Exam (elaborations) (BOOK)PSYCHIATRIC MENTAL HEALTH NURSING SUCCESS A Q & A REVIEW APPLYING CRITICAL THINKING TO TEST TAKING 3RD EDITION

(BOOK)PSYCHIATRIC MENTAL HEALTH NURSING SUCCESS A Q & A REVIEW APPLYING CRITICAL THINKING TO TEST TAKING 3RD EDITION By: Cathy Melfi Curtis and Audra Baker Fegley ISBN 0403 416 PAGES Psychiatric Mental Health Nursing Success A Q & A Review Applying Critical Thinking to Test Taking Third Edition Cathy Melfi Curtis, MSN, RN-BC Psychiatric Mental Health Nurse Sullivan’s Island, South Carolina Audra Baker Fegley, MSN, PMHNP-BC Psychiatric Mental Health Nurse Practitioner Knoxville, Tennessee Psychiatric Mental Health Nursing Success A Q & A Review Applying Critical Thinking to Test Taking Third Edition F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 Copyright © 2017 by F. A. Davis Company Copyright © 2017 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Terri Wood Allen Content Project Manager: Julia L. Curcio Electronic Project Manager: Sandra A. Glennie Design and Illustrations Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Names: Curtis, Cathy Melfi, author. | Fegley, Audra Baker, author. Title: Psychiatric mental health nursing success: A Q & A review applying critical thinking to test taking/Cathy Melfi Curtis, Audra Baker Fegley. Description: Third edition. | Philadelphia: F.A. Davis Company, [2017] | Includes index. Identifiers: LCCN 2 | ISBN 0403 Subjects: | MESH: Psychiatric Nursing | Test Taking Skills | Examination Questions Classification: LCC RC440 | NLM WY 18.2 | DDC 616.89/--dc23 LC record available at Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 0403/17 0 + $.25. The authors dedicate this book to nursing students whose eagerness to learn motivates us to teach mental health nursing concepts in a way that is clear and readily understood. Through the use of application and analysis test questions, we hope to enhance the students’ critical thinking skills and thereby promote excellence in their nursing practice. Carol Norton Tuzo helped create the last two editions of this book. We would like to thank her for sharing her knowledge of mental health nursing and her ability to say the correct thing in the least amount of words possible! We appreciate her friendship and respect her need for a break from writing. —Cathy Melfi Curtis Audra Baker Fegley I would like to dedicate this book to the memory of my sister, Sally. She was also a nursing instructor and would have appreciated the time and effort that went into this book. Also, I would like to thank my children, Scott, Emily, and Katie, who were supportive and patient during the project development. I’m now available to babysit the grandchildren, Tessa, Bobby, Eve, Jessie, Willie, Addy, Jamie, Gavin, Megan, and Macie. —Cathy Melfi Curtis This book is dedicated to my husband, Damon, whose love and understanding give me strength; to my parents, Bonnie and Stan Baker, who listen attentively and always believe in me; to my 5 year-old son, Dorian, who brings me such pride and joy; and to my 3 year-old daughter, Nora, who makes my heart melt every day. Much love. —Audra Baker Fegley vii A Fundamentals of Critical Thinking Related to Test Taking Introduction. 1 INTRODUCTION. 1 Definition of Critical Thinking. 1 MAXIMIZE YOUR CRITICAL-THINKING ABILITIES. 1 Be Positive: You Can Do It!. 1 Overcome Barriers to a Positive Mental Attitude. 2 Be Reflective: You Need to Take One Step Backward Before Taking Two Steps Forward!. 2 Overcome Barriers to Effective Reflection. 4 Be Inquisitive: If You Don’t Go There, You’ll Never Get Anywhere!. . . . . . . . . . . . . . . . . . . .5 Overcome Barriers to Being Inquisitive. 6 Be Creative: You Must Think Outside the Box!. 7 Overcome Barriers to Creativity. 7 CRITICAL THINKING APPLIED TO TEST TAKING. 8 Educational Domains. 8 Components of a Multiple-Choice Question . 8 Cognitive Levels of Nursing Questions. 9 CRITICAL-THINKING STRATEGY TO ANSWER MULTIPLE-CHOICE QUESTIONS: THE RACE MODEL. 9 Knowledge Questions: Remember Information!. 9 Cognitive Requirements . 9 Use a Critical-Thinking Strategy to Answer Knowledge-Level Questions. 11 Comprehension Questions: Understand Information!. 11 Cognitive Requirements . 11 Use a Critical-Thinking Strategy to Answer Comprehension-Level Questions. 12 Application Questions: Use Information!. 13 Cognitive Requirements . 13 Use a Critical-Thinking Strategy to Answer Application-Level Questions. 13 Analysis Questions: Scrutinize Information!. 14 Cognitive Requirements . 14 Use a Critical-Thinking Strategy to Answer Analysis-Level Questions. 15 SUMMARY. 15 B Basic Concepts in Psychiatric Mental Health Nursing 1 Mental Health/Mental Illness: Theoretical Concepts. 17 KEYWORDS 17 QUESTIONS 18 Major Theoretical Models. 18 Biological Implications. 21 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 22 ANSWERS AND RATIONALES 23 Major Theoretical Models. 23 Biological Implications. 30 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 32 Contents viii Contents 2 Psychiatric Nursing. 35 KEYWORDS 35 QUESTIONS 36 Mental Health Nursing. 36 Role of the Nurse. 37 Nursing Process. 38 Nurse-Client Relationship . 40 Transference/Countertransference . 42 ANSWERS AND RATIONALES 44 Mental Health Nursing. 44 Role of the Nurse. 46 Nursing Process. 48 Nurse-Client Relationship . 51 Transference/Countertransference . 55 3 Communication. 59 KEYWORDS 59 QUESTIONS 60 Therapeutic Communication Facilitators. 60 Blocks to Therapeutic Communication. 62 Therapeutic Communication Interventions . 63 Nonverbal Communication. 65 Cultural Considerations. 66 ANSWERS AND RATIONALES 69 Therapeutic Communication Facilitators. 69 Blocks to Therapeutic Communication. 73 Therapeutic Communication Interventions . 74 Nonverbal Communication. 78 Cultural Considerations. 80 4 Legal and Ethical Considerations . 85 KEYWORDS 85 QUESTIONS 85 Legal and Ethical Concepts. 85 Safety Issues. 86 Client Rights. 86 Voluntary and Involuntary Commitment. 87 Confidentiality. 88 Potential Liability. 89 Advance Directives. 89 ANSWERS AND RATIONALES 90 Legal and Ethical Concepts. 90 Safety Issues. 91 Client Rights. 92 Voluntary and Involuntary Commitment. 93 Confidentiality. 94 Potential Liability. 95 Advance Directives. 96 C Management of Care for Individuals With Psychiatric Disorders 5 Stress Adaptation, Trauma, and Related Disorders . 97 KEYWORDS 97 QUESTIONS 98 Theory. 98 Ego Defense Mechanisms . 99 Contents ix Nursing Process—Assessment . 101 Nursing Process—Diagnosis . 102 Nursing Process—Planning. 103 Nursing Process—Implementation. 104 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105 Psychopharmacology. 106 ANSWERS AND RATIONALES 107 Theory. 107 Ego Defense Mechanisms . 109 Nursing Process—Assessment . 112 Nursing Process—Diagnosis . 115 Nursing Process—Planning. 117 Nursing Process—Implementation. 117 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 Psychopharmacology. 121 6 Anxiety, Obessessive-Compulsive, and Related Disorders, Issues Related to Sexuality. 123 KEYWORDS 123 QUESTIONS 123 Theory. 123 Defense Mechanisms. 124 Nursing Process—Assessment . 124 Nursing Process—Diagnosis . 127 Nursing Process—Planning. 127 Nursing Process—Implementation. 129 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130 Psychopharmacology. 130 ANSWERS AND RATIONALES 133 Theory. 133 Defense Mechanisms. 134 Nursing Process—Assessment . 134 Nursing Process—Diagnosis . 138 Nursing Process—Planning. 139 Nursing Process—Implementation. 141 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144 Psychopharmacology. 