Flashcards in Chapter 17 Deck (26):
1. Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)?
a. Voluntary control of symptoms
b. Patient’s style of presentation
c. Results of diagnostic testing
d. The role of secondary gains
Patients with illness anxiety disorder (hypochondriasis) tend to be more anxious about their concerns and display more obsessive attention to detail, whereas the patient with conversion (functional neurological) disorder often exhibits less concern with the symptom they are presenting than would be expected. Neither disorder involves voluntary control of the symptoms. Results of diagnostic testing for both would be negative (i.e., no physiological basis would be found for the symptoms). Secondary gains can occur in both disorders but are not necessary to either. See relationship to audience response question.
2. Which prescription medication would the nurse expect to be prescribed for a patient diagnosed with a somatic symptom disorder?
a. Narcotic analgesics for use as needed for acute pain
b. Antidepressant medications to treat underlying depression
c. Long-term use of benzodiazepines to support coping with anxiety
d. Conventional antipsychotic medications to correct cognitive distortions
Various types of antidepressants may be helpful in somatic disorders directly by reducing depressive symptoms and hence somatic responses, but also indirectly by affecting nerve circuits that affect not only mood, but fatigue, pain perception, GI distress, and other somatic symptoms. Patients may benefit from short-term use of anti-anxiety medication (benzodiazepines) but require careful monitoring because of risks of dependence. Conventional antipsychotic medications would not be used, although selected atypical antipsychotics may be useful. Narcotic analgesics are not indicated.
3. A medical-surgical nurse works with a patient diagnosed with a somatic symptom disorder. Care planning is facilitated by understanding that the patient will probably:
a. readily seek psychiatric counseling.
b. be resistant to accepting psychiatric help.
c. attend psychotherapy sessions without encouragement.
d. be eager to discover the true reasons for physical symptoms.
Patients with somatic symptom disorders go from one health care provider to another trying to establish a physical cause for their symptoms. When a psychological basis is suggested and a referral for counseling offered, these patients reject both.
4. A patient has blindness related to conversion (functional neurological) disorder but is unconcerned about this problem. Which understanding should guide the nurse’s planning for this patient?
a. The patient is suppressing accurate feelings regarding the problem.
b. The patient’s anxiety is relieved through the physical symptom.
c. The patient’s optic nerve transmission has been impaired.
d. The patient will not disclose genuine fears.
Psychoanalytical theory suggests conversion reduces anxiety through production of a physical symptom symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. While some MRI studies suggest that patients with conversion disorder have an abnormal pattern of cerebral activation, there is no actual alternation of nerve transmission. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously). See relationship to audience response question.
5. A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should:
a. establish a “buddy” system with other patients who can feed the patient at each meal.
b. expect the patient to feed self after explaining arrangement of the food on the tray.
c. direct the patient to locate items on the tray independently and feed self.
d. address needs of other patients in the dining room, then feed this patient.
The patient is expected to maintain some level of independence by feeding self, while the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support.
6. A patient with blindness related to conversion (functional neurological) disorder says, “All the doctors and nurses in the hospital stop by often to check on me. Too bad people outside the hospital don’t find me as interesting.” Which nursing diagnosis is most relevant?
a. Social isolation c. Interrupted family processes
b. Chronic low self-esteem d. Ineffective health maintenance
The patient mentions that the symptoms make people more interested. This indicates that the patient feels uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in the scenario.
7. To assist patients diagnosed with somatic symptom disorders, nursing interventions of high priority:
a. explain the pathophysiology of symptoms.
b. help these patients suppress feelings of anger.
c. shift focus from somatic symptoms to feelings.
d. investigate each physical symptom as it is reported.
Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in the patient as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome would be that the patient would express feelings, including anger if it is present. Once physical symptoms are investigated, they do not need to be reinvestigated each time the patient reports them.
8. A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, “My chest is tight, and my heart misses beats. I’m often absent from work. I don’t go out much because I need to rest.” Which health problem is most likely?
a. Dysthymic disorder
b. Somatic symptom disorder
c. Antisocial personality disorder
d. Illness anxiety disorder (hypochondriasis)
Illness anxiety disorder (hypochondriasis) involves preoccupation with fears of having a serious disease even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Somatic symptom disorder involves fewer symptoms. Dysthymic disorder is a disorder of lowered mood. Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others. See relationship to audience response question.
9. A nurse assessing a patient diagnosed with a somatic symptom disorder is most likely to note that the patient:
a. sees a relationship between symptoms and interpersonal conflicts.
b. has little difficulty communicating emotional needs to others.
c. rarely derives personal benefit from the symptoms.
d. has altered comfort and activity needs.
The patient frequently has altered comfort and activity needs associated with the symptoms displayed (fatigue, insomnia, weakness, tension, pain, etc.). In addition, hygiene, safety, and security needs may also be compromised. The patient is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Patients with somatic symptom disorders often derive secondary gain from their symptoms and/or have considerable difficulty identifying feelings and conveying emotional needs to others.
