Chap 6 - Relationship Development and Therapeutic Comm

What happens in the Working phase

Maintain trust and rapport. Promote client's insight and perception of reality. Use problem-solving model to work toward achievement of established goals. Overcome resistance behaviors. Continuously evaluate progress toward goal attainment.

What is a therapeutic interpersonal relationship?

The process by which nurses provide care for clients in need of psychosocial intervention.

What happens in the Orientation (introductory) phase

Create an environment for trust and rapport . Establish contract for intervention. Assessment- Identify client's strengths and limitations. Diagnose Plan- Set mutually agreeable goals. Develop a realistic plan of action. Explore feelings of both client and nurse.

What happens in the Preinteraction phase

Obtain information about the client from chart, significant others, or other health team members. Examine one's own feelings, fears, and anxieties about working with a particular client.

What are the 9 interventions of the problem-solving model?

1. Identify the client's problem. 2. Promote discussion of desired changes. 3. Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively. 4. Discuss alternative strategies for creating changes that the client desires to make. 5. Weigh benefits and consequences of each alternative. 6. Help client select an alternative. 7. Encourage client to implement the change. 8. Provide positive feedback for client's attempts to create change. 9. Help client evaluate outcomes of the change and make modifications as required.

What are the 4 phases of the therapeutic nurse-client relationship?

1. Preinteraction phase 2. Orientation (introductory) phase 3. Working phase 4. Termination phase

What must a nurse possess to utilize "self" therapeutically? SATA A. Self-awareness B. Self-understanding C. Philosophical beliefs regarding life, death, and the human condition D. Self-respect E. Philosophical understanding of basic human rights.

A, B, C

Which conditions are essential to the development of a therapeutic relationship? SATA A.Rapport B. Trust C. Respect D. Genuineness E. Empathy

ABCDE

What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? 1. Clarify personal attitudes, values, and beliefs. 2. Obtain thorough assessment data. 3. Determine the client's length of stay. 4. Establish personal goals for the interaction.

ANS: 1 Rationale: The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding one's own attitudes, values, and beliefs is called self-awareness.

Which therapeutic communication technique is being used in the following nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." 1. Restatement 2. Offering general leads 3. Focusing 4. Accepting

ANS: 1 Rationale: The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. It allows the client to know whether the statement has been understood and provides an opportunity to continue.

Which client action should a nurse expect during the working phase of the nurse-client relationship? 1. The client gains insight and incorporates alternative behaviors. 2. The client establishes rapport with the nurse and mutually develops treatment goals. 3. The client explores feelings related to reentering the community. 4. The client explores personal strengths and weaknesses that impact behavioral choices.

ANS: 1 Rationale: The nurse should expect that that the client will gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals.

Which of the following individuals are communicating a message? (Select all that apply.) 1. A mother spanking her son for playing with matches 2. A teenage boy isolating himself and playing loud music 3. A biker sporting an eagle tattoo on his biceps 4. A teenage girl writing, "No one understands me" 5. A father checking for new e-mail on a regular basis

ANS: 1, 2, 3, 4 Rationale: The nurse should determine that spanking, isolating, getting tattoos, and writing are all ways in which people communicate messages to others. It is estimated that about 70% to80% of communication is nonverbal.

A mother rescues two of her four children from a house fire. In an emergency department, she cries, "I should have gone back in to get them. I should have died, not them." What is the nurse's best response? 1. "The smoke was too thick. You couldn't have gone back in." 2. "You're experiencing feelings of guilt, because you weren't able to save your children." 3. "Focus on the fact that you could have lost all four of your children." 4. "It's best if you try not to think about what happened. Try to move on."

ANS: 2 Rationale: The best response by the nurse is, "You're experiencing feelings of guilt, because you weren't able to save your children." This response uses the therapeutic communication technique of restating what the client has said. This lets the client know whether an expressed statement has been understood or if clarification is necessary.

