Chapter 10: The Psychiatric-Mental Health Nursing Process

6. The nurse is determining the success of a patient's plan of care by evaluating outcome indicators. The nurse understands that these indicators are usually determined initially at which time? A) On the day of discharge B) During the assessment process C) At the initial interview D) With goal-setting process

B) During the assessment process

The nurse is meeting with the client for the first time. During the orientation phase of the nurse-client relationship, the nurse assists the client with which activity? Developing interpersonal skills Identifying needs Discussing problems Identifying self-care strategies

Identifying needs Explanation: The orientation phase begins when the nurse and client meet. During this time, the client seeks assistance and identifies needs. Discussing problems, improving interpersonal skills, developing self-care strategies are developed during the working phase.

When communicating with a patient, which of the following would the nurse use to convey positive body language? A) Sitting erect with back against the chair B) Crossing the arms over the chest C) Sitting at the patient's eye level D) Keeping the feet flat on the floor with the legs crossed

C) Sitting at the patient's eye level

The nurse is meeting with a client experiencing a mood disorder. Which client statement indicates that the nurse-client relationship has been established? "I feel worthless and have no real use in life." "I really don't want to talk about that right now." "What difference does it make what I say to you?" "I know you are busy. I don't have much to say now."

"I feel worthless and have no real use in life." Explanation: People with psychiatric problems often feel alone and isolated. Establishing rapport helps lessen feelings of being alone. When rapport develops, a client feels comfortable with the nurse and finds self-disclosure easier. The nurse also feels comfortable and recognizes that an interpersonal bond or alliance is developing. All of these factors—comfort, sense of sharing, and decreased anxiety—are important in establishing and building the nurse-client relationship. The client stating feelings of worthlessness and having no real use in life demonstrates comfort with the nurse-client relationship. The other statements indicate that the client is not comfortable with the nurse and does not want to share information or take up much of the nurse's time.

A nurse is engaged in active listening. Which of the following would the nurse use? Select all that apply. A) Changing the subject to gather more information B) Responding indirectly to statements C) Using open-ended statements D) Concentrating on what patient says E) Allowing the patient to talk as he wishes

B) Responding indirectly to statements C) Using open-ended statements D) Concentrating on what patient says

The nurse is in the orientation phase of the nurse patient relationship with a patient diagnosed with a mental disorder. When interviewing the patient during this first encounter, which information would be most important for the nurse to obtain about the patient? A) Known allergies B) Recent hospitalizations C) Perception of the problem D) Family history

C) Perception of the problem

A client says to the nurse, "I have done something terrible." The nurse replies, "I would like to hear about it. It's okay to discuss it with me." Which therapeutic communication technique is the nurse utilizing? restatement open-ended statements interpretation acceptance

acceptance Explanation: The therapeutic technique of acceptance involves encouraging and receiving information in a nonjudgmental and interested manner. The statement from the nurse of "I would like to hear about it. It's okay to discuss it with me" demonstrates the use of the acceptance therapeutic communication technique. The technique of interpretation is putting into words what the client is implying or feeling. The open-ended statements technique introduces an idea and lets the client respond. The restatement technique repeats the main idea expressed and lets the client know what was heard. The techniques of restatement, open-ended statements, and interpretation are not utilized with the nurse's statement.

A nurse is interviewing a client who is describing difficulties with their family. The client begins crying and says, "I don't want to talk about this anymore." What boundary would the nurse be mindful to avoid crossing with the client? physical social psychological material

psychological Explanation: Boundaries are the defining limits of individuals, objects, or relationships. Boundaries mark territory, distinguishing what is "mine" from what is "not mine". Humans have many different types of boundaries. Material boundaries, such as fences or property, artificially imposed state lines, and bodies of water, define territory as well as provide security and order. Personal boundaries include physical, psychological, and social dimensions. Physical boundaries are those established in terms of physical closeness to others, such as who we allow to touch us or how close we want others to stand near us. Psychological boundaries are established in terms of emotional distance from others, such as how much of our innermost feelings and thoughts we want to share. Social boundaries, such as norms, customs, and roles, help us establish our closeness and place within the family, culture, and community. Therefore, the client in the scenario is establishing physiological boundaries that the nurse must be careful not to cross. Physical, social, or material boundaries are not at risk being crossed in the scenario.

A student nurse is preparing for a clinical placement in a psychiatric-mental health context. In order to best prepare to engage in therapeutic communication with clients, the student should: reflect critically on the student's own life experiences, perspectives, and characteristics. diligently study the pathophysiology, epidemiology, and nursing diagnoses related to mental illness. seek out a mentor who has extensive experience in the psychiatric-mental health area. decide what aspects of the student's life and experience the student is willing to disclose to clients.

reflect critically on the student's own life experiences, perspectives, and characteristics. Explanation: Self-awareness is a critical prerequisite for therapeutic communication and can only be achieved through critical self-reflection. Knowledge of disease processes is important but does not necessarily facilitate therapeutic communication. Self-disclosure is a comparatively minor variable and is provided cautiously on a case-by-case basis. A mentor is also useful but does not replace self-reflection as a precondition for therapeutic communication.

The nurse is engaged in a therapeutic nurse patient relationship. The relationship is in the working phase. With which of the following would the patient be involved? Select all that apply. A) Beginning to identify a need B) Testing new ways for problem solving C) Testing the relationship D) Discussing problems related to needs E) Examining personal issues

B) Testing new ways for problem solving D) Discussing problems related to needs E) Examining personal issues

When engaged in therapeutic communication in a therapeutic relationship with a patient with a mental health problem, which of the following would be most important for the nurse to keep in mind? A) The nurse should self-disclose when indicated. B) The patient is the primary focus of the interaction. C) The nurse should have an empathetic relationship with the patient. D) The patient's conversations should be recorded.

B) The patient is the primary focus of the interaction.

1. Which of the following questions would be most helpful in beginning an initial assessment interview for a patient who has just been admitted to a psychiatric inpatient unit? A) Have you had any previous psychiatric admissions? B) What brings you into the hospital today? C) Have you had any thoughts about trying to harm yourself? D) How would you describe your relationship with your spouse?

B) What brings you into the hospital today?

20. The nurse is assessing a patient's immediate and short-term memory. Which of the following would be most appropriate? A) Questioning the patient about an event that has occurred within the past several months B) Giving the patient a simple scenario and having him identify what would be the best response C) Giving the patient three words and asking him to recite them now and then in 5 minutes D) Asking the patient to tell the nurse the date, time, and current location

C) Giving the patient three words and asking him to recite them now and then in 5 minutes

A female psychiatric patient is talking to the nurse about her reasons for being hospitalized. She begins to discuss her relationship with her female significant other. The patient is describing the things in her relationship that are making her uncomfortable, and she asks the nurse, Should I break up with my partner? Which response by the nurse would be most effective in building rapport between the patient and nurse? A) Of course you should; being a lesbian is just not natural. B) Yes, I think you should pursue building a relationship with a man. C) It sounds like you're beginning to be uncomfortable in this relationship. D) You need to focus on yourself rather than the relationship right now.

C) It sounds like you're beginning to be uncomfortable in this relationship.

A nurse is developing a therapeutic relationship with a client from a cultural background different from the nurse. Which will occur if the nurse does not show this cultural competence? Eroding trust Leads to mental health relapse Frustration for the client Longer rehabilitation

Eroding trust Explanation: As the therapeutic relationship develops, the nurse must be aware of and respect the client's religious and spiritual beliefs. Ignoring or being judgmental will quickly erode trust and could stall the relationship. The client's responses may be varied, not just limited to frustration. This may or may not cause the client to require longer rehabilitation or to relapse.

The nurse fails to assess personal values surrounding a client's gender assignment before caring for a client who is transgender. Which issue is the nurse at most at risk for that may hinder development of the nurse-client relationship? Holding a prejudice toward this client Being manipulated by this client Neglecting to include the client's desires in the plan of care Expressing shock when assessing the client's history

Holding a prejudice toward this client Explanation: A person who does not assess personal attitudes and beliefs may hold a prejudice or bias toward a group of people because of preconceived ideas or stereotypical images of that group. This oversight may or may not cause the nurse to overlook the client's expressed desires. Manipulation results from a failure to maintain boundaries. Shock is unlikely because the nurse is evidently aware of the client's sexual orientation before caring for the client.

After meeting with a client experiencing extreme anxiety the nurse notes personal feelings of nervousness. Which action should the nurse take first to address these feelings? plan sessions to occur after the client receives medication investigate transferring to another care area analyze the source of the feelings suggest another nurse meet with client going forward

analyze the source of the feelings Explanation: It is important for the nurse to be aware of empathic linkages, or the direct communication of feelings. This commonly occurs with anxiety where the nurse may become aware of subjective feelings of anxiety. It may be difficult for the nurse to determine if the anxiety was communicated interpersonally or if the nurse is personally reacting to some of the content of what the client is communicating. Being aware of personal feelings and analyzing them is crucial to determining the source of the feeling and addressing associated problems. It would be premature for the nurse to investigate transferring to another care area. Switching nurses could harm the nurse-client relationship. Planning sessions after the client is medicated may not be beneficial to the client's healing process.

A patient is a successful insurance salesman; however, because of market changes, his level of sales has dropped. His boss tells him he will consequently be receiving a $2,000 per year cut in his salary. When the patient arrives home from work, the family dog runs to greet him as he always does, barking and jumping up and down and begging for attention. The patient yells at the dog, Get away from me; I can't take your barking right now. The patient's response reflects a defense mechanism because it was which of the following? A) An intentional behavior performed to let the dog know his behavior was inappropriate B) Automatic, protecting the patient from the anxiety related to his upcoming pay cut C) Implemented to keep the patient from having to cope with his upcoming pay cut D) Implemented so the patient could rationalize his upcoming pay cut

automatic, protecting the client from the anxiety related to his upcoming pay cut. Explanation: Defense mechanisms or coping styles are automatic psychological processes used to protect an individual against anxiety and from the awareness of internal or external dangers or stressors. Individuals often are unaware of these processes.