144 7 Depressive Disorders and the Suicidal Client. 149 KEYWORDS 149 QUESTIONS 149 Theory. 149 Nursing Process—Assessment . 150 Nursing Process—Diagnosis . 151 Nursing Process—Planning. 152 Nursing Process—Implementation. 152 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153 Psychopharmacology. 153 ANSWERS AND RATIONALES 156 Theory. 156 Nursing Process—Assessment . 157 Nursing Process—Diagnosis . 160 Nursing Process—Planning. 161 Nursing Process—Implementation. 162 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164 Psychopharmacology. 165 x Contents 8 Bipolar and Related Disorders. 171 KEYWORDS 171 QUESTIONS 171 Theory. 171 Nursing Process—Assessment . 171 Nursing Process—Diagnosis . 172 Nursing Process—Planning. 172 Nursing Process—Implementation. 173 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174 Psychopharmacology. 174 ANSWERS AND RATIONALES 177 Theory. 177 Nursing Process—Assessment . 177 Nursing Process—Diagnosis . 178 Nursing Process—Planning. 178 Nursing Process—Implementation. 179 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181 Psychopharmacology. 182 9 Substance-Related and Addictive Disorders. 187 KEYWORDS 187 QUESTIONS 188 Theory. 188 Defense Mechanisms. 188 Nursing Process—Assessment . 189 Nursing Process—Diagnosis . 192 Nursing Process—Planning. 193 Nursing Process—Implementation. 193 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194 Psychopharmacology. 195 ANSWERS AND RATIONALES 197 Theory. 197 Defense Mechanisms. 198 Nursing Process—Assessment . 199 Nursing Process—Diagnosis . 206 Nursing Process—Planning. 207 Nursing Process—Implementation. 208 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .210 Psychopharmacology. 211 10 Schizophrenia Spectrum and Other Psychotic Disorders. 215 KEYWORDS 215 QUESTIONS 216 Theory. 216 Nursing Process—Assessment . 216 Nursing Process—Diagnosis . 219 Nursing Process—Planning. 220 Nursing Process—Implementation. 220 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222 Psychopharmacology. 222 ANSWERS AND RATIONALES 226 Theory. 226 Nursing Process—Assessment . 227 Nursing Process—Diagnosis . 233 Nursing Process—Planning. 235 Nursing Process—Implementation. 237 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .239 Psychopharmacology. 240 Contents xi 11 Personality Disorders and Impulse Control Disorders. 247 KEYWORDS 247 QUESTIONS 247 Theory. 247 Defense Mechanisms. 248 Nursing Process—Assessment . 248 Nursing Process—Diagnosis . 250 Nursing Process—Planning. 251 Nursing Process—Implementation. 252 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253 Psychopharmacology. 254 ANSWERS AND RATIONALES 255 Theory. 255 Defense Mechanisms. 256 Nursing Process—Assessment . 256 Nursing Process—Diagnosis . 262 Nursing Process—Planning. 263 Nursing Process—Implementation. 265 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .267 Psychopharmacology. 268 12 Somatic Symptom and Dissociative Disorders. 271 KEYWORDS 271 QUESTIONS 271 Theory. 271 Nursing Process—Assessment . 272 Nursing Process—Diagnosis . 273 Nursing Process—Planning. 273 Nursing Process—Implementation. 274 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .275 Psychopharmacology. 276 ANSWERS AND RATIONALES 277 Theory. 277 Nursing Process—Assessment . 278 Nursing Process—Diagnosis . 280 Nursing Process—Planning. 282 Nursing Process—Implementation. 283 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .284 Psychopharmacology. 286 13 Neurocognitive Disorders. 287 KEYWORDS 287 QUESTIONS 287 Theory. 287 Nursing Process—Assessment . 288 Nursing Process—Diagnosis . 289 Nursing Process—Planning. 289 Nursing Process—Implementation. 290 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .290 Psychopharmacology. 291 ANSWERS AND RATIONALES 292 Theory. 292 Nursing Process—Assessment . 292 Nursing Process—Diagnosis . 295 Nursing Process—Planning. 296 Nursing Process—Implementation. 296 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .298 Psychopharmacology. 298 xii Contents 14 Eating Disorders. 299 KEYWORDS 299 QUESTIONS 299 Theory. 299 Nursing Process—Assessment . 300 Nursing Process—Diagnosis . 301 Nursing Process—Planning. 301 Nursing Process—Implementation. 302 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .303 Psychopharmacology. 303 ANSWERS AND RATIONALES 305 Theory. 305 Nursing Process—Assessment . 306 Nursing Process—Diagnosis . 308 Nursing Process—Planning. 309 Nursing Process—Implementation. 309 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .312 Psychopharmacology. 312 15 Children and Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .315 KEYWORDS 315 QUESTIONS 315 Theory. 315 Nursing Process—Assessment . 316 Nursing Process—Diagnosis . 317 Nursing Process—Planning. 317 Nursing Process—Implementation. 318 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .319 Psychopharmacology. 319 ANSWERS AND RATIONALES 321 Theory. 321 Nursing Process—Assessment . 322 Nursing Process—Diagnosis . 324 Nursing Process—Planning. 326 Nursing Process—Implementation. 327 Nursing Process—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329 Psychopharmacology. 330 16 Comprehensive Final Examination. 333 QUESTIONS 333 ANS WERS AND RATIONALES 347 Glossary of English Words Commonly Encountered on Nursing Examinations. 375 Index. 379 Psychiatric Mental Health Nursing Success A Q & A Review Applying Critical Thinking to Test Taking Third Edition 1 INTRODUCTION Definition of Critical Thinking Critical thinking is a cognitive strategy by which you reflect on and analyze your thoughts, actions, and decisions. Critical thinking often is integrated into traditional linear processes. Linear processes usually follow a straight line, with a beginning and a product at the end. Some linear-like processes, such as the nursing process, are considered cyclical because they repeat themselves. Some formal reasoning processes include: • Problem Solving—involves identifying a problem, exploring alternative interventions, implementing selected interventions, and arriving at the end product, which is a solution to the problem. • Decision Making—involves carefully reviewing significant information, using methodical reasoning, and arriving at the end product, which is a decision. • Diagnostic Reasoning—involves collecting information, correlating the collected information to standards, identifying the significance of the collected information, and arriving at the end product, which is a conclusion or nursing diagnosis. • The Scientific Method—involves identifying a problem to be investigated, collecting data, formulating a hypothesis, testing the hypothesis through experimentation, evaluating the hypothesis, and arriving at the end product, which is acceptance or rejection of the hypothesis. • The Nursing Process—involves collecting information (Assessment); determining significance of information and making a nursing diagnosis (Analysis/Diagnosis); identifying goals, expected outcomes, and planning interventions (Planning); implementing nursing interventions (Implementation/Intervention); and assessing the client’s response to interventions and comparing the actual to expected outcomes (Evaluation) ultimately to arrive at the end product of meeting a person’s needs. Each of these methods of manipulating and processing information incorporates critical thinking. They all are influenced by intellectual standards, such as being focused, methodical, deliberate, logical, relevant, accurate, precise, clear, comprehensive, creative, and reflective. It is helpful to incorporate