Chapter 09 Therapeutic Communication
During a clinical interview the client falls silent after disclosing that she was sexually abused as a child. The nurse should engage in which intervention in response to the client's silence? Quickly break the silence and encourage the client to continue. Reassure the client that the abuse was not her fault. Reach out and gently touch the client's arm. Allow the client to break the silence.
Allow the client to break the silence. Silence is not a "bad" thing. It gives the speaker time to think through a point or collect his or her thoughts. None of the other options will assist with further communication with this client.REF: 141-142
Which communication techniques should the nurse use with a client who has been identified as having difficulty expressing thoughts and feelings? Using emotionally charged words and gestures Offering opinions and avoiding periods of silence Asking closed-ended questions requiring "yes" or "no" answers Asking open-ended questions and seeking clarification
Asking open-ended questions and seeking clarification Open-ended questions give the client the widest possible latitude in answering. Also, the client can take the lead in the interview. Seeking clarification helps the client clarify his or her own thoughts and promotes mutual understanding. None of the options provide this support.REF: 142-143
A term is a synonym for the characteristic of genuineness? Respect Empathy Authentic Positive regard
Authentic Genuineness refers the nurse's ability to be open, honest, and authentic in interactions with patients. It is the ability to meet others person-to-person without hiding behind roles. While positive characteristics, none of the other options related to genuineness.REF: 133
The preferred seating arrangement for a nurse-client interview should incorporate which positioning? The nurse behind a desk and the client in a chair in front of the desk. The nurse and client sitting at a 90-degree angle to each other. The client sitting in a chair and the nurse standing a few feet away. The nurse and client sitting facing each other.
The nurse and client sitting at a 90-degree angle to each other. This arrangement allows the nurse to observe the client but places no barriers between the principals. The two are at the same height, so neither is in an inferior position. Face-to-face seating is a more confrontational arrangement and therefore more anxiety producing.REF: 150
A client states "That nurse never seems comfortable being with me." The nurse can be described as not seeming genuine to the client. transmitting fear of clients. unfriendly and aloof. controlling.
not seeming genuine to the client. Hiding behind a role, using stiff or formal interactions, and creating distance between self and client suggest a nurse is lacking in genuineness, or the ability to interact in a person-to-person fashion. This characteristic is not associated with the other options.REF: 126-127, 133
A recent immigrant to the United States from which country would find direct eye contact a positive therapeutic technique? Korea Mexico Japan Germany
Germany Eye contact conveys interest to most northern European individuals. Eye contact would be considered intrusive to the others.REF: Page 147-148
A patient is presenting with behaviors that indicate anger. When approached, the patient states harshly, "I'm fine! Everything's great." Which response should the nurse provide to the patient? "Okay, but we are all here to help you, so come get one of the staff if you need to talk." "I'm glad everything is good. I am going to give you your schedule for the day and we can discuss how the groups are going." "I don't believe you. You are not being truthful with me." "It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?"
"It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?" This response uses the therapeutic technique of clarifying; it addresses the difference between the patient's verbal and nonverbal communication and encourages sharing of feelings. The other options do not address the patient's obvious distress or are confrontational and judgmental. None of the other options provides this support.DIF: Cognitive Level: Analyze (Analysis)REF: pages 7-9TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity
Consider the nurse-patient relationship on an inpatient psychiatric unit. Which of the following statements made by the nurse reflects an accurate understanding of when the issue of termination should first be discussed? You are being discharged today, so I'd like to bring up the subject of termination—discussing your time here and summarizing what coping skills you have attained." "I haven't met my new patient yet, but I am working through my feelings of anxiety in dealing with a patient who wanted to kill herself." "Now that we are working on your problem-solving skills and behaviors you'd like to change, I'd like to bring up the issue of termination." "Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge."
"Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge." The issue of termination is brought up first in the orientation phase. All the other options describe other phases of the nurse-patient relationship—the termination phase, the preorientation phase, and the working phase.DIF: Cognitive Level: Analyze (Analysis)REF: page 18TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity
What is the most helpful nursing response to a client who reports thinking of dropping out of college because it is too stressful? "Don't let them beat you! Fight back!" "School is stressful. What do you find most stressful?" "I know just what you are going through. The stress is terrible." "You have only two more semesters. You will be glad if you stick it out."