10. To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms:
a. are generally chronic.
b. have a physiological basis.
c. can be voluntarily controlled.
d. provide relief from health anxiety.
At the unconscious level, the patient's primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the patient more psychologically comfortable and may also provide secondary gain, patients frequently fiercely cling to the symptoms. The symptoms tend to be chronic, but that does not explain why they are difficult to give up. The symptoms are not under voluntary control or physiologically based.
11. A patient with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to patient’s disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will:
a. assume roles and functions of other family members.
b. demonstrate performance of former roles and tasks.
c. focus energy on problems occurring in the family.
d. rely on family members to meet personal needs.
The patient with a somatic symptom disorder has typically adopted a sick role in the family, characterized by dependence. Increasing independence and resumption of former roles are necessary to change this pattern. The distracters are inappropriate outcomes.
12. Which comment by a patient who recently experienced a myocardial infarction indicates use of maladaptive, ineffective coping strategies?
a. “My employer should have paid for a health club membership for me.”
b. “My family will see me through this. It won’t be easy, but I will never be alone.”
c. “My heart attack was no fun, but it showed me up the importance of a good diet and more exercise.”
d. “I accept that I have heart disease. Now I need to decide if I will be able to continue my work daily.”
Blaming someone else and rationalizing one’s failure to exercise are not adaptive coping strategies. Seeing the glass as half full, using social and religious supports, and confronting one’s situation are seen as more effective strategies. The distracters demonstrate effective coping associated with a serious medical condition.
13. A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which comment is most likely from this patient?
a. “Since my father died, I’ve been short of breath and had sharp pains that go down my left arm, but I think it’s just indigestion.”
b. “I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I think I’m getting seriously dehydrated.”
c. “Sexual intercourse is painful. I pretend as if I’m asleep so I can avoid it. I think it’s starting to cause problems with my marriage.”
d. “I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus.”
Patients with conversion (functional neurological) disorder demonstrate a lack of concern regarding the seriousness of symptoms. This lack of concern is termed “la belle indifférence.” There is also a specific, identifiable cause for the development of the symptoms; in this instance, the death of a parent would precipitate stress. The distracters relate to sexual dysfunction and illness anxiety disorder.
14. A patient who experienced a myocardial infarction was transferred from critical care to a step-down unit. The patient then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient’s needs. When the nurse manager intervenes directly with this patient, which comment is most therapeutic?
a. “I’m wondering if you are feeling anxious about your illness and being left alone.”
b. “The staff are concerned that you are not satisfied with the care you are receiving.”
c. “Let’s talk about why you use your call light so frequently. It is a problem.”
d. “You frustrate the staff by calling them so often. Why are you doing that?”
This patient is experiencing anxiety associated with a serious medical condition. Verbalization is an effective outlet for anxiety. “I’m wondering if you are anxious…” focuses on the emotions underlying the behavior rather than the behavior itself. This opening conveys the nurse’s willingness to listen to the patient’s feelings and an understanding of the commonly seen concern about not having a nurse always nearby as in the intensive care unit. The other options focus on the behavior or its impact on nursing and do not help the patient with her emotional needs.
15. A patient reports fears of having cervical cancer and says to the nurse, “I’ve had Pap smears by six different doctors. The results were normal, but I’m sure that’s because of errors in the laboratory.” Which disorder would the nurse suspect?
a. Conversion (functional neurological) disorder
b. Illness anxiety disorder (hypochondriasis)
c. Somatic symptom disorder
d. Factitious disorder
Patients with illness anxiety disorder have fears of serious medical problems, such as cancer or heart disease. These fears persist despite medical evaluations and interfere with daily functioning. There are no complaints of pain. There is no evidence of factitious or conversion disorder.
16. A patient diagnosed with a somatic symptom disorder says, “My pain is from an undiagnosed injury. I can’t take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much.” It is important for the nurse to assess:
a. mood. c. secondary gains.
b. cognitive style. d. identity and memory.
Secondary gains should be assessed. The patient’s dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patient’s diagnosis has been established.
17. What is an essential difference between somatic symptom disorders and factitious disorders?
a. Somatic symptom disorders are under voluntary control, whereas factitious disorders are unconscious and automatic.
b. Factitious disorders are precipitated by psychological factors, whereas somatic symptom disorders are related to stress.
c. Factitious disorders are individually determined and related to childhood sexual abuse, whereas somatic symptom disorders are culture bound.
d. Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization.
The key is the only fully accurate statement. Somatic symptom disorders involve expression of stress through bodily symptoms and are not under voluntary control or culture bound. Factitious disorders are under voluntary control. See relationship to audience response question.