critical thinking into whatever framework or structure works for you. MAXIMIZE YOUR CRITICAL-THINKING ABILITIES Be Positive: You Can Do It! Assuming responsibility for the care one delivers to a client and desiring a commendable grade on a nursing examination raise anxiety because a lot is at stake: to keep the client safe, Introduction Fundamentals of Critical A Thinking Related to Test Taking 2 Psychiatric Mental Health Nursing Success to achieve a passing grade, to become a nurse ultimately, and to support one’s self-esteem. The most important skill that you can learn to help you achieve all of these goals is to be an accomplished critical thinker. We use critical-thinking skills every day in our lives when we explore, “What will I have for breakfast?” “How can I get to school from my home?” and “Where is the best place to get gas for my car?” Once you recognize that you are thinking critically already, it is more manageable to think about thinking critically. If you feel threatened by the idea of critical thinking, then you must do something positive to confront the threat. You need to be disciplined and to work at increasing your sense of control, which contributes to confidence! You can do it! Overcome Barriers to a Positive Mental Attitude Supporting a positive mental attitude requires developing discipline and confidence. Discipline is defined as self-command or self-direction. The disciplined person will work in a planned manner, explore all options in an organized and logical way, check for accuracy, and seek excellence. When you work in a planned and systematic manner with conscious effort, you are more organized and, therefore, more disciplined. Disciplined people generally have more control over the variables associated with an intellectual task. Effective critical thinkers are disciplined, and discipline helps to develop confidence. Confidence is defined as poise, self-reliance, or self-assurance. Confidence increases as one matures in the role of the student nurse. Understanding your strengths and limitations is the first step to increasing confidence. When you know your strengths, you can draw on them, and when you know your limitations, you know when it is time to seek out the instructor or another resource to help you in your critical thinking. Either way, you are in control! For example, ask the instructor for help when critically analyzing a case study, share with the instructor any concerns you have about a clinical assignment, and seek out the instructor in the clinical area when you feel the need for support. Failing to use your instructor is like putting your head in the sand. Learning needs must be addressed, not avoided. Although your instructor is responsible for your clinical practice and for stimulating your intellectual growth as a nursing student, you are the consumer of your nursing education. As the consumer, you must be an active participant in your own learning by ensuring that you get the assistance and experiences you need to build your abilities and confidence. When you increase your theoretical and experiential knowledge base, you will increase your sense of control, which ultimately increases your confidence. This applies not just to beginning nursing students but to every level of practice because of the explosion in information and technology. When you are disciplined, you are more in control; when you are more in control, you are more confident; and when you are more confident, you have a more positive mental attitude. Be Reflective: You Need to Take One Step Backward Before Taking Two Steps Forward! Reflection is the process of thinking back or recalling a situation or event to rediscover its meaning. It helps you to seek and understand the relationships among information, concepts, and principles and to apply them in future clinical or testing situations. Reflection can be conducted internally as quiet, thoughtful consideration; in a one-on-one discussion with an instructor or another student; or in a group. As a beginning nursing student, you are just starting to develop an experiential background from the perspective of a health-care practitioner. However, you have a wealth of experiences, personal and educational, that influence your development as a licensed nurse. Your personal experiences include activities using verbal and written communication, such as delegating tasks to family members or coworkers, setting priorities for daily activities, using mathematics when shopping or balancing a checkbook, and so on. A nursing program of study incorporates courses from a variety of other disciplines, such as anatomy and physiology, chemistry, physics, psychology, sociology, reading, writing, mathematics, and informatics. Every single experience is a potential valuable resource for future learning. Recognize I ntroduction 3 the value of the “you” that you bring to your nursing education and incorporate it into your reflective processes. Engaging in reflection is a highly individualized mental process. One form of reflection is writing a journal. A journal is an objective and subjective diary of your experiences. It is a chronicle that includes cognitive learning, feelings, and attitudes. In addition, it requires you to actively develop skills related to assessing, exploring the meaning of critical incidents, documenting, developing insights into thoughts and actions that compose clinical practice, and evaluating. Journal writing is a rich resource that provides a written record of where you have been, where you are, and where you are going. It helps you to incorporate experiences into the development of your professional being. After an examination, explore your feelings and attitudes regarding the experience. Be honest with yourself. Did you prepare adequately for the test? Did you find the content harder or easier than content on another test? Were you anxious before, during, or after the test, and if so, was your anxiety low, medium, or high? What would a low score or high score on the test mean to you? When you were confronted with a question that you perceived as difficult, how did you feel and how did you cope with the feeling? You do not necessarily have to ask yourself all of these questions. You should ask yourself those questions that have meaning for you. Another form of reflection is making mental pictures. Mental pictures are visual images that can be recalled in the future. For example, when caring for a client who has Parkinson’s disease, compare the client’s signs and symptoms with the classic clinical manifestations associated with the disease. Then make a visual picture in your mind. Visualize the pill-rolling tremors, masklike face, drooling, muscle rigidity, and so on so that, in the future, you can recall the visual picture rather than have to remember a memorized list of symptoms. Retrospective (after the event) reflection involves seeking an understanding of relationships between previously learned information and the application of this information in client care situations or testing experiences. This type of reflection helps you to judge your personal performance against standards of practice. A self-assessment requires the willingness to be open to identifying one’s successful and unsuccessful interventions, strengths and weaknesses, and knowledge and lack of knowledge. The purpose of retrospective reflection is not to be judgmental or to second-guess decisions but rather to learn from the situation. The worth of the reflection depends on the