A nurse maintains an uncrossed arm and leg posture when communicating with a client. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? 1. S 2. O 3. L 4. E 5. R

ANS: 2 Rationale: The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the O in the active-listening acronym SOLER. The acronym SOLER includes sitting squarely facing the client (S), observing and open posture (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).

A client diagnosed with post-traumatic stress disorder related to a rape is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique might a nurse use that is an example of "broad openings"? 1. "What occurred prior to the rape, and when did you go to the emergency department?" 2. "What would you like to talk about?" 3. "I notice you seem uncomfortable discussing this." 4. "How can we help you feel safe during your stay here?"

ANS: 2 Rationale: The nurse's statement, "What would you like to talk about?" is an example of the therapeutic communication technique of a broad opening. Using broad openings allows the client to take the initiative in introducing the topic and emphasizes the importance of the client's role in the interaction.

What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship? 1. Acknowledge the client's actions and generate alternative behaviors. 2. Establish rapport and develop treatment goals. 3. Attempt to find alternative placement. 4. Explore how thoughts and feelings about this client may adversely impact nursing care.

ANS: 2 Rationale: The priority nursing action during the orientation phase of the nurse-client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client, based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurse-client relationship.

When an individual is "two-faced," which characteristic essential to the development of a therapeutic relationship should a nurse identify as missing? 1. Respect 2. Genuineness 3. Sympathy 4. Rapport

ANS: 2 Rationale: When an individual is "two-faced," which means double-dealing or deceitful, the nurse should identify that genuineness is missing in the relationship. Genuineness refers to the nurse's ability to be open and honest and maintain congruence between what is felt and what is communicated. When a nurse fails to bring genuineness to the relationship, trust cannot be established.

Which of the following characteristics should be included in a therapeutic nurse-client relationship? (Select all that apply.) 1. Meeting the psychological needs of the nurse and the client 2. Ensuring therapeutic termination 3. Promoting client insight into problematic behavior 4. Collaborating to set appropriate goals 5. Meeting both the physical and psychological needs of the client

ANS: 2, 3, 4, 5 Rationale: The nurse-client therapeutic relationship should include promoting client insight into problematic behavior, collaboration to set appropriate goals, meeting the physical and psychological needs of the client, and ensuring therapeutic termination. Meeting the nurse's psychological needs should never be addressed within the nurse-client relationship.

An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? 1. "Why did you use the client's name on your clinical worksheet?" 2. "You were very careless to refer to your client by name on your clinical worksheet." 3. "Surely you didn't do this deliberately, but you breeched confidentiality by using names." 4. "It is disappointing that after being told you're still using client names on your worksheet."

ANS: 3 Rationale: The instructor's statement, "Surely you didn't do this deliberately, but you breeched confidentiality by using names," is an example of effective feedback. Feedback is method of communication for helping others consider a modification of behavior. Feedback should be descriptive, specific, and directed toward a behavior that the person has the capacity to modify and should impart information rather than offer advice.

A client exhibiting dependent behaviors says, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate? 1. "It would be best to do that in order to increase independence." 2. "Why would you want to leave a secure home?" 3. "Let's discuss and explore all of your options." 4. "I'm afraid you would feel very guilty leaving your parents."

ANS: 3 Rationale: The most appropriate response by the nurse is, "Let's discuss and explore all of your options." In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

Which therapeutic communication technique is being used in the following nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" 1. Reflecting 2. Making observations 3. Formulating a plan of action 4. Giving recognition

ANS: 3 Rationale: The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking. The use of this technique may serve to prevent anger or anxiety from escalating.

Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurse-client relationship? 1. "I can't bear the thought of leaving here and failing." 2. "I might have a hard time working with you, because you remind me of my mother." 3. "I really don't want to talk any more about my childhood abuse." 4. "I'm not sure that I can count on you to protect my confidentiality."