"School is stressful. What do you find most stressful?" This response acknowledges the speaker's perception of school as difficult and asks for further information. This response suggests the nurse is listening actively and is concerned.REF: 142
Which of the following statements represent a nontherapeutic communication technique? Select all that apply. "Why didn't you attend group this morning?" "From what you have said, you have great difficulty sleeping at night." "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" "If I were you, I would quit the stressful job and find something else." "I'm really proud of you for the way you stood up to your brother when he visited today." "You mentioned that you have never had friends. Tell me more about that." "It sounds like you have been having a very hard time at home lately."
"Why didn't you attend group this morning?" "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" "If I were you, I would quit the stressful job and find something else." "I'm really proud of you for the way you stood up to your brother when he visited today." All these options reflect the nontherapeutic techniques of (in order) asking "why" questions; using excessive questioning; giving advice; and giving approval. The other options describe therapeutic techniques of restating, exploring, and reflecting.DIF: Cognitive Level: Apply (Application)REF: pages 18, 19TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity
With which client should the nurse make the assessment that not using touch would probably be in the client's best interests? A recent immigrant from Russia A deeply depressed client A Chinese American client A tearful client reporting pain
A Chinese American client Chinese Americans may not like to be touched by strangers since it is a cultural characteristic.REF: 148
Of the following environments, which would be most conducive to a therapeutic session? The nurses' station A table in the coffee shop A quiet section of the day room The utility room
A quiet section of the day room Of the options provided, a quiet corner of the day room offers the safest, quietest, most private environment for a therapeutic encounter. None of the other options offer these characteristics.REF: 140-149
The nurse is finding it difficult to provide structure and set limits for a client. The nurse should self-evaluate for which characteristic of a dysfunctional nurse-patient relationship? Boundary blurring Value dissonance Covert anger Empathy
Boundary blurring Boundary blurring is often signaled by the nurse being either too helpful or not helpful enough. The behavior is not associated with any of the other options.REF: 127
When discussing her husband, a client shares that "I would be better off alone. At least I would be able to come and go as I please and not have to be interrogated all the time." What therapeutic communication technique is the nurse using when responding, "Are you saying that things would be better if you left your husband?" Focusing Restating Reflection Clarification
Clarification Clarification verifies the nurse's interpretation of the client's message. None of the other options are associated with the verification of the client's meaning.REF: 142
After a client discusses his/her relationship with his/her father, the nurse asks, "Tell me if I'm correct that you feel dominated and controlled by him?" What is the purpose of the nurse's question? Eliciting more information Encouraging evaluation Verbalizing the implied Clarifying the message
Clarifying the message Clarification helps the nurse understand and correctly interpret the client's message. It gives the client the opportunity to correct misconceptions. This is not the purpose of any of the other options.REF: 142
During a therapeutic encounter, the nurse makes an effort to ensure the use of two congruent levels of communication. What is the rationale for this? The mental image of a word may not be the same for both nurse and client. One statement may simultaneously convey conflicting messages. Many of the client's remarks are no more than social phrases. Content of messages may be contradicted by process.
Content of messages may be contradicted by process. Verbal messages may be contradicted by the nonverbal message that is conveyed. The nonverbal message is usually more consistent with the client's feelings than the verbal message. None of the remaining options are so directly associated with assuring congruency.REF: 140-141
The nurse would address which of the following goals in attempting to establish a therapeutic nurse-client relationship? -Helping patients examine self-defeating behaviors and test alternatives -Promoting self-care and independence -Providing the client with opportunities to socialize -Assisting patients with problem solving to help facilitate activities of daily living -Facilitating communication of distressing thoughts and feelings
Helping patients examine self-defeating behaviors and test alternatives Promoting self-care and independence Assisting patients with problem solving to help facilitate activities of daily living Facilitating communication of distressing thoughts and feelings Addressing the client's need to socialize is not one of the goals of establishing a therapeutic relationship. The other options are goals addressed in a therapeutic relationship.REF: 125
The outcome of the nurse's expressions of sympathy instead of empathy toward the client often leads to which outcome? Enhanced client coping Lessening of client emotional pain Increased hope for client improvement Decreased client communication
Decreased client communication Sympathy and the resulting projection of the nurse's feelings limit the client's opportunity to further discuss the problem. The remaining options are positive outcomes.REF: 133
Which of the following statements are true regarding the differences between a social relationship and a therapeutic relationship? In a social relationship, both parties' needs are met; in a therapeutic relationship, only the patient's needs are to be considered. A social relationship is instituted for the main purpose of exploring one member's feelings and issues; a therapeutic relationship is instituted for the purpose of friendship. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship, solutions are discussed but are only implemented by the patient. In a social relationship, communication is usually deep and evaluated; in a therapeutic relationship, communication remains on a more superficial level, allowing patients to feel comfortable.
