on and supports

Ashley’s personal strengths.

Ashley engages in a variety of

activities.

49


explore her interests and/or

engage in structured activity

with animals and/or children.



1. SUGGESTED ANSWER: Everett says on the video:

“I just felt that there was no hope for the future, that things just—why continue, it was

time to end it. I was unconscious for a period of time, very, very, surprised that I was still

part of the world when I came out of the unconsciousness, couldn’t understand why or

thought, what’s the reason for this? And also feeling more despair because now you

can’t even make good on a suicide attempt.”

Everett expresses extreme hopelessness and despair. He was unable to identify any reason to

remain living, unable to call into his awareness any motivation to stay engaged in life.

Furthermore, Everett spiraled deeper into depression, self-loathing, and worthlessness with

contemplation of his failed suicide attempt.


“I called my psychiatrist and told him. And he said, ‘Well, how serious is this?’ And I

said, ‘We have an agreement that before I ever did anything I’d talk to you.’ And I said,

‘That’s why I’m calling. That’s why we’re talking.’ And I said, ‘I know how you feel and

I know how my family feels.’ I said, ‘But I still have this kind of a feeling that . . . why?’

And then he said another thing. He said, ‘Well, you know how your family feels. You

know how I feel. Imagine how your MDDA family is going to feel if something happens.’

50


And I said, ‘Yeah.’ And I said, ‘I’m not going to.’ But it was a feeling.”

(a) Based upon the evidence that Everett called his physician before acting upon his suicidal

thoughts, it seems that a successful therapeutic alliance must have been fostered between

Everett and the physician.

(b) Everett’s physician was working to reawaken memories of valuable alliances and

commitments Everett had in his life. The doctor included not only himself and Everett’s

family in the framework of people who were inextricably linked to Everett’s life and would

bear the trauma of his death, but also included the members of his support group family. The

bonds that are forged among people who experience similar challenges and endure the

struggles to cope, adapt, and live with mental illness usually run very deep. A group

member’s suicide is emotionally painful and personal, as it is potentially reflective of any

group member’s loss of life.


“I thought it would be a relief. I really believed, for them I thought—I didn’t think it

would be painful. I thought it would be a relief.” 00:15:18 “For a while we didn’t talk

about It. I think that it was painful for them. It was painful for me. So we didn’t talk

about it. It was—I talked with my psychiatrist about it, but family I stayed away for quite

awhile. And finally, I said, ‘Well, I tried something. I guess, that didn’t work. How do

you feel? Are you glad or do you wish it had’ve worked?’ And I told them how I had felt

previously, that I had thought that they’d be relieved. And they all said they wouldn’t

have been relieved, it would have been horrible.”

(a) Everett voices a cognition that is negative and dichotomous. His reasoning at the time

51


revealed to him that his death would be a relief and in no way painful for his family. He was

unable to call into awareness the realization that his family might also experience

devastating emotional pain and trauma.

(b) Everett conveys shame and guilt associated with his failed suicide attempt. Shame as an

affective characteristic is supported by his avoidance of discussing his suicide attempt with

his family. He may have also physically distanced himself from his family as evidenced by

his statement of “I stayed away for quite awhile.” In addition, during this segment he avoids

referring to the suicide attempt as an act to take his life or as a suicide, but instead makes

references to “it” and “something.”

4. SUGGESTED ANSWER: In an effort to offer hope to your patient and engage any part of

the self that retains a will toward life, you can direct interventions toward problem-solving

and the creation of other, non-self-destructive, choices. As suggested in the text, you could

assist your patient in developing a list of reasons to live or die, identifying goals that were

meant to be achieved by the suicide, and developing a list of alternative solutions. By

assisting your patients to insert rational, logical thoughts instead of distorted cognitions (i.e.,

they would be “better off dead”) as responses to feelings, you help them to perceive

distortions in their thinking and a different perspective to interpretation of life event(s). By

also supporting clients in identifying a goal that they want to achieve from death, you open

their awareness to the reality that they won’t be able to experience the satisfaction or

confirmation that the goal was achieved—thereby creating an avenue of exploring other

alternatives to achieve the desired goal and experience the outcome. Frequently, a person

who feels hopeless and suicidal has such a narrowed perceptional field that he or she

believes suicide is the only avenue that will generate a response, evoke a feeling, or ensure

52


that his or her goal is achieved. The gravity and reality that death generates a permanent,

irreversible solution is not recognized.