abilities that result from it. When similar situations arise in subsequent clinical practice, previous actions that were reinforced or modified can be accessed to have a current successful outcome. A clinical postconference is an example of retrospective reflection. Students often meet in a group (formally or informally) after a clinical experience to review the day’s events. During the discussion, students have an opportunity to explore feelings and attitudes, consider interventions and alternative interventions, assess decision-making and problem-solving skills, identify how they and other students think through a situation, and so on. You can also review your own thinking when reviewing a client experience by speaking aloud what you were thinking. For example, “When I went into the room to take my postoperative client’s vital signs, I realized that the client had an IV in the right arm. I knew that if I took a blood pressure in the arm with an IV it could interfere with the IV so I knew I had to take the blood pressure in the left arm. When I looked at my client, he looked very pale and sweaty. I got a little nervous, but I continued to get the other vital signs. I put the thermometer in the client’s mouth and started to take his pulse. It was very fast and I knew that this was abnormal, so I paid special attention to its rhythm and volume. It was very thready, but it was regular. The temperature and respirations were within the high side of the expected range.” A beginning nursing student may immediately respond by saying, “I don’t know what is going on here, so I better take this information to my instructor.” A more advanced student might say, “What could be happening? Maybe the client is bleeding or has an infection. I think I should inform my instructor, but I’ll inspect the incision first.” When you review an experience like this example, you can identify your thinking skills. Taking the blood pressure reading in the left arm and assessing the rate, rhythm, and volume of the pulse were habits because you did not have to figure out a new method when responding to the situation. Remembering the expected range for the various vital signs used the thinking 4 Psychiatric Mental Health Nursing Success skill of total recall because you memorized and internalized these values. Determining further assessments after obtaining the vital signs required inquiry. You collected and analyzed information and did not take the vital sign results at face value. You recognized abnormalities and gaps in information, collected additional data, considered alternative conclusions, and identified alternative interventions. Another example of retrospective reflection is reviewing an examination. When reviewing each question, determine why you got a question wrong. For example, several statements you might make are: • I did not understand what the question was asking because of the English or medical vocabulary used in the question. • I did not know or understand the content being tested. • I knew the content being tested, but I did not apply it correctly in the question. When a limited English or medical vocabulary prevents you from answering a question correctly, you must spend time expanding this foundation. A list of English words that appear repeatedly in nursing examinations is included in a glossary at the end of this textbook. In addition, nursing/medical keyword lists have been included in each content area in this textbook. You can use these word lists to review key terminology used in nursing-related topics. To expand your vocabulary, keep English and medical dictionaries at your side when studying and look up new words, write flash cards for words you need to learn, and explore unfamiliar words with which you are confronted on tests. When you answered a question incorrectly because you did not understand the content, make a list so that you can design a study session devoted to reviewing this information. This study session should begin with a brief review of what you do know about the topic (5 minutes or less). The majority of your efforts should be devoted to studying what you identified as what you need to know. You should do this after reviewing every test. This exercise is based on the axiom strike while the iron is hot. The test is over, so your anxiety level is reduced and how nursing-related content is used in a test question is fresh in your mind. Study sessions that are goal directed tend to be more focused and productive. When you know the content being tested but have applied the information incorrectly, it is an extremely frustrating experience. However, do not become discouraged. It is motivating to recognize that you actually know the content! Your next task is to explore how to tap into your knowledge successfully. Sometimes restating or summarizing what the question is asking places it into your own perspective, which helps to clarify the content in relation to the test question. Also, you can view the question in relation to specific past experiences or review the information in two different textbooks to obtain different perspectives on the same content. Another strategy to reinforce your learning is to use the left page of your notebook for taking class notes and leave the facing page blank. After an examination, use the blank page to make comments to yourself about how the content was addressed in test questions or add information from your textbook to clarify class notes. How to review thinking strategies in relation to cognitive levels of nursing questions is explored later in this chapter. Examine your test-taking behaviors. For example, if you consistently changed your initial answers on a test, it is wise to explore what factors influenced you to change your answers. In addition, determine how many questions were converted to either right or wrong answers. The information you collect from this assessment should influence your future behaviors. If you consistently changed correct answers to incorrect answers, you need to examine the factors that caused you to change your answers. If you changed incorrect answers to correct answers, you should identify what mental processes you used to arrive at your second choice so that you can use them the first time you look at a question. Reflection is an essential component of all learning. How can you know where you are going without knowing where you have been? Therefore, to enhance your critical-thinking abilities you must take one step backward before taking two steps forward! Overcome Barriers to Effective Reflection Reflecting on your knowledge, strengths, and successes is easy, but reflecting on your lack of knowledge, weaknesses, and mistakes takes courage and humility. Courage is the attitude of confronting anything recognized as dangerous or difficult without avoiding or withdrawing I ntroduction 5 from the situation. Courage is necessary because when people look at their shortcomings, they tend to be judgmental and are their own worst critics. This type of negativity must be avoided because it promotes defensive thinking, interferes with the reception of new information, and limits self-confidence. Humility is having a modest opinion of one’s own abilities. Humility is necessary because it is important to admit your limitations. Only when you identify what you do and do not know can you make a plan to acquire the knowledge necessary to be successful on nursing examinations and practice safe nursing care. Arrogance or a “know-it-all” attitude can interfere