A 16-year-old girl has returned home following hospitalization for treatment of anorexia nervosa. The parents tell the family nurse performing a home visit that their child has always done everything to please them and they cannot understand her current stubbornness about eating. The nurse analyzes the family situation and determines it is characteristic of which relationship style?
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Solution
Enmeshment
Enmeshment is a fusion or over involvement among family members whereby the expectation exists that all members think and act alike. The child who always acts to please her parents is an example of how enmeshment affects development in many cases, a child who develops anorexia nervosa exerts control only in the area of eating behavior.
Options A, B, and D: The remaining options are not appropriate to the situation described.
The nurse is interacting with a family consisting of a mother, a father, and a hospitalized adolescent who has a diagnosis of alcohol abuse. The nurse analyzes the situation and agrees with the adolescent’s view about family rules. Which intervention is most appropriate?
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Solution
The nurse should remain objective and encourage mutual negotiation of issues.
The nurse who wishes to be helpful to the entire family must remain neutral. Taking sides in a conflict situation in a family will not encourage negotiation, which is important for problem resolution.
Option A: If the nurse aligned with the adolescent, then the nurse would be blaming the parents for the child’s current problem; this would not help the family’s situation. Learning to negotiate conflict is a function of a healthy family.
Options B and C: Encouraging the parents to adopt more realistic rules or the adolescent to comply with parental rules does not give the family an opportunity to try to resolve problems on their own.
According to the family systems theory, which of the following best describes the process of differentiation?
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Solution
Development of autonomy within the family
Differentiation is the process of becoming an individual developing autonomy while staying in contact with the family system.
Option A: Cooperative action among family members does not refer to differentiation, although individuals who have a high level of differentiation would be able to accomplish cooperative action.
Option C: Incongruent messages in which the recipient is a victim describe double-bind communication.
Option D: Maintenance of system continuity or equilibrium is homeostasis.
The nurse collecting family assessment data asks. “Who is in your family and where do they live?” which of the following is the nurse attempting o identify?
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Solution
Boundaries
Family boundaries are parameters that define who is inside and outside the system. The best method of obtaining this information is asking the family directly who they consider to be members.
Options B, C, and D: The question asked by the nurse would not elicit information about the family’s ethnicity or culture, nor does it address the nature of the family relationship.
The parents of a young man with schizophrenia express feelings of responsibility and guilt for their son’s problems. How can the nurse best educate the family?
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Solution
Explain the biological nature of schizophrenia.
The parents are feeling responsible and this inappropriate self-blame can be limited by supplying them with the facts about the biologic basis of schizophrenia.
Option A: Acknowledging the patient’s responsibility is neither accurate nor helpful to the parents and would only reinforce their feelings of guilt.
Option C: Support groups are useful; however, the nurse needs to handle the parents’ self-blame directly instead of making a referral for this problem.
Option D: Teaching the parents various ways to change would reinforce the parental assumption of blame; although parents can learn about schizophrenia and what is helpful and not helpful, the approach suggested in this option implies the parents’ behavior is at fault.
The school guidance counselor refers a family with an 8-year-old child to the mental health clinic because of the child’s frequent fighting in school and truancy. Which of the following data would be a priority to the nurse doing the initial family assessment?
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Solution
The family’s perception of the current problem
The family’s perception of the problem is essential because change in any one part of a family system affects all other parts and the system as a whole. Each member of the family has been affected by the current problems related to the school system and the nurse would be interested in the data. Options A and D: The child’s performance in school and the teacher’s attempts to solve the problem are relevant and may be assessed; however, priority would be given to the family’s perception of the problem. Option B: The family education and work history may be relevant, but are not a priority.
Which of the following outcome criteria is appropriate for the client with dementia?
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Solution
The client will follow an establishing schedule for activities of daily living.
Following established activity schedules is a realistic expectation for clients with dementia.
Options A, B, and C: All of the remaining outcome statements require a higher level of cognitive ability than can be realistically expected of clients with this disorder.
In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called:
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Solution
Sundowning
Sundowning is a common phenomenon that occurs after daylight hours in a client with a cognitive impairment disorder. The other options are incorrect responses, although all may be seen in this client.
An elderly client with Alzheimer’s disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to:
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Solution
Remain calm and talk quietly to the client.
Maintaining a calm approach when intervening with an agitated client is extremely important.
Option A: Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him.
Option B: Restraints are a last resort to ensure client safety and are inappropriate in this situation.
Option D: Sedation should be avoided, if possible, because it will interfere with CNS functioning and may contribute to the client’s confusion.
A 75-year-old client has dementia of the Alzheimer’s type and confabulates. The nurse understands that this client:
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Solution
Fills in memory gaps with fantasy.
Confabulation is a communication device used by patients with dementia to compensate for memory gaps. The remaining answer choices are incorrect.