ANS: 3 Rationale: The nurse should identify that the client statement, "I really don't want to talk any more about my childhood abuse," reflects that the client is in the working phase of the nurse-client relationship. The working phase includes overcoming resistance behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

The nurse is interviewing a newly admitted psychiatric client. Which of the following nursing statements is an example of offering a "general lead"? 1. "Do you know why you are here?" 2. "Are you feeling depressed or anxious?" 3. "Yes, I see. Go on." 4. "Can you order the specific events that led to your admission?"

ANS: 3 Rationale: The nurse's statement, "Yes, I see. Go on," is an example of a general lead. Offering general leads encourages the client to continue sharing information.

A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), washes his hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? 1. "Everyone diagnosed with OCD needs to control their ritualistic behaviors." 2. "It is important for you to discontinue these ritualistic behaviors." 3. "Why are you asking for help, if you won't participate in unit therapy?" 4. "Let's figure out a way for you to attend unit activities and still wash your hands."

ANS: 4 Rationale: The most appropriate statement by the nurse is, "Let's figure out a way for you to attend unit activities and still wash your hands." This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship.

On which task should a nurse place priority during the working phase of relationship development? 1. Establishing a contract for intervention 2. Examining feelings about working with a particular client 3. Establishing a plan for continuing aftercare 4. Promoting the client's insight and perception of reality

ANS: 4 Rationale: The nurse should place priority on promoting the client's insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the pre-interaction phase. Establishing a plan for aftercare would occur in the termination phase.

If a client demonstrates transference toward a nurse, how should the nurse respond? 1. Promote safety and immediately terminate the relationship with the client. 2. Encourage the client to ignore these thoughts and feelings. 3. Immediately reassign the client to another staff member. 4. Help the client to clarify the meaning of the relationship, based on the present situation.

ANS: 4 Rationale: The nurse should respond to a client's transference by clarifying the meaning of the nurse-client relationship based on the present situation. Transference occurs when the client unconsciously displaces feelings about a person from the past toward the nurse. The nurse should assist the client in separating the past from the present.

A mother who is notified that her child was killed in a tragic car accident states, "I can't bear to go on with my life." Which nursing statement conveys empathy? 1. "This situation is very sad, but time is a great healer." 2. "You are sad, but you must be strong for your other children." 3. "Once you cry it all out, things will seem so much better." 4. "It must be horrible to lose a child, and I'll stay with you until your husband arrives."

ANS: 4 Rationale: The nurse's response, "It must be horrible to lose a child, and I'll stay with you until your husband arrives," conveys empathy to the client. Empathy is the ability to see the situation from the client's point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

A nurse says to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? 1. The therapeutic technique of giving advice 2. The therapeutic technique of defending 3. The nontherapeutic technique of presenting reality 4. The nontherapeutic technique of giving reassurance

ANS: 4 Rationale: The nurse's statement, "Things will look better tomorrow after a good night's sleep," is an example of the nontherapeutic communication technique of giving reassurance. Giving reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings.

What is a nurse's purpose for providing appropriate feedback? 1. To give the client good advice 2. To advise the client on appropriate behaviors 3. To evaluate the client's behavior 4. To give the client critical information

ANS: 4 Rationale: The purpose of providing appropriate feedback is to give the client critical information. Feedback should not be used to give advice or evaluate behaviors.

Which is the primary nursing goal when establishing a therapeutic relationship with a client? a)To promote client growth b)To develop the nurse's personal identity c)To establish a purposeful social interaction d)To develop communication skills

ANS: A Rationale: The goal of a therapeutic nursing interaction is to promote client insight and behavioral change directed toward client growth.

As the move-out date to leave the shelter gets closer, a battered wife states, "I'm afraid to leave here. I'm afraid for my safety and the safety of my children." Which nursing statement is most supportive? a)"This is a difficult transition. Let's formulate a plan to keep you all safe in the community." b)"It's the policy that clients can only live here for 30 days. Maybe we can ask for more time." c)"You've had a month to come up with a plan for keeping you and your family safe." d)"Hopefully, your husband has been in counseling. I'm sure this will work out fine."