with maximizing your potential. For example, when reviewing examinations with students, the students who benefit the most are the ones who are willing to listen to their peers or instructor as to why the correct answer is correct. The students who benefit the least are the ones who consistently and vehemently defend their wrong answers. A healthy amount of inquiry, thoughtful questioning, and not accepting statements at their face value are important critical-thinking competencies; however, a self-righteous or obstructionist attitude more often than not impedes rather than promotes learning. Be Inquisitive: If You Don’t Go There, You’ll Never Get Anywhere! To inquire means to question or investigate. The favorite words of inquisitive people are what, where, when, and, most important, how, why, if . . . then, and it depends. When studying, ask yourself these words to delve further into a topic under consideration. The following are examples: • You raise the head of the bed when a client is short of breath. You recognize that this intervention will facilitate respirations. Ask yourself the question, “How does this intervention facilitate respirations?” The answer could be, “Raising the head of the bed allows the abdominal organs to drop by gravity, which reduces pressure against the diaphragm, which in turn permits maximal thoracic expansion.” • You insert an indwelling urinary catheter and are confronted with the decision as to where to place the drainage bag. Ask yourself what questions. “What will happen if I place the drainage bag on the bed frame?” The answer could be, “Urine will flow into the drainage bag by gravity.” “What will happen if I place the drainage bag on an IV pole?” The answer could be, “Urine will remain in the bladder because the IV pole is above the level of the bladder and fluid does not flow uphill; if there is urine in the bag, it will flow back into the bladder.” • When palpating a pulse, you should use gentle compression. Ask yourself the question, “Why should I use gentle compression?” The answer could be, “Gentle compression allows you to feel the pulsation of the artery and prevents excessive pressure on the artery that will cut off circulation and thus obliterate the pulse.” • The textbook says that in emergencies nurses should always assess the airway first. Immediately ask, “Why should I assess the airway first?” There may be a variety of answers. “In an emergency, follow the ABCs (Airway, Breathing, Circulation) of assessment, which always begin with the airway. Maslow’s hierarchy of needs identifies that physiological needs should be met first. Because an airway is essential for the passage of life-sustaining gases in and out of the lungs, this is the priority.” Although all of these responses answer the question why, only the last answer really provides an in-depth answer to the why question. If your response to the original why question still raises a why question, you need to delve deeper. “Why do the ABCs of assessment begin with the airway?” “Why should physiological needs be met first?” • When talking with a client about an emotionally charged topic, the client begins to cry. You are confronted with a variety of potential responses. Use the method of if . . . then statements. If . . . then thinking links an action to a consequence. For example, if I remain silent, then the client may refocus on what was said. If I say, “You seem very sad,” then the client may discuss the feelings being felt at the time. If I respond with an open-ended statement, then the client may pursue the topic in relation to individualized concerns. After you explore a variety of courses of action with the if . . . then method, you should be in a better position to choose the most appropriate intervention for the situation. 6 Psychiatric Mental Health Nursing Success • You will recognize that you have arrived at a more advanced level of critical thinking when determining that your next course of action is based on the concept of it depends. For example, a client suddenly becomes extremely short of breath and you decide to administer oxygen during this emergency. When considering the amount and route of delivery of the oxygen, you recognize that it depends. You need to collect more data. You need to ask more questions, such as, “Is the client already receiving oxygen? Does the client have a chronic obstructive pulmonary disease? Is the client a mouth breather? What other signs and symptoms are identified?” The answers to these questions will influence your choice of interventions. When exploring the how, what, where, when, why, if . . . then, and it depends methods of inquiry, you are more likely to arrive at appropriate inferences, assumptions, and conclusions that will ensure effective nursing care. These same techniques of inquiry can be used when practicing test taking. Reviewing textbooks that have questions with rationales is an excellent way to explore the reasons for correct and incorrect answers. When answering a question, state why you think your choice is the correct answer and why you think each of the other options is an incorrect answer. This encourages you to focus on the reasons why you responded in a certain way in a particular situation. It prevents you from making quick judgments before exploring the rationales for your actions. After you have done this, compare your rationales with the rationales for the correct and incorrect answers in the textbook. Are your rationales focused, methodical, deliberate, logical, relevant, accurate, precise, clear, comprehensive, creative, and reflective? This method of studying not only reviews nursing content but also fosters critical thinking and applies critical thinking to test taking. During or after the review of an examination, these techniques of inquiry also can be employed, particularly with those questions you got wrong. Although you can conduct this review independently, it is more valuable to review test questions in a group. Your peers and the instructor are valuable resources that you should use to facilitate your learning. Different perspectives, experiential backgrounds, and levels of expertise can enhance your inquiry. Be inquisitive. If you don’t go there, you’ll never get anywhere. Overcome Barriers to Being Inquisitive Effective inquiry requires more than just a simplistic, cursory review of a topic. Therefore, critical thinkers must have curiosity, perseverance, and motivation. Curiosity is the desire to learn or know and is a requirement to delve deeper into a topic. If you are uninterested in or apathetic about a topic, you are not going to go that extra mile. Sometimes you may have to “psych yourself up” to study a particular topic. Students frequently say they are overwhelmed by topics such as fluids and electrolytes, blood gases, or chest tubes. As a result, they develop a minimal understanding of these topics and are willing to learn by trial and error in the clinical area or surrender several questions on an examination. Never be willing to let a lack of knowledge be the norm because this results in incompetence, and never give away credits on an examination! Overcome this attitude by maximizing your perseverance. Perseverance means willingness to continue in some effort or course of action despite difficulty or opposition. Critical thinkers never give up until they obtain the information that satisfies their curiosity. To perform a comprehensive inquiry when studying requires time. Make a schedule for studying at the beginning of