CHAPTER 9

14. The nurse fails to assess personal values surrounding homosexuality before caring for a patient who is openly gay. The nurse is most at risk for which of the following when working with this patient? A) Holding a prejudice toward this patient B) Neglecting to include the patient's desires in the plan of care C) Being manipulated by this patient D) Expressing shock when assessing the patient's history

Ans: A Feedback: 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. It is not uncommon for a person to be ethnocentric about his or her own culture. Failure to consider cultural variations or reactions to initial exposure to variations is less detrimental to the therapeutic relationship than cultural bias. Manipulation results from a failure to maintain boundaries.

13. A client who had been in a substance abuse treatment program asks the nurse for a date after the client is discharged. The nurse talks to the client about the importance of a therapeutic relationship and its characteristics. The nurse is using which of the following techniques? A) Defining boundaries B) Defining therapy C) Letting the client down gently D) Reprimanding the client

Ans: A Feedback: 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. The other choices would be inappropriate techniques to use toward this client.

17. A nurse is assigned to care for a client whose sexual orientation differs from the nurse's sexual orientation. When should the nurse seek clinical supervision? A) When the nurse tries to assist the client to change values B) To discuss the nurse's feelings about the client with a supervisor C) When the nurse begins to empathize with the client D) When the nurse identifies anxieties regarding the client's values and sexuality

Ans: A Feedback: It is not the nurse's role to change the values of the client. The nurse should empathize with the client and be able to discuss feelings about the client with the nurse's supervisor, including anxieties regarding the client's values and sexuality.

20. A nurse openly admits to not being able to relate to a patient's experience. According to Munhall, this will most likely have what influence on the therapeutic relationship? A) The nurse will avoid imposing any values on the patient. B) The patient will not trust the nurse's professional abilities. C) The nurse will more likely be manipulated by the patient. D) The patient will be less likely to self-disclose to the nurse.

Ans: A Feedback: Munhall added another pattern of knowing called unknowing: For the nurse to admit she or he does not know the client or the client's subjective world opens the way for a truly authentic encounter. The nurse in a state of unknowing is open to seeing and hearing the client's views without imposing any of his or her values or viewpoints.

15. Which one of the following statements about the nurse and ethnocentrism is true? A) Nurses as people may inwardly view their own culture as superior to others. B) Ethnocentrism is a desirable trait in a nurse. C) Nurses must deny their ethnocentrism. D) A nurse must not think of his or her own attitudes and beliefs.

Ans: A Feedback: Nurses as people may inwardly view their own culture as superior to others. Ethnocentrism is not uncommon especially when the person has no experience with any culture other than his or her own. It is neither a desirable trait nor an undesirable trait. Nurses must examine their ethnocentrism, and think of their own attitudes and beliefs.

2. The nurse is working with a patient who has quit several jobs and no longer sends financial support to his two children living with their mother. This behavior is in conflict with the nurse's values concerning responsible parenting. When discussing family roles with the patient, the nurse shows positive regard through which statement? A) "How is not working right now affecting you?" B) "How do you expect your kids to be provided for?" C) "You need to somehow find a way to support your children." D) "Can the children's mother can get by for a while until you get better?"

Ans: A Feedback: The nurse who appreciates the client as a unique worthwhile human being can respect the client regardless of his or her behavior, background, or lifestyle. The nurse maintains attention on the client and avoids communicating negative opinions or value judgments about the client's behavior. In using positive regard, the nurse avoids value judgments and shifting of the focus away from the patient.

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

Ans: A Feedback: 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.

24. During the orientation phase of the nurse-patient relationship, the nurse directs the patient to do which of the following? A) Identify problems to examine B) Express needs and feelings C) Develop interpersonal skills D) Identify self-care strategies

Ans: A Feedback: The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. Expression of feelings and improving interpersonal skills are tasks of the working phase. Self-care strategies are developed and assessed nearing termination.