5. SUGGESTED ANSWER: Everett’s self-reported history of major depression during the

majority of his life, long-standing and engrained framework of suicidal ideations, coupled

with a failed suicide attempt, place him at serious risk for future suicide attempts. As the text

indicates, those rescued from suicidal behavior remain at a higher risk than the general

population through their lifetime. While we don’t know his ethnic origins or religious

practices and therefore are unable to correlate those specific cultural risks, there should be a

heightened awareness created by the age-specific characteristics he possesses. As the text

states on page 569, people who are 65 and older have the highest suicide rate of all age

groups. They make up only 13% of the population, but they account for 25% of all suicides.

Suicide rates for men are relatively constant from ages 25 to 64, but increase significantly

after age 65, and men account for 83% of suicides among persons age 65 and older (Bruce et

al., 2004). Everett was 71 years old at the time this interview was conducted. Last, many of

his past depressive episodes linked into thoughts of loss and failure as a teacher, as an

administrator, and as a spouse and father. Assessments for any major shifts in cognition,

increased depressive affective characteristics, and suicidal ideation should be incorporated

into Everett’s ongoing professional health relationships. Diminished resources that can arise

with aging, personal economic changes, or relationship losses could create a coping crisis for

Everett.

Develop a Care Plan

Nursing Diagnosis: Risks for suicide related to history of prior suicide attempt, past pattern of

53


hopeless and helpless thinking, and age-specific risk characteristics

Outcome: Everett will not harm himself.


Assess current life events and

emotional, physical, social,

and spiritual changes

associated with aging.

These changes might create a

coping crisis.

Everett discusses the meaning

of life changes.

Assess for protective factors

against suicide, such as

support group, good

Protective factors decrease the

likelihood of suicide.

Everett identifies factors that

support his will to live.

problem-solving skills,

responsibility

to family, etc.

Assess for presence of

spiritual foundations that

provide life guidance.

Values and beliefs may

support the will to live.

Everett discusses the meaning

of spirituality in his life.

Discuss death: what it means,

feelings about death, and

perceptions about death.

Open discussion may decrease

the urge to commit suicide to

solve problems.

Everett discusses thoughts

about death.

Nursing Diagnosis: Self-esteem disturbance related to a lifetime of negative expectations of self

Outcome: Everett will verbalize personal judgment of self-worth.


54


Assist in process of

identifying strengths and life

achievements.

Provides a reality base for

self-evaluation.

Everett identifies

achievements.

Minimize discussion about

past failures.

Helps focus on the positive

rather than negative.

Everett decreases time spent

talking about life failures.

Reframe weakness and failure

as an opportunity for change.

Redefinition may contribute to

new interpretations and new

behaviors.

Everett turns perceived

failures into successes.

Explore ways to accept

responsibility for behavior in a

way that is non-loathing and

without self-reproach.

Decreasing negative

statements will improve self-

esteem.

Everett verbalizes an

improved self-esteem.

Provide education that

differentiates assertive,

passive, passive-aggressive,

and aggressive behaviors.

Knowledge is necessary to

make changes in behavior.

Everett verbalizes an

understanding of the various

behaviors.

Provide feedback on assertive

behavior.

This reinforces the use of new

behaviors.

Everett engages in assertive

behavior.




55


“I knew what he was doing when I was trying not to look him straight in the face and just

kind of go about my business as if I was doing something, just normal activity. And he’d

be on the other side of the room. I could see him in my peripheral vision playing around

with the gun and just looking at it and mumbling about how beautiful it was and ‘Look at

this craftsmanship’ and how wonderfully made it was and all of this other nonsense that

would come out of his mouth when he was drunk and he would, I believe, deliberately

point the gun in my direction. He’d be sitting in this corner, I’d be over there and he

would just point it this way and just continue to look at it and tell me how beautiful it was

but it was pointing in my direction. I would be increasingly nervous and upset but trying

to remain calm and he would just look at me with a sort of demonic grin and say, ‘Oh

does this make you nervous?’ And that actually was more chilling to me than if he’d

actually pointed it at me. It may sound strange to others but dealing with that sort of

action, it’s much more concrete and I know what his intent is, I know what he’s doing.

When he’s drunk and just kind of moving the gun around and asking me questions like

that, it was more distressing actually.”

The dynamics are those of power and control. The male Sara talks about is exerting his

influence through the gun to reinforce power and control over Sara. He exhibited a regular

pattern of manipulating the gun in Sara’s presence, coercing with his actions, and

reinforcing her emotional response of fear. His behaviors left her passive and paralyzed. He,

the abuser, has learned that coercion “works,” and that it’s effective in controlling the

relationship and in reinforcing the power imbalance.

2. SUGGESTED ANSWER: Sara is voicing negative cognitive thought processes that were

reinforced in response to the cycle of violence she was exposed to within the abusive

56


relationship. She verbalizes cognitive distortions of self-blame and guilt that became a fabric

of reality in how Sara perceived herself. In addition, the dynamics of the abusive

relationship exerted control over her socialization with others and her own social networks,

ultimately fostering her low self-esteem. Isolation and withdrawal from others creates

deprivation for the victim, and in Sara’s case it left her without support and vulnerable to the

abuser’s power and control of her life. As the text states, “They begin to believe the violence

itself is evidence of personal worthlessness. Some victims even absolve the abuser from

responsibility by blaming violent behavior on a high level of stress or too much alcohol.”


“One of the biggest things was I get very nauseous. And feel dizzy and rubbery. And I

feel immobilized by the fear, physically and emotionally and psychologically. I would feel

—my heart pound, it would race, I’d feel sweaty and get clammy. Sometimes, when I was

particularly afraid, I would lose all feeling in my hands and my hands would just become

very stiff and I wouldn’t even be able to move them, some strange neurological reaction.

But mostly, I would just feel like I was going to have a heart attack and/or vomit or both.

And I still have a lot of nightmares and flashbacks now. They’re getting better and

they’re less frequent, they’re still fairly prevalent and sometimes intense.”

Sara is verbalizing the signs and symptoms associated with PTSD (posttraumatic stress

disorder).


(a) Maintain an accepting and nonjudgmental attitude while screening for the presence of

IPV. The key is to convey trust and to ensure that the patient perceives that the nurse is

57


prepared to hear his or her answer regardless of the information contained within the answer.

Ask the patient direct questions about IPV in a face-to-face assessment. The patient is more

likely to disclose active IPV during a one-to-one discussion than through a written

questionnaire. When trust has been established, openness and directness about the situation

will help to build the nurse–patient relationship.

(b) “Because violence is so common in many people’s lives, I’ve begun to ask all my

patients about it.” “I don’t know if this is a problem for you, but many of the women I see

are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up

themselves. So, I’ve started asking it routinely.”

(c) “Tell me about what happened to you.” “How do you and your partner resolve

disagreements?” “What do you do for fun?” “Who helps you with your children?” “What

time do you have for yourself?”

5. SUGGESTED ANSWER: Any two of the following actions would support responsible

nursing practice and accurate documentation:

1. Take photographs of injuries known or suspected to have resulted from domestic violence

(obtain patient consent).

2. Write legibly. Computers can also help overcome the common problem of illegible

handwriting.

3. Set off the patient’s own words in quotation marks or use such phrases as “patient states”

or “patient reports” to indicate that the information recorded reflects the patient’s words. To

write “patient was kicked in abdomen” obscures the identity of the speaker. Note any

utterances that the patient conveys. The patient’s “excited utterances” or “spontaneous

58


exclamations” about the incident are another exception to the prohibition of hearsay. These

are statements made by someone during or soon after an event, while in an agitated state of

mind. They have exceptional credibility because of their proximity in time to the event and

because they are not likely to be premeditated. The prosecution can proceed based upon

these utterances if the victim refuses to testify. A patient’s report may be admissible based

upon these utterances that occurred as stimulus to the event (abuse).

4. Avoid such phrases as “patient claims” or “patient alleges,” which imply doubt about the

patient’s reliability. If the clinician’s observations conflict with the patient’s statements, the

clinician should record the reason for the difference.

5. Describe the person who hurt the patient by using quotation marks to set off the statement.

The clinician would write, for example: The patient stated, “My boyfriend kicked and

punched me.”

6. Avoid summarizing a patient’s report of abuse in conclusive terms. If such language as

“patient is a battered woman,” “assault and battery,” or “rape” lacks sufficient

accompanying factual information, it is inadmissible.

7. Use a body map to document areas of injury.

8. Describe the patient’s demeanor, indicating, for example, whether she is crying or shaking

or seems angry, agitated, upset, calm, or happy. Even if the patient’s demeanor belies the

evidence of abuse, the clinician’s observations of that demeanor should be recorded.

9. Record the time of day the patient is examined and, if possible, indicate how much time has

elapsed since the abuse occurred. For example, the clinician might write, “Patient states that

early this morning, his boyfriend hit him.”

59


SOURCE: Answers above were retrieved from document published by the U.S. Department

of Justice, Office of Justice Programs, National Institute of Justice, Washington, DC 20531.

Isaac, N., & Enos, V. (2001). Documenting domestic violence: How healthcare providers

can help victims. Washington DC: National Institute of Justice. Retrieved May 31, 2006,

from http://www.ncjrs.org/txtfiles1/ nij/188564.txt.

Develop a Care Plan

Nursing Diagnosis: Powerlessness related to feelings of being dependent on the abuser

Outcome: Sara will verbalize feelings of empowerment and act on her own behalf.


Help formulate a list of ways

she is dependent on her

abusive boyfriend.

High levels of dependency

make it difficult for the victim

to leave the abuser without

intense support.

Sara formulates a list of

dependencies.

Help in the identification of

intrapersonal and interpersonal

strengths.

Recognition of strengths will

decrease feelings of

powerlessness.

Sara identifies strengths.

Help in the identification of

aspects of life under her

control.

Feelings of control will

decrease feelings of

powerlessness.

Sara identifies situations of

control.

Provide assertiveness training.

Caution Sara that while she

Continual submission to

violence often escalates

Sara utilizes assertive

techniques with caution.

60


remains in a relationship with

her boyfriend, assertive

behavior may escalate the

violence.

episodes of violent behavior.

Refer to community resources

for financial aid, employment

aid, and legal aid.

This will decrease dependency

on the abuser.

Sara follows through on

referrals.

Provide positive

reinforcement for Sara’s work

toward self-determination and

independence.

Feedback reinforces new

behaviors.

Sara acknowledges feedback.

Nursing Diagnosis: Social isolation related to control by abuser and shame fostered by the

interpersonal violence

Outcome: Sara will identify a plan to increase socializing activities.

Interventions Rationale Goal

Provide information about

thought processes that arise

from abusive relationships.

Helps Sara understand how

these thoughts become the

basis for faulty logic, faulty

conclusions about self, and

reinforcement for shame.

Sara verbalizes an

understanding of her thought

processes.

Assist in identifying

relationships she would like to

Isolation has ended many

relationships, which now need

Sara identifies people with

whom she would like to

61


pursue. to be rebuilt. develop friendships.

Assist in acknowledging an in-

ternal locus of control.

She has new options she did

not have when she was under

the influence of the abusive

relationship.

Sara verbalizes an internal lo-

cus of control.

62

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