the week and adhere to it. This prevents procrastination later in the week when you may prefer to rationalize doing something else and postpone studying. In addition, studying 1 hour a day is more effective than studying 7 hours in 1 day. Breaks between study periods allow for the processing of information and provide time to rest and regain focus and concentration. The greatest barrier to perseverance is a deadline. When working under a time limit, you may not have enough time to process and understand information. The length of time to study for a test depends on the amount and type of content to be tested and how much previous studying has been done. If you study 2 hours every day for 2 weeks during a unit of instruction, a 1-hour review may be adequate for an examination addressing this content. If you are preparing for a comprehensive examination for a course at the end of the semester, you may decide to study 3 hours I ntroduction 7 a night for 1 to 2 weeks. If you are studying for a National Council Licensure Examination (NCLEX) examination, you may decide to study 2 hours a day for 3 months. Only you can determine how much time you need to study or prepare for a test. Perseverance can be enhanced by the use of motivation strategies. Motivation strategies inspire, prompt, encourage, or instigate you to act. For example, divide the information to be learned into segments and set multiple short-term goals for studying. After you reach a goal, cross it off the list. Also, this is the time to use incentives. Reward yourself after an hour of studying. Think about how proud you will be when you earn an excellent grade on the examination. Visualize yourself walking down the aisle at graduation or working as a nurse during your career. Incentives can be more tangible (e.g., eating a snack, reading a book for 10 minutes, playing with your children, or doing anything that strikes your fancy). You need to identify the best pattern of studying that satisfies your needs; use motivation techniques to increase your enthusiasm, and then draw on your determination to explore in depth the how, what, where, when, whys, if . . . then, and it depends of nursing practice. Be Creative: You Must Think Outside the Box! Creative people are imaginative, inventive, innovative, resourceful, original, and visionary. To find solutions beyond common, predictable, and standardized procedures or practices, you must be creative. Creativity is what allows you to be yourself and individualize the nursing care you provide to each client. With the explosion of information and technology, the importance of thinking creatively will increase in the future because the “old” ways of doing things will be inadequate. No two situations or two people are ever alike. Therefore, you must think outside the box! Overcome Barriers to Creativity To be creative, you must be open-minded, have independence of thought, and be a risk taker. It is difficult to think outside the box when you are not willing to color outside the lines! Being open-minded requires you to consider a wide range of ideas, concepts, and opinions before framing an opinion or making judgments. You need to identify your opinions, beliefs, biases, stereotypes, and prejudices. We all have them to one extent or another, so do not deny them. However, they must be recognized, compartmentalized, and placed on a “back burner.” Unless these attitudes are placed in perspective, they will interfere with critical thinking. In every situation, you need to remain open to all perspectives, not just your own. When you think that your opinion is the only right opinion, you are engaging in egocentric thinking. Egocentric thinking is based on the belief that the world exists or can be known only in relation to the individual’s mind. This rigid thinking creates a barrier around your brain that obstructs the inflow of information, imaginative thinking, and the outflow of innovative ideas. An example of an instance in which you have been open-minded is one in which you have changed your mind after having had a discussion with someone else. The new information convinced you to think outside of your original thoughts and opinions. Independence of thought means the ability to consider all the possibilities and then arrive at an autonomous conclusion. To do this you need to feel comfortable with ambiguity. Ambiguous means having two or more meanings and is therefore being uncertain, unclear, indefinite, and vague. For example, a nursing student may be taught by an instructor to establish a sterile field for a sterile dressing change by using the inside of the package of the sterile gloves. When following a sterile dressing change procedure in a clinical skills book, the directions may state to use a separate sterile cloth for the sterile field. When practicing this procedure with another student, the other student may open several 4×4 gauze packages and leave them open as the sterile fields. As a beginning nursing student, this is difficult to understand because of a limited relevant knowledge base and experiential background. Frequently, thinking is concrete and follows rules and procedures, is black and white, or is correct or incorrect. It takes knowledge and experience to recognize that you have many options and may still follow the principles of sterile technique. Remember, “There is more than one road to Rome!” 8 Psychiatric Mental Health Nursing Success To travel a different path requires taking risks. Risk in the dictionary means the chance of injury, damage, or loss. However, risk taking in relation to nursing refers to considering all the options, eliminating potential danger to a client, and acting in a reasoned, logical, and safe manner when implementing unique interventions. Being creative requires intellectual stamina and a willingness to go where no one has been before. Risk takers tend to be leaders, not followers. The greatest personal risk of creativity is the blow to the ego when confronted with failure. However, you must recognize that throughout your nursing career, you will be faced with outcomes that are successful as well as those that are unsuccessful. How you manage your feelings with regard to each, particularly those that are unsuccessful, will influence your willingness to take future creative risks. Successful outcomes build confidence. Unsuccessful outcomes should not be defeating or prevent future creativity when appropriately examined. The whole purpose of evaluation in the nursing process is to compare and contrast client outcomes with expected outcomes. If expected outcomes are not attained, the entire process must be re-examined and then re-performed. You must recognize that: • Unsuccessful outcomes do occur. • Unsuccessful outcomes may not be a reflection of your competence. • The number of successful outcomes far outnumbers the unsuccessful outcomes. When you accept these facts, then you may feel confident to take risks with your creativity. CRITICAL THINKING APPLIED TO TEST TAKING Educational Domains Nursing as a discipline includes three domains of learning—affective, psychomotor, and cognitive. The affective domain is concerned with attitudes, values, and the development of appreciations. An example of nursing care in the affective domain is the nurse quietly accepting a client’s statement that there is no God without the nurse imposing personal beliefs on the client. The psychomotor domain is concerned with manipulative or motor skills related to procedures or physical interventions. An