The manager is reviewing the implementation of the Transitional Relationship Model (TRM) on a care area. Which data should the manager identify that supports the successful implementation of this model? Select all that apply. discharge of clients 5 days earlier than in the past nurse reassignment increased 8% over the last month number of readmissions down 6% over the last 2 months client dissatisfaction with care up 10% over the last month staff attendance at educational programs down 9% over the last month

discharge of clients 5 days earlier than in the past number of readmissions down 6% over the last 2 months Explanation: In addition to producing positive therapeutic outcomes, the Transitional Relationship Model also reduces time spent in hospital and readmissions. Discharging clients earlier and a lower number of readmissions indicates the model has been successful. Reassigning nurses, client dissatisfaction, and low attendance at educational programs are not indicators to measure the effectiveness of this model.

A nurse has interactions with several clients throughout the day. The nurse would require a formal setting for discussion for which client? A client showing signs of sadness A client with difficulty maintaining boundaries A client that is displaying aggressive behaviors A client that is displaying hearing voices

more time to think Explanation: Sometimes silence or long pauses indicate the client is thoughtfully considering the question before responding. In this situation, it would be most therapeutic if the nurse could provide the client more time to think. Talking about the issue another time, avoiding the topic or disengaging from the interaction can only be confirmed if the nurse asks questions. However, it is important to allow the client sufficient time to respond, even if it seems like a long time.

A college student decides to go to a party the night before a major exam instead of studying. After receiving a low score on the exam, the student tells a fellow student, "I have to work too much and don't have time to study. It wouldn't matter anyway because the teacher is so unreasonable." The defense mechanisms the student is using are: reaction formation and resistance. denial and displacement. rationalization and projection. regression and compensation.

rationalization and projection. Explanation: When stating that it wouldn't matter if the student had studied, the student is using rationalization, which is excusing individual behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect. When stating that the teacher is unreasonable, the student is using projection, or the unconscious blaming of unacceptable inclinations or thoughts as an external object. Denial is the failure to acknowledge an unbearable condition. Displacement is the ventilation of intense feelings toward persons less threatening than the one who aroused those feelings. Reaction formation is acting the opposite of what one thinks or feels. Resistance is overt or covert antagonism toward remembering or processing anxiety-producing information. Regression is moving back to a previous developmental stage to feel safe or have needs met. Compensation is overachievement in one area to offset real or perceived deficiencies in another area.

The nurse is talking with the client about lowering cholesterol and raising high density lipoproteins (HDLs). The nurse states, "Niacin with applesauce helps to prevent the flushing sensation that often accompanies taking this drug." What is the nurse providing with this statement? self-disclosure active listening self-awareness empathetic linkages

self-disclosure Explanation: Self-disclosure is revealing personal information (biographical information, personal ideas, thoughts and feelings) about oneself to clients. Purposeful, well-planned disclosure, can improve rapport between the nurse and client. The nurse can use self-disclosure to convey support, educate clients and demonstrate that a client's anxiety is normal and that many people deal with stress and problems in their lives. The nurse is not providing empathetic linkages, active listening or self-awareness in this statement.

A nurse reviews a client's psychiatric and medical history before approaching the client for an assessment. The history reveals the client has a history of sexual abuse from a caregiver in early adolescence. Which zone would be the best place for the nurse to sit the nurse to begin the assessment? intimate social personal public

social Explanation: The client has a known history of sexual abuse. Clients with a history of abuse have had others touch them in harmful, hurtful ways, usually without their consent. This client may be hesitant or even unable to tell the nurse when closeness or touch are uncomfortable. The most appropriate position for the nurse would be to sit in the social zone while conducting the assessment. The nurse would be sitting 4-12 feet away from the client. The intimate zone would only leave 0-18 inches between the client and the nurse. This would not be appropriate, particularly given the client's history of sexual abuse. The personal zone leaves only 18-36 inches between the nurse and client. It would be more appropriately used between two people who know each other well. The public zone leaves 12-25 feet between the nurse and client. This distance is too far to carry out an assessment and may, in fact, compromise confidentiality.

A nurse is caring for a client in a severe anxiety state. What is an important nursing consideration while communicating with the client experiencing anxiety? increasing concentration on the task increasing environmental stimulation for distraction using short and simple statements or questions teaching the client coping skills

using short and simple statements or questions Explanation: While communicating with clients, it is important for the nurse to consider an individual's mental health challenges when selecting specific communication strategies. For example, clients with increased levels of anxiety may have poor concentration, requiring the nurse to use shorter and simpler statements or questions. Therefore, an important nursing consideration while communicating with the client experiencing anxiety includes using short and simple statements or questions. Teaching the client coping skills is important, but after the client's anxiety level is lower. Increasing concentration on the task would not be appropriate because the client has poor concentration while feeling anxious. Increasing environmental stimulation for distraction would not be appropriate because it would increase the client's anxiety.

The nurse has been providing regular care to a client diagnosed with an anxiety-related disorder for the past 2 weeks. Which statement made by the nurse suggests a possible professional boundary issue? "I am going to rearrange my schelude today so we can spend more time talking." "We can meet at 2:30 pm today to practice stress management techniques." "It would be helpful if your family attended your next session with me." "It is good to see you smiling today."

"I am going to rearrange my schedule today so we can spend more time talking." Explanation: Maintaining professional boundaries may be more difficult in an ongoing therapeutic relationship. Indicators that the relationship may be moving outside of professional boundaries are gift giving on either party's part, providing the client with a personal phone number, or spending more time than usual with a particular client. None of the other options present with behaviors or attitudes that breech the criteria for professional boundaries.

A psychiatric-mental health nurse has been off of work for the past 4 days, as per the normal work schedule on the unit. On the nurse's first day back, a longterm client says, "I haven't seen you around here since Thursday. How was your time off?" What is the nurse's most appropriate response? "I've been off for the past four days. What have you done since I last saw you?" "I'm not at liberty to talk about my personal life outside of work, unfortunately. How have you been?" "How do you like to spend your time when you're able to do whatever you like?" "If you had to guess, what do you think I might have done on my days off?"

"I've been off for the past four days. What have you done since I last saw you?" Explanation: The nurse should avoid self-disclosure. Whenever possible, it is more therapeutic to redirect the conversation rather than setting an explicit boundary. Saying, "How do you like to spend your time when you're able to do whatever you like?" redirects the conversation but is less therapeutic because the nurse has ignored the client's question. Asking the client to speculate serves no therapeutic purpose.

A client diagnosed with a mental illness asks the nurse, "Does mental illness run in your family?". Which response to the client by the nurse would be therapeutic? "Mental illness does run in families. I've had a lot of experience caring for people with mental illnesses." "Actually, my sister is being treated for schizophrenia. It's been hard on our whole family." "I struggle with anxiety and depression at times. I have learned a lot from the group sessions here." "That's not an appropriate question for me. Let's talk about something else."

"Mental illness does run in families. I've had a lot of experience caring for people with mental illnesses." Explanation: One of the most important principles of therapeutic communication for the nurse to follow is to focus the interaction on the client's concerns. Self-disclosure, telling the client personal information, generally is not a good idea. If the client asks the nurse personal questions, the nurse should elicit the underlying reason for the request. The nurse can then determine how much personal information to disclose, if any. Therefore, the nurse's response of "Mental illness does run in families. I've had a lot of experience caring for people with mental illnesses" would be therapeutic to say to the client. The nurse's responses of "Actually, my sister is being treated for schizophrenia. It's been hard on our whole family" and "I struggle with anxiety and depression at times. I have learned a lot from the group sessions here" are providing too much self-disclosure and are inappropriate in a therapeutic nurse-client relationship. The nurse's response of "That's not an appropriate question for me. Let's talk about something else" is giving disapproval and changing the subject, which are both nontherapeutic techniques for the client.

A nurse is working with a client diagnosed with chronic depression. Which statement(s) made by the nurse demonstrates compliance with the basic principles of therapeutic communication? Select all that apply. "Our talks are confidential unless what you share poses a danger to you or someone else." "I have been depressed before and found medication to be most helpful." "Tell me more about what you mean when you call your partner abusive." "It is very hard to help you when you miss our sessions so often." "My divorce was the most painful thing I have ever experienced."

"Our talks are confidential unless what you share poses a danger to you or someone else." "Tell me more about what you mean when you call your partner abusive." Explanation: Principles of therapeutic communication include maintaining client confidentiality unless there is a danger present, and clarifying information the client has presented. The focus on the interaction should be the client, not the personal feelings or experiences of the nurse. The nurse should avoid being judgmental about the client or the client's behavior.

During the next meeting during the working phase of the relationship the client brings the nurse homemade chocolate chip cookies and a box of chocolates. Which response should the nurse make to the client about these gifts? "Thank you so much. I will share them with the other nurses." "They look delicious and I love candy but I'm on a diet and really can't accept them." "How did you know that I'm a chocoholic? Will you have a cookie with me while we talk?" "Thank you but I will not accept these gifts because they extend over our discussed boundaries."

"Thank you but I will not accept these gifts because they extend over our discussed boundaries." Explanation: During the orientation phase, professional boundaries are set. If the client violates these boundaries, the nurse needs to acknowledge the behavior and reestablish or reinforce the boundaries by not accepting the gifts. Accepting the gifts to share with other nurses or the client violates the professional boundary. Declining the gifts for anything besides the violation of the professional relationship is not honest and may deteriorate the trusting relationship.

The nurse is talking with a client that states, "I am so sad today. It is the anniversary of my parent's death." Which response by the nurse may impede the communication process between the nurse and client? "I will sit here with you for a while." "You will feel better tomorrow." "I am sorry you feel sad. Would you like to talk?" "It's okay to feel sad about your parents."

"You will feel better tomorrow." Explanation: Although the nurse is not intentionally impeding the communication process and intending for the client to feel better, using a statement like "You will feel better tomorrow" is dismissive and nontherapeutic. It does not allow the client to talk about the sadness or feel the nurse is empathetic to the client. Allowing the client to talk about it, giving permission to grieve, or just giving of self are therapeutic responses to the statement.

During the admission interview, the nurse asks the client what led to the client's hospitalization. The client responds, "They lied about me. They said I murdered my mother. You're the killers. You all killed my mother. She died before I was born." What would be the best initial response by the nurse? "I just saw your mother. She's fine." "You're having very frightening thoughts." "We'll put you in a private room until you're in better control." "If your mother died before you were born, you wouldn't be here."

"You're having very frightening thoughts." Explanation: When the nurse states, "You're having very frightening thoughts," the nurse is verbalizing the implied or voicing what the client has hinted or suggested. Confrontation or rationalization are likely to make the client agitated and will ultimately harm the therapeutic relationship and communication.

While providing care to a patient with a mental disorder, the patient asks the nurse, Does mental illness run in your family? Which response by the nurse would be most inappropriate? A) Mental illnesses do run in families, and I've had a lot of experience caring for people with mental illness. B) It sounds like you are concerned that there may be a family connection to your current problem? C) Yes, it does. I have a sister who was diagnosed several years ago with severe major depression. D) Mental illness can be family related. Let's focus the discussion on you and how you're doing today.

C) Yes, it does. I have a sister who was diagnosed several years ago with severe major depression.

A nurse and client are in the orientation phase of the nurse-client relationship. Which behavior would occur during this phase? Select all that apply. Explanation of the purpose of the relationship Discussion of client's expectations Reviewing the client history Exploration of problems Strengthening of relationships

Explanation of the purpose of the relationship Discussion of client's expectations Reviewing the client history Explanation: During the orientation phase, the nurse explains the purpose of the relationship, discusses the client's expectations, and listens to the client's history and perception of the problems. The nurse begins to understand the client and identify themes. Exploration of problems occurs during the working phase. Strengthening of relationships occurs during the resolution phase.

A nurse is meeting a client for the first time. The nurse observes that the client smiles appropriately but is using rambling speech while answering the nurse's questions. Which would most likely be the reason for this behavior? The client is nervous and insecure. The client is experiencing symptoms of a disorder. The client is demonstrating a normal reaction. The client is attempting to engage in a social relationship.

The client is nervous and insecure. Explanation: In the beginning, clients may deny problems, employ various forms of defense mechanisms, or prevent the nurse from getting to know them. The client is usually nervous and insecure during the first few sessions and may exhibit behavior reflective of these emotions, such as rambling. Additional assessment would be needed to determine if the client was exhibiting symptoms of a disorder. The behavior would not be considered normal. If a social relationship was the goal, the client would be engaging the nurse to find out more about the nurse.

A nurse is caring for a client who is crying and describes an argument that they had with their spouse. The client expressed that after the argument with the partner, the client turned to their friend for emotional support. Which defense mechanism will the nurse document that the client is using? dissociation anticipation acting out affiliation

affiliation Explanation: The defense mechanism, affiliation, is turning to others for help or support (sharing problems with others without implying that someone else is responsible for them). The client turning to their friend for emotional support after the argument is demonstrating affiliation. Anticipation is experiencing emotional reactions in advance or anticipating consequences of possible future events and considering realistic, alternative responses or solutions. Acting out is using actions rather than reflections or feelings during periods of emotional conflict. Dissociation is experiencing a breakdown in the usually integrated functions of self or the environment, or sensory and motor behavior.

A psychiatric-mental health nurse must perform a physical examination on a newly admitted client. What is the nurse's priority action before entering the client's personal space for the examination? asking for the client's permission assessing the client's mental status assessing the client's emotional state asking the client's family for permission

asking for the client's permission Explanation: Physical boundaries are those established in terms of physical closeness to others, such as who we allow to touch us or how close we want others to stand near us. When boundaries are infringed upon, the client feels threatened and responds to the perceived threat. Before implementing interventions that invade the client's personal space, the nurse must elicit permission from the client. Therefore, the priority intervention by the nurse is to ask for the client's permission before conducting a physical examination on the client. Assessing the client's mental status and emotional state is important to conduct, but the priority action is to ask the client's permission before conducting an examination on the client. Asking the client's family for permission would not be appropriate if the client is able to give permission for themselves.

A nurse is working with a client whose background is very different from the nurse. Which is a good question to ask to assure the nurse can be effective working with this client? "Can this person understand me?" "Is this person going to be able to relate to me?" "Do I understand this client's expectations of me?" "What experiences do I have with people with different backgrounds?"

"What experiences do I have with people with different backgrounds?" Explanation: To best assess self-awareness, the nurse should ask, "What experiences have I had with people from ethnic groups, socioeconomic religions, age groups, or communities different from my own?" The nurse should not focus on the client when examining self-awareness; rather, the nurse should reflect on how the nurse's experiences have shaped attitudes and beliefs.

The nurse is admitting a client into the behavioral health unit that has sexually assaulted several people. How will the nurse avoid finding the client's behavior unacceptable and distasteful? Be aware of the client's behavior and background before beginning the relationship, and exploring with a colleague the potential for a conflict. Use facial expressions of annoyance if the client expresses behavior that the nurse disapproves of. Use silence instead of verbal responses for all instances of the client describing their behavior. Turn away from the client when the nurse does not want the client to see their facial expression.

Be aware of the client's behavior and background before beginning the relationship, and exploring with a colleague the potential for a conflict. Explanation: The nurse-client relationship can be jeopardized if the nurse finds the client's behavior unacceptable or distasteful and allows these feelings to show by avoiding the client or making verbal responses or facial expressions of annoyance or turning away from the client. The nurse should be aware of the client's behavior and background before beginning the relationship; if the nurse believes there may be conflict, they must explore this possibility with a colleague. Overusing the technique of silence does not help the nurse provide therapeutic responses. Showing annoyance and turning away from the client inhibit therapeutic rapport and communication.

A client being discharged from a substance use disorder treatment program asks the nurse for a date. The nurse talks to the client about the importance of a therapeutic relationship and its characteristics. Which technique is the nurse using to manage this situation? Defining therapy Reprimanding the client Letting the client down gently Defining boundaries

Defining boundaries Explanation: A therapeutic relationship is professional, and there are no mutual social goals; it is focused on meeting the client's needs and is terminated when the client no longer needs services. It is up to the nurse to maintain professional boundaries. This is a healthy and empathic response, not a reprimand. This is not part of the definition of therapy, though successful therapy includes healthy boundaries.

A nursing instructor is teaching a class on empathy. The instructor determines that the class needs additional education when the students identify that empathy involves what? Careful listening Being in touch with what the client is saying Feeling the same emotions that the client is feeling at a given time Having insight into the meaning of clients' thoughts, feelings, and behaviors

Feeling the same emotions that the client is feeling at a given time Explanation: Empathy is the ability to experience, in the present, a situation as another did at some time in the past. It is the ability to put oneself in another person's circumstances and to imagine what it would be like to share in those feelings. The nurse does not actually have to have had the experience but has to be able to imagine the feelings associated with it.

A psychiatric-mental health nurse recognizes the importance of reflecting thoughtfully and critically on the feelings experienced when interacting with clients. The nurse engages in this self-reflection to achieve which outcome? Reduce the risk for developing empathic linkages. Ensure protection of the client's right to confidentiality. Speed up the progression to the working phase of the nurse-client relationship. Maintain the professional boundaries in the nurse-client relationship.

Reduce the risk for developing empathic linkages. Explanation: Awareness and analysis of one's own feelings are vital to the prevention of empathic linkages in the nurse-client relationship. In this relationship, it is important to prioritize confidentiality, boundaries, and the timely transition to the working phase; however, these are not directly achieved by the nurse's analysis of his or her feelings.

A nurse and client are engaged in a therapeutic relationship during which time the client expresses ambivalence about the relationship. The nurse and client are most likely in which phase of the nurse-client relationship? Resolution Orientation Working Withholding

Resolution Explanation: During the resolution phase, the client may express ambivalence about the relationship and its termination. During the orientation phase, the client seeks assistance. During the working phase, there is a discussion of problems that have underlying needs. The withholding phase applies to a deteriorating relationship in which the nurse is perceived as "withholding" nursing support. The nurse fails to recognize that the patient is a person with an illness or health needs.

A nurse is caring for a client with posttraumatic stress disorder. Which behavior of the client indicates the resolution phase? The client becomes more expressive about the client's feelings to the nurse. The client explores the emotions and feelings related to the traumatic experience. The client tries different coping strategies to deal with stress. The client is able to independently express feelings and emotions with the client's friends.

The client is able to independently express feelings and emotions with the client's friends. Explanation: During the resolution phase, the client connects with community resources, solidifies a newly found understanding, and practices new behaviors. The client also interacts with significant others in new ways. Trying different coping strategies, exploring emotions and feelings, and increasing ability to express feelings would occur during the working phase.

Which nursing intervention demonstrates congruence in a therapeutic nurse-client relationship? discussing the client's request for additional privileges with the treatment team getting an appointment with the client at the time previously agreed upon implementing restatement as a therapeutic communication method sharing examples of stress management techniques

getting an appointment with the client at the time previously agreed upon Explanation: Congruence occurs when words and actions match. The nurse demonstrates this by fulfilling the promise made to the client. While the remaining options are appropriate behaviors that positively affect the nurse-client relationship, they do not demonstrate congruence.

In a nontherapeutic relationship, the nurse and client both feel very frustrated and keep varying their approach with each other in an attempt to establish a meaningful relationship. A deteriorating relationship starts with which phase? withholding avoiding ignoring struggling with and making sense of

withholding Explanation: A deteriorating relationship starts with the withholding phase, in which the nurse is perceived as "withholding" nursing support. The middle phase of a deteriorating relationship consists of two subphases: avoiding and ignoring. The nurse ignores and avoids the client's request for help; in turn, the client becomes more anxious. The end phase is termed "struggling with and making sense of." In the final phase of a deteriorating, nontherapeutic relationship, the client struggles with, and tries to understand, the unsatisfactory relationship.

15. A nurse is assessing a patient's spirituality. Which question would be most appropriate to ask? A) Have you ever tried to harm yourself? B) How important is your family to you? C) How do you define good and evil? D) What gives your life meaning?

D) What gives your life meaning?

The client says to the nurse, "I wonder what's playing at the movies tonight." Which response by the nurse would be most therapeutic? "We may have some DVDs available." "Are you telling me you would like to go to the movies?" "There's nothing worth watching." "Why don't you look in the newspaper."

"Are you telling me you would like to go to the movies?" Explanation: This nurse is restating or verbalizing the implied, which involves voicing what the client has hinted at or suggested. The nurse should apply this technique to confirm the implications of the client's statement before suggesting solutions to the presumed meaning.

A fellow nurse was confronted by the pharmacist about a medication error that was detected in the automated dispensing device. The medication administered to a client receiving palliative care may have caused an earlier death since the medication significantly decreases the client's respiratory rate when given at the administered dose. Which statement by the nurse displays the use of rationalization? "Are you sure I made this error? I can't recall this incident." "I didn't think I needed to disclose this error since the client is going to die anyway." "Please don't tell my supervisor. She will put me on probation if she knows this information." "Thank you for pointing this error out. I will fill out an incident report immediately."

"I didn't think I needed to disclose this error since the client is going to die anyway." Explanation: Rationalization is when one avoids anxiety by explaining an unacceptable or disappointing behavior or feeling in a logical, rationale way. Rationalization may protect self-esteem and self-concept. Suppression reduces anxiety by intentionally avoiding thinking about disturbing problems, wishes, feelings, or experiences. It is useful in many situations such as test-taking situations. Denial avoids feelings associated with recognizing a problem.

A psychiatric-mental health client tells the nurse, "The doctor hates me. The doctor promised to come check on me after dinner yesterday but never came." What is the nurse's most therapeutic response? "Unfortunately, the doctor has an extremely busy schedule, and she doesn't always keep promises." "I don't know why the doctor didn't check on you yesterday, but I think it's unlikely that the doctor hates you." "Since the doctor didn't come yesterday, would you like me to page her to see you right now?" "I'm sure that the doctor will come and see you as soon as she can."

"I don't know why the doctor didn't check on you yesterday, but I think it's unlikely that the doctor hates you." Explanation: One therapeutic communication technique is to express doubt. This is appropriate when the client expresses a thought that stretches credibility. The nurse does not agree or disagree but does express skepticism, which encourages the client to reconsider. It would be inappropriate for the nurse to characterize the health care provider to the client as someone who "doesn't keep promises." The nurse cannot justifiably reassure the client that the health care provider will come as soon as she is able; the nurse cannot make commitments for the provider. Similarly, it would likely be inappropriate for the nurse to page the health care provider solely in response to the client's statement.

A client was admitted to the psychiatric-mental health unit 2 days ago. Upon assessment, the client states, "You locked me up and threw away the key." What is the most therapeutic response made by the nurse to the client? "We don't ever throw away the keys." "I wasn't working when you got admitted." "Are you feeling angry?" "It must be frustrating to feel locked up."

"It must be frustrating to feel locked up." Explanation: Nurses should not necessarily take verbal messages literally, especially when a client is upset or angry. If the nurse takes the comment literally, the nurse may respond defensively, and communication would likely be blocked. The nurse must identify the desired client outcome by engaging with the client and attempt to interpret the client's feelings. Therefore, the nurse's response of "It must be frustrating to feel locked up" would be most therapeutic in this situation. The nurse's response, "Are you feeling angry?" is a closed-ended question and is not as therapeutic as interpreting their emotions. The nurse's responses of "We don't ever throw away the keys" and "I wasn't working when you got admitted" are defensive comments, which would block communication.

A client states, "I am just devastated that my marriage is falling apart." Which statement made by the nurse best demonstrates an empathetic response? "I feel so bad for what you are going through." "You feel like your world is falling apart right now." "It will get better; let's talk about it." "I have been divorced, too. I know how hard it is."

"You feel like your world is falling apart right now." Explanation: Therapeutic communication techniques, such as reflection, restatement, and clarification, help the nurse to send empathetic messages to the client. The nurse's statement, "You feel like your world is falling apart right now" restates the client's concern. The nurse must understand the difference between empathy and sympathy (feelings of concern or compassion one shows for another). Sympathy often shifts the emphasis to the nurse's feelings ("I feel so bad for what you are going through"), hindering the nurse's ability to view the client's needs objectively. It is inaccurate and nontherapeutic to state that the nurse has experienced the same feelings as the client. Stating that things will get better provides false reassurance.

16. A nurse is assisting a patient in using simple relaxation techniques. Which of the following would the nurse do first? A) Have the patient assume a relaxed position. B) Advise the patient to let the sensations happen. C) Ensure a quiet, nondisrupting environment. D) Instruct the patient to take an initial slow, deep breath.

C) Ensure a quiet, nondisrupting environment.

A nurse has interactions with several clients throughout the day. The nurse would require a formal setting for discussion for which client? A client that is displaying aggressive behaviors A client with difficulty maintaining boundaries A client showing signs of sadness A client that is displaying hearing voices

A client with difficulty maintaining boundaries Explanation: A formal setting for a discussion would be desired if a client has difficulty maintaining boundaries or has been making sexual comments. The aggressive client must have boundaries reinforced when they occur regardless of location. Clients that show sadness can be allowed to be in a private area as long as there is not suicidal ideations, and the client hearing voices can be in any setting as long as they are no threat to self or others.

A nurse administrator is observing the behavior of nurses in the hospital. Which behaviors would the nurse administrator consider inappropriate? Select all that apply. A nurse speaking to a depressed client in a very strict, disciplinarian tone A nurse hugging a client who had come in for an initial visit A nurse palpating the neck of a client during the assessment A nurse speaking to a client at a distance of 4 feet A nurse holding the hand of a client who is depressed because of the client's child's chronic illness.

A nurse hugging a client who had come in for an initial visit A nurse speaking to a depressed client in a very strict, disciplinarian tone Explanation: Hugging a client who has come in for an initial visit is an inappropriate nursing behavior. This behavior indicates that the nurse is not maintaining professional boundaries. Speaking to a depressed client in a very strict, disciplinarian tone is an inappropriate nursing behavior. The depressed client needs support, and speaking in a strict tone would not be helpful to the client. Speaking to a client at a distance of 3-6 feet facilitates good therapeutic communication. Holding the hand of a client who is depressed because of her child's chronic illness is an appropriate nursing behavior, as the client needs a person to support the client at this moment.

The nurse uses a variety of therapeutic communication skills when working with clients. Which is a therapeutic goal that can be accomplished through the use of therapeutic communication skills? Assist the client to control emotions Inform the client of priority problems Assess the client's perception of a problem Provide the client with a plan of action

Assess the client's perception of a problem Explanation: Therapeutic communication can help nurses to accomplish many goals, including identifying the most important concern to the client at that moment, assessing the client's perception of the problem, facilitating the client's expression of emotions, and guiding the client toward identifying a plan of action. The nurse should normally facilitate the client's expression of emotions more than the control of emotions. The nurse must collaborate with the client to develop a plan of action, not simply provide one to the client. Similarly, problem identification must be a collaborative process, not something that the nurse informs the client of.

The nurse is caring for a client recently admitted for depression. Which behavior demonstrated by the nurse indicates positive regard? Select all that apply. Considering the client's ideas and preference when planning care Responding openly Communicating judgments about the client's behavior Spending time with the client Calling the client by name

Calling the client by name Spending time with the client Responding openly Considering the client's ideas and preference when planning care Explanation: Calling the client by name, spending time with the client, and listening and responding openly are measures by which the nurse conveys respect and positive regard to the client. The nurse also conveys positive regard by considering the client's ideas and preferences when planning care. The nurse maintains attention on the client and avoids communicating negative opinions or value judgments about the client's behavior in order to promote positive regard.

A male client comes to the emergency department and appears to be intoxicated. He fell and hit his head at home and has a minor laceration. The nurse asks when his last drink was. The client states that he didn't have a drink and "never touches the stuff." The client is exhibiting which defense mechanism? Devaluation Dissociation Denial Displacement

Denial Explanation: Denial is refusing to acknowledge some painful aspect of eternal reality or subjective experience that is apparent to others. The client is in denial that he has a substance use problem. Devaluation is attributing exaggerated negative qualities to oneself or others. Displacement is the transference of feelings about one object to another (or a response from one object to another). Dissociation is a breakdown in the usually integrated functions of consciousness, memory, perception of oneself or the environment, or sensory and motor behavior.

A nurse is engaged in a therapeutic relationship with a client. What should the nurse do in order to ensure therapeutic communication takes place? Select all that apply. Focus on the client during the interaction Use self-disclosure frequently for empathy Ensure the client's confidentiality Employ theoretically based interventions Give the client advice about what to do

Focus on the client during the interaction Ensure the client's confidentiality Employ theoretically based interventions Explanation: A nurse engaged in therapeutic communication with a client should follow the principles of therapeutic communication: making the client the primary focus of the interaction; using self-disclosure cautiously and only when it serves a therapeutic purpose; maintaining client confidentiality; implementing interventions from a theoretic base; and avoiding the giving of advice.

Which action by the nurse or client represents the working phase of the therapeutic relationship? Communicating interest in the client Testing the relationship Reviewing work that has been done Identifying past ineffective behaviors

Identifying past ineffective behaviors Explanation: In the working phase of the relationship, the client is involved actively in achieving goals set during the initial phase. The tasks of the working phase of the therapeutic relationship include identifying past behaviors that have been ineffective for coping with the focal problem; developing a plan of action, practicing implementing it, and evaluating its effectiveness; integrating a new self-concept, worldview, or attitude toward one's illness as a result of changes in behavior and circumstances; and increasing hopefulness for the future and ability to function independently. Communicating interest in the client is the role of the nurse, and this takes place in the orientation phase of the relationship. The client tests the relationship during the orientation phase. Reviewing the work that has been done takes place during the resolution phase of the relationship.

The nurse observes the parent of a child client holding the child close on the lap during the initial assessment. Which distance zone is the parent exhibiting for people who mutually desire personal contact? Social Intimate Personal Public

Intimate Explanation: The intimate zone is the amount of space that is comfortable for parents with young children and those who desire personal contact. The social zone is the distance acceptable for communication in social, work, and business settings. The personal zone is comfortable between family and friends who are talking. The public zone is an acceptable distance between a speaker and an audience.

A client is discussing the client's problems at the workplace. Which nonverbal cues would indicate that the nurse is attentive to the client? Select all that apply. Mirroring the client's facial expression Looking down to the floor Leaning toward the client Sitting with closed arms and crossed legs Maintaining eye contact with the client

Leaning toward the client Maintaining eye contact with the client Explanation: The nonverbal cues that convey that the nurse is paying attention are leaning toward the client and maintaining eye contact while speaking to the client. If the nurse looks down toward the floor when the client is trying to talk, this indicates that the nurse is disinterested. Having a sad facial expression does not indicate attentiveness. Sitting with closed arms and crossed legs indicates that the nurse is not willing to listen to the client.

A psychiatric-mental health nurse is engaged in communication with a client. Which nonverbal behavior by the nurse would convey a positive message? Select all that apply. Nurse sits at the same eye level as the client. Nurse crosses arms in front of the chest. Nurse leans slightly forward in the chair. Nurse sits upright with back rigidly straight. Nurse stands next to client sitting in a chair

Nurse sits at the same eye level as the client. Nurse leans slightly forward in the chair. Explanation: Nurses should use positive body language, such as sitting at the same eye level as the patient (not standing while the patient is sitting in a chair) with a relaxed posture that projects interest and attention. Leaning slightly forward helps engage the patient. Generally, the nurse should not cross his or her arms or legs during therapeutic communication because such postures erect barriers to interaction. Uncrossed arms and legs project openness and a willingness to engage in conversation.

A psychiatric-mental health nurse is using the Transitional Relationship Model as a strategy for developing therapeutic relationships. When applying this model, the nurse understands that it is based on the works of which theorist? Orem Rogers Freud Peplau

Peplau Explanation: The Transitional Relationship Model (TRM) is theoretically grounded in the work of Hildegard Peplau; healing occurs in relationships. Freud, Rogers, and Orem are not associated with this model.

A client accused the nurse of "really not caring" and is now consistently 10 minutes late for sessions. To best preserve the nurse-client relationship, how should the nurse respond? The nurse continues to arrive for the session at the agreed-upon scheduled time. The nurse reschedules sessions to start 10 minutes later than originally agreed on. The nurse asks the client, "What can I do to prove to you that I really do care about you?" The nurse tells the client, "I do care and I am surprised you think I do not care."

The nurse continues to arrive for the session at the agreed-upon scheduled time. Explanation: The first part of the orientation phase, also called the "honeymoon phase," is usually pleasant but the client usually begins to test the relationship to be convinced that the nurse will really accept them. Typical "testing behaviors" include forgetting a scheduled session or being late for appointments. Clients may also express anger at something a nurse says or may accuse the nurse of breaking confidentiality. If the nurse simply accepts the behavior and continues to be available and consistent with the client, these behaviors usually subside. Testing needs to be understood as a normal way that human beings develop trust. Neither rescheduling the time of the sessions nor demonstrating such personal responses to the client's claim will help preserve the nurse-client relationship.

A client with a history of depression has told the nurse that the client is feeling especially "low" this morning. The nurse has responded by stating, "Try thinking about some of the blessings you have in your life." How should the nurse's statement be best interpreted? The nurse has inhibited the nurse-client relationship by challenging the client The nurse has inhibited therapeutic communication by giving advice The nurse has violated the ethical principles of beneficence and nonmaleficence The nurse made an inappropriate suggestion because it was not preceded by assessment

The nurse has inhibited therapeutic communication by giving advice Explanation: The nurse has blocked communication by giving advice. This action generally inhibits communication, whether or not it is preceded by assessment. This is not an example of challenging. The statement is inappropriate and simplistic but not necessarily a violation of beneficence and nonmaleficence.

While interacting with a client, a nurse says, "I think you are saying that you think things are hopeless." The nurse is using which therapeutic communication technique? Interpretation Active listening Validation Reflection

Validation Explanation: With "I think you are saying . . . ," the nurse is checking his or her understanding of what the client has stated. The nurse is using validation, a communication technique that is useful for clarifying comprehension of a situation the client is trying to describe. With validation, the listener explicitly checks their own understanding with another person, owning their own thoughts or feelings by using "I" statements. With active listening, the nurse focuses intently on what the client is communicating, verbally and nonverbally, in order to interpret and respond objectively to the message. Reflection involves redirecting the idea back to the client for classification of important emotional overtones, feelings, and experiences; this technique helps the listener maintain a nonjudgmental stance. If the client says, "Things are just hopeless," the nurse might respond, "So you believe that things are hopeless." Interpretation involves putting into words what the client may be implying or feeling but is not directly stating. If the client says, "I tried to start cleaning the closet, and then I tried to go do the shopping, but I didn't do either because there seemed to be no point," the nurse might respond, "It sounds like you feel things are hopeless."

The nurse prepares to assess a client for the first time. Which action should the nurse take to develop a rapport with this client? Select all that apply. listen intently to the client explain problems and issues explain what confidential information will be shared with others compliment the client regarding clothing selection establish professional boundaries suggest that another nurse meet with the client because of arriving late

establish professional boundaries listen intently to the client explain problems and issues explain what confidential information will be shared with others Explanation: When meeting a client for the first time, professional boundaries need to be established in order for the relationship to remain therapeutic. Listening intently demonstrates care and concern. Explaining the need to share information with others helps to establish trust. Reacting to disapproval suggests non-acceptance and will negate efforts to establish rapport. Arriving late is a behavior used to test parameters. The nurse should not react as this behavior works to develop trust.

The nurse is assessing a client who is hospitalized for an episode of mania. When the nurse sits down across from the client to begin the interview, the client moves to sit right less than a foot away from the nurse. The client is positioned in which body space zone of the nurse? intimate public personal social

intimate Explanation: If the client is sitting next to the nurse, there are only a few inches of space between them. This is the intimate zone and is appropriate for parents with young children, people who mutually desire personal contact, or people whispering. Invasion of this intimate zone by anyone else is threatening and produces anxiety.

A care area is implementing motivational interviewing. What skills will be implemented by the nurse for this technique to be successful? Select all that apply. strong communication self-awareness active listening empathetic linkages use of a variety of defense mechanisms

self-awareness active listening empathetic linkages strong communication Explanation: Because the success of motivational interviewing is dependent on contingent factors, nurses will need frequent instruction and feedback on its use. Strong communication, self-awareness, empathetic linkages, and active listening are all essential skills for motivational interviewing. Unhelpful defense mechanisms should be avoided.

The nurse is caring for a client who is very confused. In addition to verbal communication with the client, which intervention should the nurse use? displaying a flat affect so the client will not misinterpret the nurse using gentle touch during activities of daily living speaking louder so the client can hear providing instructions to the client for feeding oneself

using gentle touch during activities of daily living Explanation: The nurse should supplement verbal communication with therapeutic nonverbal communication, including gentle touch, to reinforce caring feelings for the confused client. Providing instructions for feeding oneself and speaking louder are aspects of verbal communication and, in addition, would not be helpful. Displaying a flat affect is not an aspect of therapeutic nonverbal communication.

A nurse engaged in an interaction with a patient recognizes body space zones. Which of the following would the nurse identify as the individual's personal zone? A) Beginning at the boundary of the intimate zone and ending at the social zone B) Extending outward from the border to the public zone C) Surrounding and protecting an individual from others, especially outsiders D) The most distant boundary that can be used for recognizing intruders

A) Beginning at the boundary of the intimate zone and ending at the social zone

9. A home health nurse is making a home visit to a psychiatric patient who was recently discharged from a mental health unit. During the visit, the nurse plans on clarifying with the patient when she will return for the next home visit. During which stage would the nurse discuss the next home visit with the patient? A) Closure stage B) Service implementation C) Greeting stage D) Focus establishment

A) Closure stage

A group of nursing students are preparing a class presentation on therapeutic and nontherapeutic techniques of communication. The students demonstrate understanding of the information when they select which techniques to demonstrate as therapeutic? Select all that apply. A) Confrontation B) Open-ended statements C) Reflection D) Reassurance E) Agreement F) Challenges

A) Confrontation B) Open-ended statements C) Reflection

When engaged in a nontherapeutic relationship, which of the following would the nurse identify as occurring first? A) Failure to recognize the patient as a person with a need B) Patient avoiding the nurse C) The nurse being perceived as rude D) Patient feeling hopeless and frustrated

A) Failure to recognize the patient as a person with a need

A group of students are reviewing the process of verbal communication. The students demonstrate understanding of the information when they identify which of the following as the first component of process? A) Formulation of an idea B) Message encoding C) Transmission of message D) Message reception

A) Formulation of an idea

A patient who is hospitalized with depression tells the nurse, I don't want to take the medication because I'm afraid I'll become suicidal. Which response by the nurse would be most appropriate? A) Have you ever thought about hurting yourself? B) It's important that you take this medication. C) I agree with you. I wouldn't want to take this medication either. D) Another patient took that medication, and he really felt better.

A) Have you ever thought about hurting yourself?

10. The nurse is reviewing the assessment data of a patient diagnosed with a mental illness. The patient is to be prescribed medication to treat the illness. The nurse would identify changes in which laboratory values as being the least significant? A) Hemoglobin B) Alanine aminotransferase (ALT) C) Blood urea nitrogen (BUN) level D) Serum creatinine

A) Hemoglobin

5. A staff nurse on a psychiatric unit knows that patients often have trouble sleeping because of their psychiatric conditions. Which of the following would reflect a psychiatric nursing intervention to appropriately address this problem? A) Limiting amounts of evening snacks and beverages B) Involving patients in a volleyball game immediately before bedtime C) Enforcing the rule that all patients be in bed with lights out by 10:30 PM D) Encouraging patients to take short naps in the afternoons

A) Limiting amounts of evening snacks and beverages

A hospitalized patient diagnosed with depression asks the nurse, Should I go home this weekend? Which response by the nurse uses the technique of reflection? A) Should you go home for the weekend? B) Home means what to you? C) It sounds as if you don't want to go home this weekend. D) I doubt that you really should go home this weekend.

A) Should you go home for the weekend?

18. A patient is engaged in bibliotherapy and begins to express his feelings because he closely associates his experience with that provided by the reading material. The nurse interprets this as which of the following? A) Insight B) Catharsis C) Anxiety reduction D) Problem solving

B) Catharsis

During an interview, a patient tells the nurse that he was recently let go from his job. As the interaction continues, the patient states, I was really overqualified for that position anyway. It was definitely below my area of expertise. The nurse interprets this information as reflecting which of the following? A) Denial B) Intellectualization C) Projection D) Passive aggression

B) Intellectualization

A patient is talking to the nurse about the recent death of her grandmother. She is obviously very sad, and a tear rolls down her cheek as she talks. The nurse remembers how she felt when her own grandmother died the previous summer. The nurse puts her hand on the patient's shoulder and says, This must be very difficult for you. The nurse is demonstrating empathy based on which of the following? A) The response comment reflects an attempt to communicate understanding of patient's feelings. B) The nurse's response and use of reassuring touch reinforce the nurse's concern for the patient. C) The nurse demonstrates understanding of how the patient feels because of her own grandmother's death. D) The nurse's statement expresses compassion and kindness toward the patient.

A) The response comment reflects an attempt to communicate understanding of patient's feelings.

A nurse responds to a patient's statement with silence based on the rationale that this technique is used primarily to do which of the following? A) Allow the nurse to determine an appropriate response B) Permit the patient to gather his or her thoughts C) Encourage self-reflection by the nurse D) Demonstrate passive listening

B) Permit the patient to gather his or her thoughts

13. The nurse is reviewing the drawing that a patient completed as a self-portrait. The nurse observes that the drawing lacks arms and feet. The nurse interprets this as indicating which of the following? Select all that apply. A) Low self-esteem B) Powerlessness C) Insecurity D) Inadequacy

B) Powerlessness D) Inadequacy

During the orientation phase of a nurse-client relationship, the nurse notes a change in the client's behavior. The client has forgotten a scheduled session and then accuses the nurse of breaking confidentiality. The nurse interprets this as suggesting what? Acting out Dissatisfaction with the care Rejection of the nurse Lack of understanding of the plan

Acting out Explanation: The client begins to test the relationship to become convinced that the nurse will really accept the client. Typical acting out includes forgetting a scheduled session, being late, or making an accusation that communicates the client's initial mistrust. In this case, the client also expresses anger at something a nurse says or accuses the nurse of breaking confidentiality. Another common pattern is for the client to first introduce a relatively superficial issue as if it is the major problem. The nurse must recognize that these behaviors are designed to test the relationship and establish its parameters, not to express rejection or dissatisfaction with the nurse. These behaviors also are not an indication of a lack of understanding.

A psychiatric-mental health nurse works to avoid using nontherapeutic communication techniques when engaging with clients. Which technique would the nurse most likely avoid using? Select all that apply. Silence Voicing doubt Agreeing Challenging Disapproving Exploring

Agreeing Challenging Disapproving Explanation: Silence is a therapeutic technique that involves the absence of verbal communication, which provides time for the client to put thoughts or feelings into words, to regain composure, or to continue talking. Voicing doubt is a therapeutic technique that involves expressing uncertainty about the reality of the client's perceptions. Agreeing is a nontherapeutic technique that involves indicating accord with the client. Agreeing indicates the client is "right" rather than "wrong" and there is no opportunity for the client to change his or her mind without being "wrong." Challenging is a nontherapeutic communication technique that involves demanding proof from the client, and this may cause the client to defend delusions or misperceptions more strongly than before. Disapproving is a nontherapeutic communication technique that involves judging the patient's situation and behaviors. Exploring is a therapeutic technique that involves delving further into a subject or idea.

The manager schedules a staff nurse to attend a motivational interviewing training session. Which nurse behavior caused the manager to make this decision? Select all that apply. interrupting the client minimizing the client's concerns asking the client to clarify a particular issue arguing with a client over agreed upon plans restating the client's perception of a problem

interrupting the client minimizing the client's concerns arguing with a client over agreed upon plans Explanation: The success of motivational interviewing depends upon the quality of interaction between the nurse and client. Strong communication is the cornerstone of this technique and unhelpful defense mechanisms such as interrupting, minimizing, and arguing do not support the motivational interviewing process. Asking for clarification and restating a perception support the motivational interviewing process.

2. A patient is being admitted to the psychiatric unit. While explaining his reason for seeking admission, he describes how his 32-year-old son recently died of a heart attack. Which response by the nurse would enhance the effectiveness of this interview? A) How is your wife handling your son's death? B) Do you have any other living children that can help you cope with this loss? C) This must be a very difficult time for you. D) I know exactly how you're feeling; my 23-year-old son died unexpectedly last year.

C) This must be a very difficult time for you.

The client is in the working phase of the therapeutic nurse-client relationship. Which action by the nurse would best help the client to explore problems? Identifying possible solutions for the client's problems Referring the client to a self-help group Encouraging the client to clarify feelings and behavior Comparing past and present coping strategies

Encouraging the client to clarify feelings and behavior Explanation: Helping the client to clarify feelings and behavior is a first step in problem identification and exploration. Comparing coping strategies and choosing solutions should follow the identification of problems. Referring the client to a group does not help the client identify problems with the context of a nurse-client relationship.

The nurse is initiating a therapeutic relationship with a client. Which information will the nurse include when explaining the purpose of this relationship to the client? Alleviating stressors in life Facilitating a positive change Allowing the client to know the nurse's feelings Establishing a friendship

Facilitating a positive change Explanation: The focus of the therapeutic relationship is on the client's needs, not the nurse's. Positive change is necessary for all clients, though the characteristics and foci of this change will vary widely. Therapeutic relationships are a means to this outcome of positive change, rather than an end in and of themselves. Friendship and the nurse's feelings are not a valid focus of the therapeutic relationship, which focuses solely on the client's needs. Alleviation of stressors may be needed for some, but not all, clients.

The nurse is reviewing the client's history, identifies themes, and considers how the nurse can be most therapeutic to a client who was recently admitted to a psychiatric unit. The nurse is functioning in which phase of the therapeutic relationship? Working Withholding Resolution Orientation

Orientation Explanation: The orientation phase is the phase during which the nurse and client get to know each other. The nurse reads background materials available on the client and considers his or her personal strengths and limitations in working with this client. The working stages involves problem identifcation and exploitation. Resolution, or the termination phase, begins when problems are resolved and signals the end of the therapeutic relationship. Withholding is a phase in a deteriorating relationship in which the nurse is perceived as withholding nursing support.

Which is often considered the most difficult yet most effective communication technique? silence restating reflecting clarifying

silence Explanation: Although restating, reflecting, and clarifying are effective therapeutic communication techniques, one of the most difficult but often most effective communication techniques is the use of silence during verbal interactions. By maintaining silence, a nurse allows the client to gather thoughts and to proceed at his or her own pace.

Which statement by the nurse demonstrates an understanding of the first step in helping a client learn the problem solving process? "What could you do when you are angry that doesn't involve throwing things?" "Can you explain to me what made you so angry?" "What do you think is the best thing to do when you are angry?" "What are you going to do the next time you get angry?"

"Can you explain to me what made you so angry?" Explanation: Identifying the problem (trigger for the anger) is the initial step in the problem solving process followed by brainstorming all possible solutions (different ways to manage the anger). Selecting the best alternative, implementing the selected alternation, and then evaluating the situation are the remaining steps in the process.

A client remarks, "You know, it's the same thing every time." The nurse should respond by stating: "I understand." "I'm sure everyone is doing their best." "I'm not sure what you mean. Please explain." "It's the same thing every time?"

"I'm not sure what you mean. Please explain." Explanation: Sometimes, words, phrases, or slang terms have different meanings and can be easily misunderstood. In this case, it is important for the nurse to clarify the meaning in order to avoid making assumptions. Stating that everyone is doing their best is a response that is based on an assumed meaning. Restating the client's statement will not necessarily provide clarification. Stating, "I understand" is simplistic and inaccurate because the nurse cannot claim to fully understand the client's situation.

A client is crying and shaking when talking about a recent argument they had with a family member. Which response made by the nurse would demonstrate the effective use of validation? "I would like to hear about the situation; it's okay to discuss it with me." "Let me see if I understand." "What does the argument mean to you?" "You should probably tell the family member how you feel."

"Let me see if I understand." Explanation: The therapeutic communication technique of validation is used to clarify the nurse's understanding of the situation. The response by the nurse, "Let me see if I understand" is using the validation technique. The nurse's response, "I would like to hear about the situation; it's okay to discuss it with me" is utilizing the acceptance technique, not validation. The nurse's response, "What does the argument mean to you?" is demonstrating the technique of open-ended statements, not validation. The nurse's response, "You should probably tell the family member how you feel" is giving advice, which is not therapeutic for the client.

4. After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patient's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate? A) Ineffective Role Performance B) Risk for Infection C) Risk for Suicide D) Risk for Self-Mutilation

C) Risk for Suicide

A nursing instructor is describing the nurse patient relationship to a group of nursing students. Which of the following would the instructor emphasize as crucial for establishing and maintaining the relationship? A) Rapport B) Empathy C) Self-awareness D) Values

C) Self-awareness

Which statement is true of empathy? Select all that apply. It is the ability to place oneself into the experience of another for a moment in time. It involves interjecting the nurse's personal experiences and interpretations of the situation. It is developed by gathering information from the client. It results in negative therapeutic outcomes. The client must learn to develop empathy for the nurse.

It is the ability to place oneself into the experience of another for a moment in time. It is developed by gathering information from the client. Explanation: Empathy is the ability to place oneself into the experience of another for a moment in time. Nurses develop empathy by gathering as much information about an issue as possible directly from the client to avoid interjecting their personal experiences and interpretations of the situation. It results in positive therapeutic outcomes. The nurse must develop empathy with the client but there is no expectation on clients to reciprocate empathy for the nurse.

A nurse and client are engaged in a therapeutic relationship. The nurse explains the boundaries of the relationship and clarifies expectations. The nurse and client are in which phase of the nurse-client relationship? Resolution Orientation Working Withholding

Orientation Explanation: During the orientation phase, the nurse establishes the boundaries and clarifies expectations. During the working phase, the nurse supports development of healthy problem solving and encourages the client to prepare for the future. During the resolution phase, the nurse encourages independence and promotes positive family interactions. The withholding phase occurs in a nontherapeutic relationship during which the nurse is perceived as "withholding" nursing support. The nurse fails to recognize that the patient is a person with an illness or health needs. The patient feels uncomfortable, anxious, frustrated, and guilty about being ill and does not develop a sense of trust. A barrier exists between the patient and nurse.

The nurse is caring for a client when the client begins to revert to child-like behavior. Which action by the nurse can continue to nurture the client while establishing and maintaining appropriate boundaries? Employ an authoritative manner to take charge of the situation. Stop the interaction with the client and leave, returning at a later time. Allow the client's behavior to continue since it will eventually stop. Retain an easygoing, non-judgmental attitude.

Retain an easygoing, non-judgmental attitude. Explanation: By retaining an open, easygoing, nonjudgmental attitude, the nurse can continue to nurture the client while establishing boundaries. Employing an authoritative attitude may encourage the client to continue the behaviors and become more resistant to the change. The limits for behavior should be set and not encouraged to continue and reset the limits if needed. The nurse should not leave the client and return later since that will not be effective in maintaining trust in the nurse-client relationship.

During a therapeutic communication session, the nurse tells the client of a past experience. Which statement best reflects the nurse's use of self-disclosure? It forms the solid foundation for effective communication. The more the nurse discloses, the more the client will disclose. Self-disclosure on the nurse's part should benefit the client. Self-disclosure should be used with all clients to some degree.

Self-disclosure on the nurse's part should benefit the client. Explanation: Disclosing personal information to a client can be harmful and inappropriate, so it must be planned and considered thoughtfully in advance. The nurse should determine what benefit any given client will gain from nurse self-disclosure; only when that benefit can be clearly identified should self-disclosure be used, and then it should be used judiciously and within the boundaries of the relationship. Effective communication often does not require self-disclosure by the nurse and is unnecessary during many client interactions. The client's disclosure does not normally depend on the nurse's reciprocation.

Which form of nonverbal communication would be least effective for the nurse to engage in to demonstrate interest in and acceptance of the client? Leaning slightly forward toward the client Sitting behind a desk Keeping arms and legs uncrossed Facing the client at eye level

Sitting behind a desk Explanation: Sitting behind a desk imposes a barrier between the nurse and the client and is therefore the least effective technique listed here. Therapeutic nonverbal communication uses positive body language, such as sitting at the same eye level as the client with a relaxed posture that projects interest and attention. Leaning slightly forward also helps engage the client. Generally, the nurse should not cross the arms or legs during therapeutic communication because such postures erect barriers to interaction; uncrossed arms and legs project openness and a willingness to engage in conversation.

The nurse asks a client diagnosed with bipolar disorder how they are feeling today. The client replies, "guns and bombs are exploding". Which documentation by the nurse would be appropriate for the client? concrete thinking self-observation autistic fantasy symbolism

symbolism Explanation: In people with mental illnesses, the use of words to symbolize events, objects, or feelings is often idiosyncratic, and they cannot explain their choices. For example, a person who is feeling scared and anxious may tell the nurse that bombs and guns are exploding. Therefore, the client in the scenario is utilizing symbolism and the nurse would document that observation. Concrete thinking is a type of thinking that the client with a mental illness may have and demonstrates a literal interpretation of the conversation or question. Self-observation is a defense mechanism that occurs when the client notices and expresses their feelings. Autistic fantasy is a defense mechanism that includes excessive daydreaming as a substitute for human relationships, more effective action, or problem solving.

During a regular home health visit to an elderly client, the nurse observes that the client has feelings of hopelessness and despair. The client says, "I'm old, and my life has no purpose anymore. But promise me you won't tell anyone." How should the nurse respond? "Don't worry, I won't tell anyone else." "I'm sorry, but I can't keep that kind of secret." "Let's talk about something to cheer you up." "What can we do to help you feel better?"

"I'm sorry, but I can't keep that kind of secret." Explanation: Keeping secrets with a client is not permissible, especially when the client's safety is concerned. Not telling someone violates professional boundaries and is unethical in light of the importance of the client's safety. Changing the subject and asking what the nurse can do to make things better ignores the client's feelings and are nontherapeutic.

19. After teaching a group of nursing students about milieu therapy, the instructor determines that additional teaching is needed when the students identify which of the following as a key concept of milieu therapy? A) Structure interaction B) Open communication C) Validation D) De-escalation

D) De-escalation

A nurse and client are engaged in a discussion. The client says, "I feel really close to you. You are the only true friend I have." Which response by the nurse would be most therapeutic? "I am sure there are other people in your life who are your friends; besides, we just met." "It makes me feel good that you trust me so much; it is important for the work we are doing together." "Since ours is a professional relationship, let's explore other opportunities in your life for friendship." "We are definitely not friends. This is strictly professional."

"Since ours is a professional relationship, let's explore other opportunities in your life for friendship." Explanation: The nurse's response must let the client know in clear terms that the relationship is professional while not demeaning or ridiculing the client. Stating "we just met" presents an excuse, rather than a professional boundary. The nurse should avoid focusing their feelings, which would be the case if the nurse said, "It makes me feel good." Stating, "We are not friends. This is strictly professional" is a true statement, but the bluntness is likely to harm rapport.

A client diagnosed with depression is being counseled by the nurse for cognitive distortions. The client says, "Bad things always happen to me." Which response by the nurse would be therapeutic? "Did you sleep last night?" "There must have been some good things in your life." "Are you feeling more depressed today?" "Tell me about a time when things went your way."

"Tell me about a time when things went your way." Explanation: Clients diagnosed with depression may use communication styles such as overgeneralizations ("This always happens to me..., everything always turns out for the worse..."). The nurse can assist the client to be more specific, such as asking about a specific time or a specific exception. The client in the scenario is overgeneralizing; therefore, the nurse's response, "Tell me about a time when things went your way" would be therapeutic for the client. The nurse's responses, "Did you sleep last night?", and "Are you feeling more depressed today?" are changing the subject, which is not therapeutic. The nurse's response, "There must have been some good things in your life" is minimizing the client's feelings, which is not therapeutic.

The nurse educator is teaching the class about communication. Which statement by the student nurse best describes the basic elements of communication? "The basic elements of communication include message, sender, feedback, and gesture." "The basic elements of communication include feedback, sender, receiver, and messages." "The basic elements of communication include sender, receiver, flow and message." "The basic elements of communication include receiver, feedback, flow, and expression."

"The basic elements of communication include feedback, sender, receiver, and messages." Explanation: Communication includes the elements of sender delivers the message, messages are the content of the communication, receiver receives and decodes the message, and feedback is the message returned by the receiver and indicates whether the sender's message was understood. Flow, expression, and gesture are not included in the basic elements of communication.

14. A nurse identifies a nursing diagnosis of chronic low self-esteem. Which statement by a patient would support this nursing diagnosis? A) I feel so ugly.' B) No one wants to date me. C) I'm so fat, like a cow. D) I never do anything right.

D) I never do anything right.

A client is sitting alone, slouched, with eyes closed. The nurse approaches. Which statement by the nurse is most likely to encourage the client to communicate? "Is something wrong?" "If you are sleepy, would you like me to help you back to your room?" "Why are you sitting with your eyes closed?" "You look like you are deep in thought."

"You look like you are deep in thought." Explanation: Verbalizing what the nurse perceives can give a natural opening for the client to engage in dialogue. The nurse cannot presume the meaning of the client's behavior (i.e. that they are sleepy). Asking if something is wrong may put the client on the defensive. Asking why the client is sitting this way is a blunt question that may limit, rather than enhance, dialogue.

Which of the following clients would be most likely to benefit from the application of the transitional relationship model (TRM)? A patient with a long history of alcohol abuse who has been admitted with symptoms of alcohol withdrawal A patient with bipolar disorder who has had challenges with personal and professional relationships A patient who has been diagnosed with major depression several months after the death of his wife A patient with schizophrenia who will be discharged from the hospital after several months of inpatient treatment

A patient with schizophrenia who will be discharged from the hospital after several months of inpatient treatment Explanation: The TRM is most applicable for patients who are transitioning from care in a health care setting to care in the community. The client with schizophrenia best exemplifies this transition. None of the other listed patients is currently undergoing this transition from inpatient care to community care.

11. A nurse is performing a biopsychosocial assessment of a patient with depression. Which of the following would the nurse assess as part of the psychological domain? Select all that apply. A) Abstract reasoning B) Medication use C) Mood D) Orientation E) Self-care

A) Abstract reasoning C) Mood D) Orientation

7. Based on assessment data, the nurse formulates the nursing diagnosis for a patient as sleep pattern disturbance. After teaching the patient how to relax before bedtime, the nurse determines that the teaching was effective by which outcome? A) Discusses feelings about not being able to fall asleep B) Reports feeling rested on awakening in the morning within 3 days C) Requests sleeping medication each night before bedtime D) Is able to sleep for short intervals throughout the night

B) Reports feeling rested on awakening in the morning within 3 days

Termination takes place during the resolution phase of a nurse patient relationship. During the termination process, a patient brings up resolved problems and presents them as new issues to work toward. The nurse interprets the patient's action as indicating which of the following? A) The patient is angry that the nurse is abandoning him. B) The patient requires additional therapy. C) The patient is unhappy that the therapy was ineffective D) The patient is attempting to prolong the nurse patient relationship.

D) The patient is attempting to prolong the nurse patient relationship.

A nurse has engaged in self-awareness and has come to understand his own personal beliefs and attitudes and has recognized some prejudicial ideas. Based on this understanding, which of the following would the nurse now be able to accomplish? A) Have a therapeutic relationship with a patient. B) Influence patients with certain biases. C) Change learned behaviors. D) Formulate values and morals.

C) Change learned behaviors.

8. A patient was brought to the emergency department for an injury he received while working as a migrant worker. It soon becomes evident that the patient cannot speak English. A nurse on duty offers to find an interpreter so the patient can communicate with the medical staff. The nurse's offer is an example of which type of nursing intervention? A) Milieu therapy B) Conflict resolution C) Cultural brokering D) Structured interaction

C) Cultural brokering

12. During assessment, the nurse asks a patient to explain what the following means: A penny saved is a penny earned. The nurse is assessing which of the following? A) Affect B) Attention C) Concentration D) Abstract reasoning

D) Abstract reasoning

3. A patient was admitted to the hospital after a suicide attempt made after his daughter was killed in an automobile accident during which he had been driving and survived with only minor injuries. Even though the accident was unavoidable, he feels responsible. During the assessment interview, the patient begins to describe the last conversation he had with his daughter before he lost control of the automobile. As he speaks about his daughter, his voice trembles, and a silent tear rolls down his face. He makes a visible attempt to straighten up and smiles superficially at the nurse, stating, I'll get over this. I just need to keep a stiff upper lip. I think all I need to do is stay overnight. I'll be as good as new by tomorrow. Which response by the nurse would be most appropriate? A) Tell me about your daughter. How would you describe the relationship you had with her? B) I'm sure you are right; a good night's rest should make a big difference. C) As good as new? D) You made a serious attempt on your life; you will not be ready go home by tomorrow.

D) You made a serious attempt on your life; you will not be ready go home by tomorrow.

A nurse knows that rapport has been established when the client begins to do what action? Select all that apply. Displays decreased anxiety and feels comfortable in the presence of the nurse. Tries to isolate themselves from others in the group. Develops a sense of sharing. Acknowledges that they wish to keep many topics off limit and private. Begins speaking with a more rapid, repetitive speech.

Develops a sense of sharing. Displays decreased anxiety and feels comfortable in the presence of the nurse. Explanation: When rapport develops, a client feels comfortable with the nurse and finds self-disclosure easier. The nurse also feels comfortable and recognizes that an interpersonal bond or alliance is developing. All of these factors—comfort, sense of sharing, and decreased anxiety—are important in establishing and building the nurse-client relationship. The other choices are signs that the client is distrustful of the therapeutic relationship.

A client experienced physical abuse by his father when he was a child. The client explains some of the intense financial and interpersonal stress that his father was experiencing at the time and describes the relationship between psychosocial stress and abuse. How should the nurse best interpret the client's statement? The client has delusions about the circumstances surrounding his abuse The client is intellectualizing this traumatic event in order to deal with the emotions involved The client has likely processed this trauma successfully as evidenced by his ability to discuss it The client is in denial that his father's actions were abusive

The client is intellectualizing this traumatic event in order to deal with the emotions involved Explanation: Detached rationalization and discussion of a trauma suggests the client is using the defense mechanism of intellectualization. This is not synonymous with delusion thinking, however, and the client is not necessarily in denial that the experience was wrong and painful. Intellectualization does not indicate successful processing of a trauma.

A nurse is reading a journal article about the therapeutic relationship. The nurse demonstrates understanding of the information when the nurse identifies which aspect as the primary difference between social and therapeutic relationships? The kind of information given. The focus of the relationship. The amount of emotion invested. The degree of satisfaction obtained.

The focus of the relationship. Explanation: The nurse has the responsibility for the therapeutic relationship. The therapeutic relationship focuses on the needs, experiences, feelings, and ideas of the client only. A social relationship is fundamentally different because it is primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task. Both types of relationships can be intensely emotional, though in different ways. The information given in each relationship will differ but the most significant difference is in the purpose. Similarly, both relationships can be satisfying, but in very different ways.

A client expresses worry about the client's child's aggressive behavior. The nurse says "You are in a very challenging situation. Your child's aggressive behavior is very stressful for you, is this correct?" What does this nurse's statement indicate? The nurse is comforting the client. The nurse is sympathizing with the client. The nurse is showing genuine interest in the client. The nurse is empathizing with the client.

The nurse is empathizing with the client. Explanation: Empathizing is the ability of the nurse to perceive the feelings and emotions that the client is trying to communicate. The nurse's statement indicates that the nurse is trying to perceive the problem by relating the problem with the self. This would help the client to feel comfortable and safe while sharing feelings with the nurse. Sympathy is the ability of the nurse to project his or her concern toward the client. The nurse does not perceive the problem of the client. If the nurse is able to empathize with the client then it indicates that the nurse is showing genuine interest and is listening actively to the client.

Which situation would most likely indicate a violation of professional boundaries? Select all that apply. The nurse refuses a gift from a client and the client's family. The nurse strongly defends a client's behavior during a staff meeting. A nurse reports information to the physician after the client asks that it be kept a secret. A nurse tells other staff that the nurse is the only one who understands the client. A nurse begins to spend increasing amounts of time with one client on the unit.

The nurse strongly defends a client's behavior during a staff meeting. A nurse tells other staff that the nurse is the only one who understands the client. A nurse begins to spend increasing amounts of time with one client on the unit. Explanation: Indicators that the relationship may be moving outside the professional boundaries are gift giving on either party's part, spending more time than usual with a particular client, strenuously defending or explaining the client's behavior in team meetings, the nurse feeling that he or she is the only one who truly understands the client, keeping secrets, or frequently thinking about the client outside of work. Refusing a gift and reporting information to avoid "secrets" would be appropriate professional behavior that does not violate professional boundaries.

How can a nurse avoid the possibility of finding the client's behavior unacceptable or distasteful? By being aware of the client's behavior and background before beginning the relationship, and exploring with a colleague the possibility of a conflict. By using silence instead of verbal responses for all instances of the client describing his or her behavior. By using facial expressions of annoyance if the client expresses behavior that the nurse disapproves of. By turning away from the client when the nurse does not want the client to see his or her facial expression.

By being aware of the client's behavior and background before beginning the relationship, and exploring with a colleague the possibility of a conflict. Explanation: The nurse--client relationship can be jeopardized if the nurse finds the client's behavior unacceptable or distasteful and allows these feelings to show by avoiding the client or making verbal responses or facial expressions of annoyance or turning away from the client. The nurse should be aware of the client's behavior and background before beginning the relationship; if the nurse believes there may be conflict, he or she must explore this possibility with a colleague. Overusing the technique of silence does not help the nurse provide therapeutic responses. Showing annoyance and turning away from the client inhibit therapeutic rapport and communication.

17. A group of nursing students are reviewing information about counseling interventions. The students demonstrate a need for additional review when they identify counseling interventions as involving which of the following? A) Specific, time-limited intervention B) Focus on coping improvement C) Goal of regaining functional abilities D) Prevention of disability

C) Goal of regaining functional abilities

The nurse wears a cross and has a Facebook page displaying pictures of the family, home and updates on what the nurse is currently doing. These actions are examples of what? self-disclosure self-awareness social zone exploitation

self-disclosure Explanation: The most important principles of therapeutic communication is to focus the interaction on the patient's concerns. Self-disclosure is telling the client personal information. The nurse can determine how much personal information, if any, to disclose. In revealing personal information, the nurse should be purposeful and have identified therapeutic outcomes. Self-awareness, social zone and exploitation are not principles of therapeutic communication.

A client has learned about defense mechanisms. Which behavior of the client would demonstrate the effective use of sublimination defense mechanism? The client reaffirms what they want to with social activities. The client notices their feelings and informs their friend of their feelings. The client views one friend as being perfect and views another friend as evil. When the client is angry about their boss, they go to a boxing class.

When the client is angry about their boss, they go to a boxing class. Explanation: Sublimination defense mechanism is channeling potentially maladaptive feelings or impulses into socially acceptable behavior. When the client goes to a boxing class when they are angry about their boss, this demonstrates the sublimination defense mechanism. The example of the client viewing one friend as being perfect and viewing another friend as evil is demonstrating the splitting defense mechanism. The example of the client reaffirming what they want to with social activities is the self-assertion defense mechanism. The example of the client noticing their feelings and informing their friend of their feelings is demonstrating the self-observation defense mechanism.

A nurse is assigned to care for a client whose sexual orientation differs from the nurse's sexual orientation. At which time should the nurse seek guidance from the supervisor? When the nurse desires to assist the client to change values When the nurse wants to discuss goals and the plan of care When the nurse begins to empathize with the client When the nurse accepts the client's values and sexuality

When the nurse desires to assist the client to change values Explanation: It is not the nurse's role to change the values of the client. This would be a cause for concern and an indication the the nurse's personal beliefs are interfering with the therapeutic relationship. In this case the nurse should seek out the guidance of the supervisor. Discussing goals, empathizing, and accepting differences are not situations that require additional guidance from the supervisor.