18. A patient says, “I know I have a brain tumor despite the results of the MRI. The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day.” Which response by the nurse fosters cognitive reframing?
a. “You do not have a brain tumor. The more you talk about it, the more it reinforces your belief.”
b. “Let’s see if there are any other possible explanations for your vomiting.”
c. “You seem so worried. Let’s talk about how you’re feeling.”
d. “We need to talk about something else.”
Questioning the evidence is a cognitive reframing technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective.
19. Which treatment modality should a nurse recommend to help a patient diagnosed with a somatic symptom disorder to cope more effectively?
a. Flooding c. Relaxation techniques
b. Response prevention d. Systematic desensitization
Somatic symptom disorders are commonly associated with complicated reactions to stress. These reactions are accompanied by muscle tension and pain. Relaxation can diminish the patient’s perceptions of pain and reduce muscle tension. The distracters are modalities useful in treating selected anxiety disorders.
20. Which assessment question could a nurse ask to help identify secondary gains associated with a somatic symptom disorder?
a. “What are you unable to do now but were previously able to do?”
b. “How many doctors have you seen in the last year?”
c. “Who do you talk to when you’re upset?”
d. “Did you experience abuse as a child?”
Secondary gains should be assessed. Secondary gains reinforce maladaptive behavior. The patient’s dependency needs may be evident through losses of abilities. When secondary gains are prominent, the patient is more resistant to giving up the symptom. There may be a history of abuse or doctor shopping, but the question does not assess the associated gains.
21. A patient diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The patient says, “Although I’m still having pain, I notice it less and am able to perform more activities.” The nurse should evaluate the treatment plan as:
a. marginally successful. c. partially successful.
b. minimally successful. d. totally achieved.
Decreased preoccupation with symptoms and increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of patient resistance.
1. A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder by proxy is suspected. Which nursing interventions are appropriate? Select all that apply.
a. Increase private visiting time for the parents to improve bonding.
b. Keep careful, detailed records of visitation and untoward events.
c. Place mittens on the child to reduce access to ports and incisions.
d. Encourage family members to visit in groups of two or three.
e. Interact with the patient frequently during visiting hours.
ANS: B, D, E
Factitious disorder by proxy is a rare condition wherein a person intentionally causes or perpetuates the illness of a loved one (e.g., by periodically contaminating IV solutions with fecal material). When this disorder is suspected, the child’s life could be at risk. Depending on the evidence supporting this suspicion, interventions could range from minimizing unsupervised visitation to blocking visitation altogether. Frequently checking on the child during visitation and minimizing unobserved access to the child (by encouraging small group visits) reduces the opportunity to take harmful action and increases the collection of data that can help determine whether this disorder is at the root of the child’s illness. Detailed tracking of visitation and untoward events helps identify any patterns there might be between select visitors and the course of the child’s illness. Increasing private visitation provides more opportunity for harm. Educating visitors about aseptic techniques would not be of help if the infections are intentional, and preventing inadvertent contamination by the child himself would not affect factitious disorder by proxy.
2. Which presentations suggest the possibility of a factitious disorder, self-directed type? Select all that apply.
a. History of multiple hospitalizations without findings of physical illness
b. History of multiple medical procedures or exploratory surgeries
c. Going from one doctor to another seeking the desired response
d. Claims illness to obtain financial benefit or other incentive
e. Difficulty describing symptoms
ANS: A, B
Persons with factitious disorders, self-directed type, typically have a history of multiple hospitalizations and medical workups, with negative findings from workups. Sometimes they have even had multiple surgeries seeking the origin of the physical complaints. If they do not receive the desired response from a hospitalization, they may elope or accuse staff of incompetence. Such persons usually seek treatment through a consistent health care provider rather than doctor-shopping, are not motivated by financial gain or other external incentives, and present symptoms in a very detailed, plausible manner indicating considerable understanding of the disorder or presentation they are mimicking. See relationship to audience response question.
3. A patient diagnosed with a somatic symptom disorder says, “Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear.” Which nursing diagnoses apply to this patient? Select all that apply.
a. Spiritual distress
b. Decisional conflict
c. Adult failure to thrive
d. Impaired social interaction
e. Ineffective role performance
ANS: A, E
The patient’s verbalization is consistent with spiritual distress. The patient’s description of being unable to provide for and burdening the family indicates ineffective role performance. No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional conflict.
4. A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment findings regarding this patient support the suspected diagnosis? Select all that apply.
b. Reports frequent syncope
c. Rates pain as “1” on a scale of “10”
d. First diagnosed with psoriasis at age 12
e. Reports insomnia often results from back pain
ANS: A, B, E
There is no chronic disease to explain the symptoms for patients with somatic symptom disorder. Patients report multiple symptoms; gastrointestinal and pseudoneurological symptoms are common. This disorder is more common in women than in men. Patients with conversion disorder would have a tendency to underrate pain.