In a social relationship, both parties' needs are met; in a therapeutic relationship, only the patient's needs are to be considered. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship, solutions are discussed but are only implemented by the patient. The other options describe the opposite meanings of social and therapeutic relationships.DIF: Cognitive Level: Analyze (Analysis)REF: pages 4, 5TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity
A nurse on the psychiatric unit has a past history of alcoholism and has regular meetings with a mentor. Which statement made to the nurse's mentor would indicate the presence of countertransference? "My patient is being discharged tomorrow. I provided discharge teaching and stressed the importance of calling the help line number should she become suicidal again." "My patient has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" "My patient started drinking after 14 years of sobriety. We are focusing on his treatment plan of attending AA (Alcoholics Anonymous) meetings five times a week after discharge." "My patient, is an elderly woman with depression. She calls me by her daughter's name because she says I remind her of her daughter."
My patient has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" This statement indicates countertransference; the nurse may be overidentifying with the patient because of a past history of alcoholism. Providing adamant advice to the patient that, besides being nontherapeutic, may be more relevant to personal past experiences than to the patient's. The discharge teaching for a patient being discharged and focusing on the treatment plan for the alcoholic patient are appropriate and show no signs of countertransference. The patient calling the nurse by her daughter's name is transference rather than countertransference.DIF: Cognitive Level: Analyze (Analysis)REF: pages 11, 12TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity
A patient is sitting with arms crossed over his or her chest, his or her left leg is rapidly moving up and down, and there is an angry expression on his or her face. When approached by the nurse, the patient states harshly, "I'm fine! Everything's great." Which statement related to communication should the nurse focus on when working with this patient? Verbal communication is always more accurate than nonverbal communication. Verbal communication is more straightforward, whereas nonverbal communication does not portray what a person is thinking. Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. Nonverbal communication is about 10% of all communication, and verbal communication is about 90%.
Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. Communication is roughly 10% verbal and 90% nonverbal, so nurses must pay close attention to nonverbal cues to accurately assess what the patient is really feeling. The other options are all untrue of verbal and nonverbal communication and are actually the opposite of what is believed of communication.DIF: Cognitive Level: Analyze (Analysis)REF: pages 7-9TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity
During what stage of the therapeutic nurse-client relationship is a formal or informal contract between the nurse and client established? Preorientation Orientation Working Termination
Orientation Contracting is part of the orientation phase of the relationship. Establishing the operational "rules" provides a foundation for the relationship. This function is not associated with any of the other options.REF: 130-131
A client tells the nurse "I really feel close to you. You are like the friend I never had." The nurse can assess this statement as indicating the client may be experiencing which unconscious emotion? Congruence Empathetic feelings Countertransference Positive transference
Positive transference Transference involves the client experiencing feelings toward a nurse that belong to a significant person in the client's past. If a patient is motivated to work with you, completes assignments between sessions, and shares feelings openly, it is likely the patient is experiencing positive transference. The behavior is not associated with any of the other options.REF: 127-128
During a therapeutic encounter the nurse remarks to a client, "I noticed anger in your voice when you spoke of your father. Tell me about that." What communication techniques is the nurse using? Giving information and encouraging evaluation Presenting reality and encouraging planning Clarifying and suggesting collaboration Reflecting and exploring
Reflecting and exploring Reflecting conveys the nurse's observations of the client when a sensitive issue is being discussed. Exploring seeks to examine a certain idea more fully.REF: 142
Which phase of the nurse-client relationship may cause client anxieties to reappear and past losses to be reviewed? Preorientation phase Orientation phase Working phase Termination phase
Termination phase Termination, a stage in which the client must face the loss or ending of the therapeutic relationship, often reawakens the pain of earlier losses. This is not generally associated with the other phases.REF: 132-133
A patient who recently loss a parent begins crying during a one-to-one session with the nurse. Which of the following responses by the nurse illustrates empathy? "I'm so sorry. My father died 2 years ago, so I know how you are feeling." "You need to focus on yourself right now. You deserve to take time just for you." "That must have been such a hard situation for you to deal with." "I know that you will get over this. It just takes time."