ANS: A Rationale: The nurse is using the therapeutic techniques of "reflection" and "formulating a plan of action." The use of these communication facilitators indicates that the nurse is supportive of the client's feelings and appreciates the need for a safety plan.

The unit manager needs to meet with a client who is exhibiting escalating hostility. Which would be the most appropriate location for the nurse to meet with this client? a)The client's room with the door shut b)A quiet corner of the day room c)The nurse's station d)The unit's treatment room

ANS: B Rationale: A quiet corner of the day room provides for some privacy in a neutral space while not limiting access to help if safety issues arise.

The nurse is performing an initial assessment on a newly admitted client who is oriented times four. Which of the following communication techniques would best facilitate obtaining accurate and complete client data? a)Closed-ended questions b)Requesting an explanation c)Open-ended questions d)Interpreting

ANS: C Rationale: Open-ended questions are phrased in a way that gathers as much information as possible. By the use of phrases such as "Tell me about..." or "Describe to me..." a varied and rich body of information can be assessed.

___________________ refers to a nurse's behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurse's past.

ANS: Countertransference Rationale: Countertransference refers to a nurse's behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurse's past or they may be generated in response to transference feelings on the part of the client.

A client threatens to kill himself, his wife, and their children if the wife follows through with divorce proceedings. During the pre-interaction phase of the nurse-client relationship, which interaction should the nurse employ? a)Acknowledging the client's actions and encouraging alternative behaviors b)Establishing rapport and developing treatment goals c)Providing community resources on aggression management d)Exploring personal thoughts and feelings that may adversely impact the provision of care

ANS: D Rationale: In the pre-interaction phase, the nurse must clarify personal attitudes, values, and beliefs to become aware of how these might affect the nurse's ability to care for various clients. This occurs before the nurse meets the client.

The term ________________________ implies special feelings on the part of both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude.

ANS: rapport Rationale: Rapport implies special feelings on the part of both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. Establishing rapport may be accomplished by discussing non-health-related topics.

What is the role of the nurse in a therapeutic nurse-client relationship?

According to Hays and Larson, the role of the nurse is to provide the client with the opportunity to: 1. Identify and explore problems in relating to others. 2. Discover healthy ways of meeting emotional needs. 3. Experience a satisfying interpersonal relationship.

What is a therapeutic relationship?

An interaction between two people (usually a caregiver and a care receiver) in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention. * The foundation on which psychiatric nursing is established.

SATA regarding therapeutic relationships. A. Nurse-patient relationships are brief B. Therapeutic relationships are goal oriented C. Therapeutic relationship are most effective when the nurse tells the patient exactly what to do. D. Therapeutic relationships are directed at learning and growth promotion E. Goals are often achieved through use of the problem-solving model.

B, D, E

What is required for a therapeutic nurse-client relationship to occur? A. Mental health insurance coverage B. Acknowledgement that each participant is a unique human being C. An in-depth understanding of personality disorders and medications D. Specific goals oriented at growth and learning

B. Acknowledgement that each participant is a unique human being

What are Interpersonal communication techniques? (General)

Both verbal and nonverbal "tools" of psychosocial intervention.

What does the Therapeutic use of self mean?

The instrument for delivery of that care.... YOU! *Ability to use one's personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions

What happens in the Termination phase

Therapeutic conclusion of the relationship •Progress has been made toward attainment of the goals. •A plan of action for more adaptive coping with future stressful situations has been established. •Feelings about termination of the relationship are recognized and explored.

What's the difference between transference and countertransference?

Transferences occurs when the client unconsciously displaces (or "transfers") to the nurse feelings formed toward a person from the past. Countertransference refers to the nurse's behavioral and emotional response to the client.

What are two bad things that can happen during the working phase?

transference and countertransference