example of nursing care in the psychomotor domain is the nurse administering an intramuscular injection to a client. The cognitive domain is concerned with recall, recognition of knowledge, comprehension, and the development and application of intellectual skills and abilities. An example of nursing care in the cognitive domain is the nurse clustering collected information and determining its significance. When discussing the application of critical thinking to test taking, the focus will be on the cognitive domain. Components of a Multiple-Choice Question A multiple-choice question is called an item. Each item has two parts. The stem is the part that contains the information that identifies the topic and its parameters and then asks a question or forms the beginning portion of a sentence that is completed by the correct option. The second part consists of one or more possible responses, which are called options. One of the options is the correct answer, and the others are wrong answers (also called distractors). What is the primary purpose of leg exercises after abdominal surgery? STEM 1. Promote venous return CORRECT ITEM ANSWER 2. Prevent muscle atrophy OPTIONS 3. Increase muscle strength 4. Limit disabling contractures DISTRACTORS v ∂ ¶ ∂ v I ntroduction 9 Cognitive Levels of Nursing Questions Questions on nursing examinations reflect a variety of thinking processes that nurses use when caring for clients. These thinking processes are part of the cognitive domain, and they progress from the simple to the complex, from the concrete to the abstract, and from the tangible to the intangible. There are four types of thinking processes represented by nursing questions: • Knowledge Questions—the emphasis is on recalling remembered information. • Comprehension Questions—the emphasis is on understanding the meaning and intent of remembered information. • Application Questions—the emphasis is on remembering understood information and utilizing the information in new situations. • Analysis Questions—the emphasis is on comparing and contrasting a variety of elements of information. CRITICAL-THINKING STRATEGY TO ANSWER MULTIPLE-CHOICE QUESTIONS: THE RACE MODEL Answering a test question is like participating in a race. Of course you want to come in first and be the winner. However, the thing to remember about a race is that success is based not just on speed but also on strategy and tactics. The same is true about success on nursing examinations. Although speed may be a variable that must be considered when taking a timed test so that the amount of time spent on each question is factored into the test strategy, the emphasis should be on the use of critical-thinking strategies to answer multiple-choice questions. The RACE model presented here is a critical-thinking strategy to use when answering nursing multiple-choice questions. If you follow the RACE model every time you examine a test question, its use will become second nature. This methodical approach will improve your abilities to critically analyze a test question and improve your chances of selecting the correct answer. The RACE model has four steps to answering a test question: R - Recognize what information is in the stem. • Recognize the keywords in the stem. • Recognize who the client is in the stem. A - Ask what the question is asking. • Ask specifically what the question is asking you to do. C - Critically analyze the options in relation to the question asked in the stem. • Critically scrutinize each option in relation to the information in the stem. • Critically identify a rationale for each option. • Critically compare and contrast the options in relation to the information in the stem and their relationships to one another. E - Eliminate as many options as possible. • Eliminate one option at a time. The following discussion explores this critical-thinking strategy in relation to the thinking processes represented in multiple-choice nursing questions. Thoughtfully read the Cognitive Requirements under each type of question (e.g., Knowledge, Comprehension, Application, and Analysis). It is important to understand this content to apply the critical-thinking strategies inherent in each cognitive-level question. In addition, four sets of sample test questions are presented to demonstrate the increasing complexity of thinking reflected in the various cognitive levels, focusing on specific fundamentals of nursing content. Knowledge Questions: Remember Information! Cognitive Requirements Knowledge is information that is filed or stored in the brain. It represents the elements essential to the core of a discipline. In nursing, this information consists of elements such as 10 Psychiatric Mental Health Nursing Success terminology and specific facts including steps of procedures, phenomena, expected laboratory values, classifications, and the expected ranges of vital signs. This type of information requires no alteration from one use or application to another because it is concrete. The information is recalled or recognized in the form in which it was originally learned. This information is the foundation of critical thinking. You must have adequate, accurate, relevant, and important information on which to base your more theoretical, abstract thinking in the future. Beginning nursing students find knowledge-level questions the easiest because they require the recall or regurgitation of information. Information may be memorized, which involves repeatedly reviewing information to place it and keep it in the brain. Information also can be committed to memory through repeated experiences with the information. Repetition is necessary because information is forgotten quickly unless reinforced. When answering knowledge-level questions, you either know the information or you don’t. The challenge of answering knowledge questions is defining what the question is asking and tapping your knowledge. See the textbook TEST SUCCESS: Test-Taking Techniques for Beginning Nursing Students, F.A. Davis, for specific study techniques related to knowledge-level questions. I ntroduction 11 Use a Critical-Thinking Strategy to Answer Knowledge- Level Questions 1. What is the description of the interviewing technique of paraphrasing? 1. Asking the client to repeat what was just said. 2. Condensing a discussion into an organized review. 3. Restating what the client has said using similar words. 4. Asking goal-directed questions concentrating on key concerns. CRITICAL-THINKING STRATEGY Recognize keywords. What is the description of the interviewing technique of paraphrasing? Recognize who the client is. There is no client in this question. Ask what the question is asking. What is the description of paraphrasing? Critically analyze options in relation to the question. To answer this question, you must know the definition or characteristic of paraphrasing. It is information that you must recall from your memory. You do not have to know other interviewing skills or their descriptions and characteristics to answer this question. Rationales: 1. Asking a client to repeat what was just asked is known as clarifying, not paraphrasing. 2. Reviewing a discussion is known as summarizing, not paraphrasing. 3. Paraphrasing or restating is an interviewing skill in which the nurse listens for a client’s basic message and then repeats the contents of the message in similar words. This validates information from the client without changing the meaning of the statement and provides an opportunity for the client to hear what was said. 4. Asking goal-directed questions that concentrate on key concerns is known as focusing, not paraphrasing. Eliminate incorrect options. Options 1, 2, and 4 are not examples of paraphrasing and can be eliminated. Comprehension Questions: Understand Information! Cognitive Requirements Comprehension is the ability to understand that which is known. To be safe practitioners, nurses must understand information such as reasons for nursing interventions, physiology and pathophysiology, consequences of actions, and responses to medications. To reach an understanding of information in nursing, you must be able to translate information into your own words to personalize its meaning. Once information is rearranged in your own mind, you must interpret the essential components for their intent, corollaries, significance, implications, consequences, and conclusions in accordance with the conditions described in the original communication. The information is manipulated within its own context without being used in a different or new situation. Beginning nursing students generally consider comprehension-level questions slightly more difficult than knowledge-level questions but less complicated than application- and analysis-level questions. Students often try to deal with comprehension-level information by memorizing the content. For example, when studying local signs and symptoms of an infection, students may memorize the following list: heat, erythema, pain, edema, and exudate. Although this can be done, it is far better to understand why these adaptations occur. Erythema and heat occur because of increased circulation to the area. Edema occurs because of increased permeability of the capillaries. Pain occurs because the accumulating fluid in 12 Psychiatric Mental Health Nursing Success the tissue presses on nerve endings. Exudate occurs because of the accumulation of fluid, cells, and other substances at the site of infection. The mind is a wonderful machine, but unless you have a photographic memory, lists of information without understanding often become overwhelming and confusing. The challenge of answering comprehension questions is to understand the information. See TEST SUCCESS: Test-Taking Techniques for Beginning Nursing Students for specific study techniques related to comprehension-level questions. Use a Critical-Thinking Strategy to Answer Comprehension-Level Questions 1. How does the interviewing technique of paraphrasing promote communication? 1. Requires clients to defend their points of view. 2. Limits clients from continuing a rambling conversation. 3. Allows clients to take their conversations in any desired direction. 4. Offers clients an opportunity to develop a clearer idea of what they said. CRITICAL-THINKING STRATEGY Recognize keywords. How does the interviewing technique of paraphrasing promote communication? Recognize who the client is. There is no client. Ask what the question is asking. How does paraphrasing promote communication? Critically analyze options in relation to the question. The word in the stem that indicates that this is a comprehension-level question is promote. What is the consequence of paraphrasing? You need to scrutinize each option to identify whether the description in the option correctly explains how paraphrasing works to promote communication. Rationales: 1. This describes the results of challenging statements that usually are barriers to communication. 2. This describes one purpose of the interviewing skill of focusing, which is the use of questions or statements to center on one concern mentioned within a wordy, confusing conversation. 3. This is the purpose of open-ended questions or statements. 4. Paraphrasing involves actively listening for client concerns that are then restated by the nurse in similar words. This intervention conveys that the nurse has heard and understood the message and gives the client an opportunity to review what was said. Eliminate incorrect options. Options 1, 2, and 3 do not accurately describe how paraphrasing works to promote communication and can be eliminated. I ntroduction 13 Application Questions: Use Information! Cognitive Requirements Application is the ability to use known and understood information in new situations. It requires more than just understanding information because you must demonstrate, solve, change, modify, or manipulate information in other than its originally learned form or context. With application questions, you are confronted with a new situation that requires you to recall information and manipulate the information from within a familiar context to arrive at abstractions, generalizations, or consequences regarding the information that can be used in the new situation to answer the question. Application questions require you to make rational, logical judgments. Beginning nursing students frequently find these questions challenging because they require a restructuring of understood information into abstractions, commonalities, and generalizations, which are then applied to new situations. You do this all the time. Although there are parts of your day that are routine, every day you are exposed to new, challenging experiences. The same concept holds true for application questions. With application questions you will be confronted by situations that you learned about in a book, experienced personally, relived through other students’ experiences, or never heard about or experienced before. This will happen throughout your entire nursing career. The challenge of answering application questions is going beyond rules and regulations and using information in a unique, creative way. See TEST SUCCESS: Test-Taking Techniques for Beginning Nursing Students for specific study techniques related to application-level questions. Use a Critical-Thinking Strategy to Answer Application-Level Questions 1. A client scheduled for major surgery, who is perspiring and nervously picking at the bed linen, says, “I don’t know if I can go through with this surgery.” The nurse responds, “You’d rather not have surgery now?” Which interviewing technique was used by the nurse? 1. Focusing. 2. Reflection. 3. Paraphrasing. 4. Clarification. CRITICAL-THINKING STRATEGY Recognize keywords. A patient scheduled for major surgery, who is perspiring and nervously picking at the bed linen, says, “I don’t know if I can go through with this surgery.” The nurse responds, “You’d rather not have surgery now?” Which interviewing technique was used by the nurse? Recognize who the client is. The patient is the client. Ask what the question is asking. What interviewing technique is being used by the nurse when the nurse says in response to the client, “You’d rather not have surgery now?” Continued 14 Psychiatric Mental Health Nursing Success Critically analyze options in relation to the question. The word in the stem that indicates that this is an application question is used. To identify which technique was used by the nurse, you have to understand the elements of a paraphrasing statement, and you need to be able to recognize a paraphrasing statement when it is used. Although it is helpful to understand the elements of the other interviewing techniques because it will help you eliminate incorrect options, it is not necessary to understand this information to answer the question. Rationales: 1. The example in the stem is not using focusing because the client’s statement was short and contained one message that was reiterated by the nurse. Focusing is used to