That must have been such a hard situation for you to deal with." This response reflects understanding of the patient's feelings, which is empathy. Feeling sorry for the client represents sympathy, whereas not addressing the patient's concern belittles the patient's feelings of grief she is expressing by changing the subject. Telling the patient she will get over it does not reflect empathy and is closed-ended.DIF: Cognitive Level: Analyze (Analysis)REF: pages 22, 23TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity
When preparing to hold an admission interview with a client, the nurse pulls up a chair and sits facing the client with his or her knees almost touching. When the nurse leans in close to speak, the client becomes visibly flustered and gets up and leaves the room. What is the most likely explanation for client's behavior? The nurse violated the client's personal space by physically being too close. The client has issues with sharing personal information. The nurse failed to explain the purpose of the admission interview. The client is responding to the voices by ending the conversation.
The nurse violated the client's personal space by physically being too close. By sitting and leaning in so closely, the nurse has entered into intimate space (0 to 18 inches), rather than social distance. This has likely made the patient may feel uncomfortable with being so close to someone unknown to them. All the other options lack evidence and jump to conclusions regarding the patient's behavior.DIF: Cognitive Level: Analyze (Analysis)REF: page 34TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity
What is the focus during clinical supervision? The nurse's behavior in the nurse-client relationship Analysis of the client's motivation for transferences Devising alternative strategies for client growth Assisting the client to develop increased independence
The nurse's behavior in the nurse-client relationship Clinical supervision helps the nurse look at his or her own behavior and determine more effective approaches to working with clients. None of the other options are associated with clinical supervision.REF: 151
A 55-year-old patient recently came to the United States from England on a work visa. The patient was admitted for severe depression following the death of a life partner weeks ago. While discussing the death and its effects the patient shows little emotion. Which of the following explanations is most plausible for this lack of emotion? The patient in denial. The response may reflect cultural norms. The response may reflect personal guilt. The patient may have an antisocial personality.
The response may reflect cultural norms. Showing little emotion while in distress may be a cultural phenomenon. Some cultures, such as the British and German cultures, tend to value highly the concept of self-control and may show little facial emotion in the presence of emotional turmoil. There is no evidence to suggest the patient's lack of emotion is a result of any of the other options.DIF: Cognitive Level: Analyze (Analysis)REF: page 9TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity
When a nurse and client meet informally or have an otherwise limited but helpful relationship, what term is used to identify this relationship? Crisis intervention Therapeutic encounter Autonomous interaction Preorientation phenomenon
Therapeutic encounter A therapeutic encounter is a short but helpful interaction between the nurse and client. None of the other options reflect this form of relationship.REF: 126-127
The client makes the decision to sit about 5 feet away from the nurse during the assessment interview. The nurse can accurately make what assumption about the client's perception of the nurse? The nurse is a safe person to interact with. The nurse is a new friend. They view the nurse as a stranger. They view the nurse as a peer.
They view the nurse as a stranger. Social distance (4-12 feet) is reserved for strangers or acquaintances. This is often the client's perception of staff during the initial phase of relationship-building. This behavior is not associated with any perception provided by any other option.REF: Page 151
What is the primary difference between a social and a therapeutic relationship? Type of information exchanged Amount of satisfaction felt Type of responsibility involved Amount of emotion invested
Type of responsibility involved In a therapeutic relationship the nurse assumes responsibility for focusing the relationship on the client's needs, facilitating communication, assisting the client with problem-solving, and helping the client identify and test alternative coping strategies.REF: 127-128
What therapeutic communication technique is the nurse using by asking a newly admitted patient, "Please tell me what was happening that led to your hospitalization here?" Using a minimal encourager Using an open-ended question Paraphrasing Reflecting
Using an open-ended question Open-ended questions require more than one-word answers. This question encourages the patient to provide a narrative concerning the circumstances surrounding the need for admission.REF: 143
A client has been admitted to your inpatient psychiatric unit with suicidal ideation. In a one-to-one session with the nurse, he shares the terrible guilt he feels over sexually abusing his stepdaughter and wanting to die because of it. Which of the following responses you could make reflects a helpful trait in a therapeutic relationship? "It's good that you feel guilty. That means you still have a chance of being helped." "Of course you feel guilty. You did a horrendous thing. You shouldn't even forget what you did." "The biggest question is, will you do it again? You will end up having even worse guilt feelings because you hurt someone again." "You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living."
You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living." This response demonstrates suspending value judgment, a helpful trait in establishing and maintaining a therapeutic relationship. Although it is difficult, nurses are more effective when they don't use their own value systems to judge patients' thoughts, feelings, or behaviors. The other options are all judgmental responses. Judgment on the part of the nurse will most likely interfere with further explorations of feelings and hinder the therapeutic relationship.DIF: Cognitive Level: Analyze (Analysis)REF: pages 25 TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity