Prep U's - The Nurse-Patient Relationship - Chapter 9

Which of the following occurs when the client unconsciously transfers to the nurse feelings he or she has for significant others? A. Transference B. Countertransference C. Exploration D. Self-disclosure

Answer: Rationale: Transference occurs when the client unconsciously transfers to the nurse feelings he or she has for significant others. Countertransference occurs when the nurse responds to the client based on personal, unconscious needs and conflicts. During exploration, the client identifies the issues or concerns causing problems. Self-disclosure means revealing personal information, such as biographical data and personal ideas.

When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind? A. The client is the primary focus of the interaction. B. The nurse should self-disclose when indicated. C. The nurse should have an empathetic relationship with the client. D. The client's conversation should be recorded.

Answer: A

A nurse is caring for a client on an inpatient mental health unit of a hospital. The nurse tells the client, "You are scheduled to attend therapy sessions every morning at 9:00 a.m. Please make sure that you complete your morning routine, such as using the restroom, bathing, and eating breakfast, before you come for the sessions." Which phase of the nurse-client relationship does this communication indicate, according to the Peplau's model? A. Orientation phase. B. Exploitation phase. C. Termination phase. D. Identification phase.

Answer: A Rationale: According to the conversation, the nurse is informing the client about the daily schedule of the therapy. This conversation is indicative of the orientation phase of the nurse-client relationship. During this phase, the nurse explains the schedules of meeting, identifies the client's problems, and clarifies the expectations of the client. In the identification phase, the client tries to find the problems that would affect treatment. In the exploitation phase, the client examines the feelings and responses and tries to develop better coping skills and a more positive self-image. The client starts becoming independent in this stage. In the termination phase, the problems of the client are resolved, and the nurse-client relationship comes to an end.

Which observation should lead the nurse manager to recognize that countertransference is affecting the therapeutic effectiveness of an individual nurse on the unit? A. The nurse frequently refers to an elderly, cognitively impaired client as "my granny." B. The nurse asks to be transferred to another unit to avoid burnout and to work with different disorders. C. The nurse begins to experience the symptoms of depression and calls out sick. D. The nurse is referred to as being in a relationship with a client by that client, and the client wants the nurse to accompany the client to the prom.

Answer: A Rationale: Countertransference occurs when a mental health care professional redirects his or her feelings toward a client or becomes emotionally entangled with a client, as is occurring with the nurse's "granny." Being asked to the prom by a client is not an example of countertransference but rather reflects a client's misdirected emotion, referred to as transference. Countertransference does not involve the development of a mental illness or the resulting absenteeism. And countertransference does not involve burnout or the desire to expand one's professional expertise.

During which phase of the nurse-client relationship does the client identify and explore specific problems? A. Working phase B. Debriefing phase C. Orientation phase D. Resolution phase

Answer: A Rationale: During the working phase, the client uses the relationship to examine specific problems and learn new ways of approaching them. Debriefing is not a phase of the nurse-client relationship. During the orientation phase, the nurse and client get to know each other. The final phase, resolution, is the termination stage of the relationship and lasts from the time the problems are resolved to the close of the relationship.

Which statement is the most empathic response to a client's disclosure that the client's father abandoned the family when the client was a young child? A. "That must have been terribly hurtful experience for you." B. "What do you think motivated your father to do that." C. "I too have been disappointed by important people in my life." D. "You will find that one of the constants in life is that people will often let you down."

Answer: A Rationale: Empathy is important, yet challenging, to communicate. A genuine, open-ended, and nonjudgmental response can often convey empathy to a client. Claiming the same experience, turning the statement into a "lesson," or exploring before acknowledging are communication techniques that can impair communication.

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? A. Encouraging the client to clarify feelings and behavior. B. Comparing past and present coping strategies. C. Referring the client to a self-help group. D. Identifying possible solutions for the client's problems.

Answer: A Rationale: 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.

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? A. analyze the source of the feelings. B. suggest another nurse meet with client going forward. C. investigate transferring to another care area. D. plan sessions to occur after the client receives medication.

Answer: A Rationale: 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 nurse is conducting a 6-week social skills training program. A young adult with schizophrenia asks the nurse to call the client on the weekends so the client has someone to talk to who really cares. Which action should the nurse take? A. Remind the client about the importance of boundaries to keep the relationship therapeutic. B. Tell the client the nurse will call once per week during office hours so that the client can practice phone skills. C. Tell the client to call the office answering service in case of an emergency. D. Call the client once each weekend to build trust.

Answer: A Rationale: Nurses need to set limits with clients so that the boundaries of the relationship remain intact. Becoming overly involved with clients in inappropriate ways is evidence of a lack of self-awareness (making extra visits when time does not allow for them or calling clients when off duty).

Which theorist was most widely known for the belief that the cornerstone of all nursing care is the therapeutic relationship? A. Hildegard Peplau B. Jean Watson C. Florence Nightingale D. Clara Barton

Answer: A Rationale: Peplau's theory is based on the nurse-client relationship as a therapeutic tool.

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: A. reflect critically on the student's own life experiences, perspectives, and characteristics. B. decide what aspects of the student's life and experience the student is willing to disclose to clients. C. seek out a mentor who has extensive experience in the psychiatric-mental health area. D. diligently study the pathophysiology, epidemiology, and nursing diagnoses related to mental illness.

Answer: A Rationale: 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.

In what phase of the therapeutic relationship does the assessment process begin? A. During the initiating or orienting phase. B. After the working phase has been completed. C. During the working phase. D. After the initiating or orienting phase has been completed.

Answer: A Rationale: The first step of the therapeutic relationship is called the initiating or orienting phase. During this phase, the nurse sets the stage for a one-to-one relationship by becoming acquainted with the client. At the same time, the nurse also begins the assessment process.

The most important tool of psychiatric nursing is the: A. self B. physician C. environment D. nurse

Answer: A Rationale: The most important tool of psychiatric nursing is the self.

During a therapeutic communication session, the nurse tells the client of a past experience. Which of the following statements is true about a nurse's self-disclosure? A. Self-disclosure on the nurse's part should benefit the client. B. Self-disclosure should be used with all clients to some degree. C. It is the basis for effective communication. D. The more the nurse discloses, the more the client will disclose.

Answer: A Rationale: 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.

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

Answer: A Rationale: The nurse's response must let the client know in clear terms that the relationship is professional while not demeaning or ridiculing the client. Choices A, B, and D would not be appropriate replies in this situation.

Avoiding which outcome is the primary reason for establishing professional boundaries with clients? A. The loss of therapeutic effectiveness. B. The possibility of losing control of the milieu. C. The possibility of inappropriate sexual tension developing. D. The likelihood of a client becoming too dependent on the nurse.

Answer: A Rationale: The priority reason the psychiatric nurse is careful to maintain professional boundaries with clients is to avoid the loss of therapeutic effectiveness. While the other options can result during the course of a relationship, none of them is the priority reason the psychiatric nurse is careful to maintain professional boundaries with clients.

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? A. Assess the client's perception of a problem. B. Assist the client to control emotions. C. Inform the client of priority problems. D. Provide the client with a plan of action.

Answer: A Rationale: 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.

Which of the following occurs when the client unconsciously transfers to the nurse feelings he or she has for significant others? A. Transference B. Exploration C. Countertransference D. Self-disclosure

Answer: A Rationale: Transference occurs when the client unconsciously transfers to the nurse feelings he or she has for significant others. Countertransference occurs when the nurse responds to the client based on personal, unconscious needs and conflicts. During exploration, the client identifies the issues or concerns causing problems. Self-disclosure means revealing personal information, such as biographical data and personal ideas.

The client tells the nurse, "I don't think you can help me. Every time I talk to you, I am reminded of my mother, and I hated her." How does the nurse interpret this behavior? A. Transference B. Incongruence C. Countertransference D. Confrontation

Answer: A Rationale: Transference occurs when the client unconsciously transfers to the nurse feelings they have for significant others. Confrontation is a technique used to highlight the incongruence between a person's verbalizations and actual behavior. Countertransference occurs when the therapist displaces onto the client attitudes or feelings from their past. Incongruence occurs when the communication content and process disagree.

Which communication technique involves expressing uncertainty about the reality of the client's perception? A. Voicing doubt B. Restating C. Silence D. Reflecting

Answer: A Rationale: Voicing doubt is expressing uncertainty about the reality of the client's perceptions. Silence is the absence of communication. Restating is repeating the main idea expressed. Reflecting is directing client actions, thoughts, and feelings back to the client.

A nurse recently began working with a client in the community. The client arrived 15 minutes late for the last appointment and did not show up for today's scheduled appointment, despite confirming the day before. How should the nurse best interpret this client's behavior? A. The client is testing the parameters of the relationship. B. The client mistrusts the nurse's ability to promote recovery. C. The client is in denial about the severity of the illness. D. The client's illness is being treated by another clinician.

Answer: A Rationale: In the early phases of the nurse-client relationship, lateness and absence often characterize the client's testing of the relationship. This is a well-recognized phenomenon and is not normally interpreted as the client being in denial, receiving treatment elsewhere, or mistrusting the nurse's abilities.

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

Answer: A, C, D Rationale: 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.

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. A. strong communication B. use of a variety of defense mechanisms C. active listening D. empathetic linkages E. self-awareness

Answer: A, C, D, E Rationale: 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 preparing to meet a new client. Which goal(s) would the nurse plan to achieve during the orientation phase of the nurse-client relationship? Select all that apply. A. Explain the purpose of the relationship. B. Identify problems to focus on. C. Listen to the client's perception of problems. D. Explain the boundaries. E. Discuss the client's expectations.

Answer: A, C, D, E Rationale: The orientation phase begins when the nurse and client meet. During this phase, the nurse explains the boundaries of the relationship, discusses the client's expectations, explains the purpose of the relationship, and listens to the client's perception of problems. Identifying problems to focus on is an activity completed during the working phase of the nurse-client relationship.

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. A. Maintaining eye contact with the client. B. Mirroring the client's facial expression. C. Sitting with closed arms and crossed legs. D. Leaning toward the client. E. Looking down to the floor.

Answer: A, D Rationale: 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 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? A. The nurse is sympathizing with the client. B. The nurse is empathizing with the client. C. The nurse is showing genuine interest in the client. D. The nurse is comforting the client.

Answer: B Rationale: 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.

The nurse and client are discussing discharge plans. Which statement should the nurse make that demonstrates empathy for the client's fear of returning to a group home environment? A. "Just think of all of the things you can do in the home that you can't do here." B. "It can be scary to leave a place that you trust and feel supported." C. "You are more than ready to get out of here. Have faith in your accomplishments." D. "Don't you think you're ready to be independent?"

Answer: B Rationale: 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 their feelings. The nurse does not actually have to have had the experience but has to be able to imagine the feelings associated with it. For empathy to develop, there must be a giving of self to the other individual and a reciprocal desire to know each other personally. The process involves the nurse receiving information from the client with open, nonjudgmental acceptance and communicating this understanding of the experience and feelings, so the client feels understood. Acknowledging that leaving the hospital can be scary because the client will miss the trust and support provided demonstrates empathy. Questioning about independence, having the client think about things that can be done in the home versus the hospital, and telling the client to have faith in accomplishments do not demonstrate empathy for the client's fear.

An advanced practice nurse has chosen to apply motivational interviewing (MI) in the care of a client who will transition back to the community from inpatient treatment. The nurse should begin to apply this method by: A. emphasizing the importance of adhering to the prescribed drug regimen. B. validating the client's ability to make decisions and effect change. C. teaching the client about the concept of recovery and the likelihood of setbacks. D. reviewing the benefits of the client's treatment to this point.

Answer: B Rationale: MI begins with focusing and reinforcing the client's ability to change and leveraging the client's own decision-making ability. Each of the other listed actions is an appropriate aspect of care, but none is an explicit component of the MI process.

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? A. Rejection of the nurse B. Acting out C. Dissatisfaction with the care D. Lack of understanding of the plan

Answer: B Rationale: 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 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? A. The nurse has inhibited the nurse-client relationship by challenging the client. B. The nurse has inhibited therapeutic communication by giving advice. C. The nurse has violated the ethical principles of beneficence and nonmaleficence. D. The nurse made an inappropriate suggestion because it was not preceded by assessment.

Answer: B Rationale: 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.

A nurse is caring for a client with hemiplegia who has been depressed. The client tells the nurse, "I don't feel I would ever be independent again. I would be a burden to everybody in my house." The nurse responds by stating, "Your family misses you a lot and wants you home as soon as possible. The rehab team is very confident about your progress." Which phase of nurse-client relationship is occurring? A. Mutual withdrawal B. Working C. Resolution D. Orientation

Answer: B Rationale: The nurse is helping the client to examine the feelings and responses and tries to develop better coping skills and a more positive self-image. The conversation indicates that the client is upset about the client's disability and the nurse is trying to motivate the client. Thus, this conversation is indicative of the working phase. In the orientation phase, the nurse explains the purpose of their meeting and the schedules of the treatment sessions, identifies themes surrounding the client's problems, and clarifies expectations. In the resolution phase, the problems of the client are resolved and the nurse-client relationship comes to an end. Mutual withdrawal is a phase in a nontherapeutic relationship in which the client and nurse give up on each other due to extreme frustration.

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. A. minimizing the client's concerns. B. restating the client's perception of a problem. C. arguing with a client over agreed upon plans. D. asking the client to clarify a particular issue. E. interrupting the client.

Answer: B, C, E Rationale: 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.

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. A. suggest that another nurse meet with the client because of arriving late. B. establish professional boundaries. C. explain what confidential information will be shared with others. D. compliment the client regarding clothing selection. E. listen intently to the client explain problems and issues.

Answer: B, C, E Rationale: 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.

During the working phase, a client demonstrates open hostility in reaction to the nurse's last question. Which response should the nurse make to avoid countertransference? A. "I am only doing my job." B. "I am only trying to help you." C. "Tell me why you are angry about what I just said." D. "If you don't want to continue with me, I'll find someone else."

Answer: C Rationale: Countertransference is an emotional reaction to the client based upon personal unconscious needs and conflicts. The nurse should recognize that countertransference can occur and prevent it from eroding the professional boundaries. One way to prevent countertransference is to ask the client to explain why the statement caused hostility. Defending the statement such as saying, "I am only doing my job," "I am only trying to help you," and "I'll find someone else," demonstrates countertransference.

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? A. The more the nurse discloses, the more the client will disclose. B. It forms the solid foundation for effective communication. C. Self-disclosure on the nurse's part should benefit the client. D. Self-disclosure should be used with all clients to some degree.

Answer: C Rationale: 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.

During which phase of the nurse-client relationship does the client identify and explore specific problems? A. orientation B. resolution C. working D. debriefing

Answer: C Rationale: During the working phase, the client uses the relationship to examine specific problems and learn new ways of approaching them. Debriefing is not a phase of the nurse-client relationship. During the orientation phase the nurse and client get to know each other. The final phase, resolution, is the termination stage of the relationship and lasts from the time the problems are resolved to the close of the relationship.

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? A. autistic fantasy B. concrete thinking C. symbolism D. self-observation

Answer: C Rationale: 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.

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? A. The client is demonstrating a normal reaction. B. The client is attempting to engage in a social relationship. C. The client is nervous and insecure. D. The client is experiencing symptoms of a disorder.

Answer: C Rationale: 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 35-year-old was discharged from care after recovery from depression. The nurse therapist and the client spent many hours working through issues related to the depression. Six months later, the client is admitted again for depression associated with issues similar to those that were previously addressed in the client's therapy. The nurse therapist says to a coworker, "This is unbelievable; we're back at square one again. The client should know better at this point." The nurse's comments reflect what? A. Poor boundaries B. Countertransference C. A judgmental attitude D. Exploitation

Answer: C Rationale: Judgmental attitudes and preconceptions deter the development of therapeutic relationships. Nurses must examine their own beliefs about mental illness, such as believing that mental illness is as real as any physical illness, suspecting that clients are overdramatizing their symptoms or using them as a crutch to avoid work and social responsibility, viewing mental illness as a sign of a weak character, or asking, "Why doesn't this person just snap out of it, put his or her problems in perspective, or focus on something else?" Countertransference refers to the nurse's response to the client based on personal unconscious needs and conflicts. Exploitation refers to the phase in the therapeutic relationship when the nurse guides the client to examine feelings and responses to develop better coping mechanisms and a more positive self-image. Poor boundaries refers to inappropriate levels of personal disclosure to the client or overly social/intimate relationships with the client.

A client describes panic attacks during which the client rushes to the emergency department with a feeling that death may be imminent. The nurse discloses having had panic attacks during which the nurse also felt very fearful. Which statement about the nurse's self-disclosure is accurate? A. Self-disclosure should be detailed so the client doesn't feel unimportant or devalued. B. Self-disclosure allows the client to see the nurse as a real human being. C. Self-disclosure can help normalize the client's experience. D. Self-disclosure can help the client feel like a friend.

Answer: C Rationale: Nurses may use self-disclosure in the nurse-client relationship to comfort a client who is feeling frustrated and hopeless, enhance trust, decrease role distancing, facilitate the client's self-disclosure, convey support, or normalize the client's experience.

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

Answer: C Rationale: 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.

The client stated, "I was so upset about my friend ignoring me when I was talking about being ashamed." Which nontherapeutic communication technique should the nurse be using when stating, "How are your stress reduction classes going?" A. Challenging B. Disapproving C. Changing the subject. D. Offering advice

Answer: C Rationale: The nurse did not respond to the client's statement and instead introduced an unrelated topic. Advising would be telling the client what to do. Challenging would be demanding proof from the client. Disapproving would be denouncing the client's behavior or ideas.

The nurse says to the client, "You become very anxious when we start talking about your drinking." Which of the following techniques is the nurse using? A. Confronting behavior. B. Verbalizing the implied. C. Making an observation. D. Translating into feelings.

Answer: C Rationale: The nurse is stating what he or she sees; the client can validate it or reject it. The nurse is not confronting the behavior in this situation. The nurse is not translating the message into feelings, nor is he verbalizing the implied.

The nurse is in the process of developing a therapeutic nurse-client relationship with a newly admitted client. Which is the most important behavior the nurse demonstrates to enhance the relationship? A. Confrontation B. Reframing C. Empathy D. Humor

Answer: C Rationale: The nurse must be able to express caring and concern for the client. Empathy is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client. The ability to use confrontation, humor, and reframing are also important skills in particular circumstances but not as important and universally applicable as the skill of empathy.

Which phase of the nurse-client relationship involves establishment of a therapeutic environment by the nurse? A. Working B. Termination C. Orientation D. Resolution

Answer: C Rationale: The orientation phase of the nurse-client relationship involves the establishment of a therapeutic environment by the nurse. The working phase of the nurse-client relationship includes exploration of feelings and participation in identifying problems. The termination phase is the final stage in the nurse-client relationship.

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? A. Active listening B. Reflection C. Validation D. Interpretation

Answer: C Rationale: 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."

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? A. The nurse is sympathizing with the client. B. The nurse is showing genuine interest in the client. C. The nurse is empathizing with the client. D. The nurse is comforting the client.

Answer: C Rationale: 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.

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? A. Rejection of the nurse. B. Dissatisfaction with the care. C. Acting out. D. Lack of understanding of the plan.

Answer: C Rationale: 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.

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? A. "They look delicious, and I love candy but I'm on a diet and really can't accept them." B. "Thank you so much. I will share them with the other nurses." C. "How did you know that I'm a chocoholic? Will you have a cookie with me while we talk?" D. "Thank you but I will not accept these gifts because they extend over our discussed boundaries."

Answer: D Rationale: 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.

What occurs during the working phase of the nurse-client relationship? A. Discussion of expectations of the relationship. B. Rejection of client needs. C. Discussion regarding termination of the relationship. D. Evaluation of mutually identified goals.

Answer: D Rationale: Evaluation of mutually identified goals occurs in the working phase of the nurse-client relationship. The nurse discusses expectations during the orientation phase. During the working phase, the nurse assesses client needs. Discussion regarding the termination of the relationship occurs during the orientation phase.

A nurse is communicating with a client who is highly anxious. During the conversation, the nurse notices that the nurse's speech is matching the fast pace of the client's speech, and the nurse's heart rate is increasing. The nurse identifies this as: A. defense mechanism B. rapport C. boundary violation D. empathetic linkage

Answer: D Rationale: It is important for the nurse to be aware of empathic linkages, the direct communication of feelings (Peplau, 1952). This commonly occurs with anxiety. For example, a nurse may be speaking with a client who is highly anxious, and the nurse may notice his or her own speech becoming more rapid in tandem with the client's. The nurse may also become aware of subjective feelings of anxiety. It may be difficult for the nurse to determine whether the anxiety was communicated interpersonally, or whether the nurse is personally reacting to some of the content of what the client is communicating. Rapport (interpersonal harmony characterized by understanding and respect) is important in developing a trusting, therapeutic relationship. Nurses establish rapport through interpersonal warmth, a nonjudgmental attitude, and a demonstration of understanding. Every individual is surrounded by four different body zones that provide varying degrees of protection against unwanted physical closeness during interactions. A boundary violation would involve intrusion into the comfort zone. Defense mechanisms (also known as coping styles) are defined in the Diagnostic and Statistical Manual of Mental Disorders-V as mechanisms that mediate the client's reaction to emotional conflicts and to external stressors.

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

Answer: D Rationale: 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.

Which would indicate that the nurse-client relationship has passed from the orienting phase to the working phase? A. The client has revitalized the relationship with the client's sister. B. The client expresses a desire to be mothered and pampered. C. The nurse has designated a specific time each day to interact with the client. D. The client recognizes feelings of anger and expresses them appropriately.

Answer: D Rationale: When the client can begin to recognize feelings and talk about them, the relationship has moved into a working phase.

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?

Answer: Orientation phase Rationale: 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.

A nurse is assigned to care for a client whose sexual orientation differs from her own. She would need to seek clinical supervision if she attempted to ... A. Empathize with the client. B. Assist the client to change values. C. Discuss her feelings about the client with a supervisor. D. Identify anxieties regarding the client's values and sexuality.

Answer: B Rationale: It is not the nurse's role to change the values of the client.

Which of the following occurs during problem identification of the working phase? A. The nurse assists the client to develop better coping skills. B. The nurse assists the client to have a more positive self-image. C. The nurse guides the client to examine feelings. D. The client identifies issues or concerns.

Answer: D Rationale: The client identifies issues or concerns during problem identification of the working phase. During exploration, the nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive self-image.

When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind?

The client is the primary focus of the interaction. Rationale: A fundamental principle of therapeutic communication is that the client must be the focus of the interaction. Self-disclosure should be avoided. Empathy is important and develops over time as the nurse receives information from the client with open, nonjudgmental acceptance. The nurse communicates this understanding of the experience so that the client feels understood. Conversations with clients should be kept confidential.