6. Which of the following is the most important skill the nurse must bring to the therapeutic nurse-client relationship? A) Confrontation B) Empathy C) Humor D) Reframing

Ans: B Feedback: 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 but not as important as the skill of empathy.

25. The nurse has been working with a patient with an eating disorder for one week. During the morning treatment team meeting, the treatment plan is updated. Which of the following would be appropriate interventions at this time in the nurse-patient relationship? Select all that apply. A) Exploring perceptions of reality B) Promoting a positive self-concept C) Explaining the boundaries of the relationship D) Working through resistance E) Assisting in identifying problems

Ans: A, B, D Feedback: Specific tasks of the working phase include maintaining the relationship, gathering more data, exploring perceptions of reality, developing positive coping mechanisms, promoting a positive self-concept, encouraging verbalization of feelings, facilitating behavior change, working through resistance, evaluating progress and redefining goals as appropriate, providing opportunities for the client to practice new behaviors, and promoting independence. Establishing boundaries and identifying problems are completed in the orientation phase.

3. Which of the following statements is true of the component of a therapeutic relationship—"acceptance"? A) The nurse accepts the behavior of any inappropriate behavior. B) It is avoiding judgments of the person, no matter what the behavior is. C) It involves punishment for inappropriate behavior. D) It is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client.

Ans: B Feedback: Acceptance is avoiding judgments of the person, no matter what the behavior is. It means accepting the person but not necessarily the behavior. It does not involve punishment for inappropriate behavior. Empathy is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client.

29. During the working phase of a therapeutic relationship, which of the following actions by the nurse would best help the client to explore problems? A) Comparing past and present coping strategies B) Encouraging the client to clarify feelings and behavior C) Identifying possible solutions for the client's problems D) Referring the client to a self-help group

Ans: B Feedback: Helping the client to clarify feelings and behavior is a first step in problem identification and exploration. The nurse must remember that it is the client who examines and explores problem situations and relationships. The nurse must be nonjudgmental and refrain from giving advice. The other choices would not help the client to explore problems.

28. What would be the most appropriate action by the student nurse when the client asked the student nurse to keep it secret that the client plans to kill a family member? A) The student nurse must respect the client's privacy and not tell anyone. B) The student nurse must tell the client that the student nurse cannot keep that secret and then report it to the instructor and/or staff members. C) The student nurse must tell the client that the student nurse will keep the secret and then tell the instructor and/or staff members. D) The student nurse must tell the instructor and then ask the instructor to keep it secret.

Ans: B Feedback: If a client tells a professional that the he or she has homicidal thoughts, the professional is released from privileged communication. The nurse is then required to notify intended victims and police of such a threat. The nurse must report the homicidal threat to the nursing supervisor and attending physician so that both the police and the intended victim can be notified.

27. 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? A) "Don't worry, I won't tell anyone else." B) "I'm sorry, but I can't keep that kind of secret." C) "Let's talk about something to cheer you up." D) "What can we do to help you feel better?"

Ans: B Feedback: Keeping secrets with a client is not permissible, especially when the client's safety is concerned. The other choices would be inappropriate responses in this situation.

18. A nurse notices a patient sitting quietly alone, eyes downcast, and looking sad. The nurse says to the patient, "You look like something is bothering you." Which pattern of knowing did the nurse use to respond to the patient? A) Empirical knowing B) Personal knowing C) Ethical knowing D) Aesthetic knowing

Ans: B Feedback: Personal knowing is obtained from life experience. An example would be a client's face shows the panic. Empirical knowing is obtained from the science of nursing. An example would be a client with panic disorder begins to have an attack. Panic attack will raise pulse rate. Ethical knowing is obtained from the moral knowledge of nursing. An example is although the nurse's shift has ended, she remains with the client. Aesthetic knowing is obtained from the art of nursing. Although the client shows outward signals now, the nurse has sensed previously the client's jumpiness and subtle differences in the client's demeanor and behavior.

21. The nurse and patient are visiting about upcoming sporting events of which they both share an interest. This form of interaction has the potential to threaten the nurse-patient relationship by A) influencing whether the patient likes the nurse or not. B) avoiding serious work that can help the patient change. C) letting the patient know that the nurse is genuine with diverse interests. D) overstepping ethical boundaries that the nurse should maintain.

Ans: B Feedback: Small talk or socializing is acceptable in nursing, but for the nurse-client relationship to accomplish the goals that have been decided on, social interaction must be limited. If the relationship becomes more social than therapeutic, serious work that moves the client forward will not be done.

35. Which role of the nurse is most likely to create difficulty for the nurse-client relationship if the client confuses physical care with intimacy and sexual interest? A) Teacher B) Caregiver C) Advocate D) Parent surrogate

Ans: B Feedback: Some clients may confuse physical care with intimacy and sexual interest, which can erode the therapeutic relationship. When the nurse is engaged in the role of teacher, the nurse may teach the client new methods of coping and solving problems or he or she may instruct the client about the medication regimen and available community resources. In the advocate role, the nurse informs the client and then supports him or her in whatever decision he or she makes. When a client exhibits child-like behavior or when a nurse is required to provide personal care such as feeding or bathing, the nurse may be tempted to assume the parental role.

1. The nurse understands that empathy is essential to the therapeutic relationship. When a patient makes the statement, "I am just devastated that my marriage is falling apart," the nurse can best show empathy through which of the following responses? A) "I feel so bad for what you are going through." B) "You feel like your world is falling apart right now." C) "I have been divorced too. I know how hard it is." D) "It will get better; let's talk about it."

Ans: B Feedback: Therapeutic communication techniques, such as reflection, restatement, and clarification, help the nurse to send empathetic messages to the client. 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, hindering the nurse's ability to view the client's needs objectively.

4. Which of the following behaviors by the nurse demonstrate positive regard? Select all that apply. A) Communicating judgments about the client's behavior B) Calling the client by name C) Spending time with the client D) Responding openly E) Considering the client's ideas and preference when planning care

Ans: B, C, D, E Feedback: 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.

31. Which of the following statements correctly depict the problem of feeling sympathy toward the client? Select all that apply. A) This can cause the nurse to feel sad and be unable to help the client. B) When the nurse's behavior is rooted in sympathy, the client finds it easier to manipulate the nurse's feelings. C) The client is discouraged from exploring his or her problems, thoughts, and feelings. D) The client is discouraged from growth. E) The client feels dependent on the nurse.

Ans: B, C, D, E Feedback: The nurse who feels sorry for the client often tries to compensate by trying to please him or her. When the nurse's behavior is rooted in sympathy, the client finds it easier to manipulate the nurse's feelings. This discourages the client from exploring his or her problems, thoughts, and feelings; discourages client growth; and often leads to client dependency.

22. The nurse is mindful of maintaining relationships with patients that are therapeutic. Certain characteristics of the relationships the nurse will foster include: Select all that apply. A) offering sound advice to the patient. B) establishing boundaries for both the nurse and patient. C) maintaining a patient-focus at all times. D) sharing personal feelings openly with the patient. E) avoiding concern with whether the patient likes the nurse.

Ans: B, C, E Feedback: The therapeutic relationship focuses on the needs, experiences, feelings, and ideas of the client only. In the therapeutic relationship, the parameters are clear: the focus is the client's needs, not the nurse's. The nurse should not be concerned about whether or not the client likes him or her or is grateful. A social relationship is focuses on sharing ideas, feelings, and experiences and meets the basic need for people to interact. In social relationships, advice is often given. This should be avoided in therapeutic relationships.

26. A patient being discharged appears angry with the nurse when the nurse attempts to review discharge instructions with the patient. The nurse can best assist the patient in this stage of the relationship with which of the following responses? A) "We have to go over these instructions before you can go. Please try to listen." B) "Would you rather not be discharged today?" C) "I can sense you are angry this morning. Tell me how you feel about being discharged today." D) "You should be able to regulate your feelings better by now. Why are you angry?"

Ans: C Feedback: Both nurse and client usually have feelings about ending the relationship; the client especially may feel the termination as an impending loss. Often clients try to avoid termination by acting angry or as if the problem has not been resolved. The nurse can acknowledge the client's angry feelings and assure the client that this response is normal to ending a relationship. If the client tries to reopen and discuss old resolved issues, the nurse should identify the client's stalling maneuvers and refocus the client on newly learned behaviors and skills to handle the problem.

33. A nurse and patient have just completed reviewing the patient's take-home medications. The nurse is exemplifying which role during this intervention? A) Advocate B) Caregiver C) Teacher D) Parent Surrogate

Ans: C Feedback: During the working phase of the nurse-client relationship, the nurse may teach the client new methods of coping and solving problems. He or she may instruct about the medication regimen and available community resources. The caregiver role is used when the nurse helps the client meet psychosocial or physical needs. When functioning as an advocate, the nurse is acting on the client's behalf when he or she cannot do so. Nurses may need to assume a parental role when the patient needs nurturing or limit setting.

12. 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) "I am sure there are other people in your life who are your friends; besides, we just met." B) "It makes me feel good that you trust me so much; it is important for the work we are doing together." C) "Since ours is a professional relationship, let's explore other opportunities in your life for friendship." D) "We are not friends. This is strictly professional."

Ans: C Feedback: The nurse's response must let the client know in clear terms that the relationship is professional while not demeaning or ridiculing the client. The other choices would not be appropriate replies in this situation.

11. A nurse is working with a patient whose background is very different from hers. A good question to ask herself to assure she can be effective working with this patient would be, A) "Can this person understand me?" B) "Do I understand this patient's expectations of me?" C) "What experiences do I have with people with similar backgrounds?" D) "Is this person going to be able to relate to me?"

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

7. Which is a standard for establishing a code of conduct for living? A) Acceptance B) Empathy C) Values D) Positive regard

Ans: C Feedback: Values are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living. Acceptance occurs when the nurse does not become upset or respond negatively to a client's outbursts, anger, or acting out. Empathy is the ability of the nurse to perceive the meaning and feelings of the client and to communicate that understanding to the client. Positive regard is an unconditional, nonjudgmental attitude.

16. A nurse is using the Johari window to identify the degree to which he feels comfortable communicating with others. After completing the exercise, the nurse discovers that quadrant 1 has the longest list of qualities. This indicates which of the following about the nurse? A) The nurse conceals personal information about himself. B) The nurse needs to increase insight into his own characteristics. C) The nurse is open to others. D) The patient is sharing more than the nurse in the therapeutic relationship.

Ans: C Feedback: When using the Johari window, if quadrant 1 is the largest, this indicates that the nurse is open to others; a smaller quadrant 1 means that the nurse shares little about himself or herself with others. If quadrants 1 and 3 are both small, the person demonstrates little insight.

8. A nurse makes the statement in a treatment team meeting, "It's not worth it to try to teach this patient how to make better choices. He has been here many times before and goes back home and does the same thing." The nurse is sharing which of the following? A) Value B) Awareness C) Belief D) Attitude

Ans: D Feedback: Attitudes are general feelings or a frame of reference around which a person organizes knowledge about the world and people. Values are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living. Beliefs are ideas that one holds to be true; for example, "All old people are hard of hearing," and "If the sun is shining, it will be a good day."

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

Ans: D Feedback: 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.

34. An adolescent patient has just been found to have broken one of the unit rules. The nurse imposes the consequence of losing phone privileges. In this instance, the nurse is acting as A) advocate. B) caregiver. C) teacher. D) parent surrogate.

Ans: D Feedback: During the working phase of the nurse-client relationship, nurses may need to assume a parental role when the patient needs nurturing or limit-setting. The nurse may also function as a teacher when the client needs to learn new skills, such as methods of coping and solving problems. The caregiver role is used when the nurse helps the client meet psychosocial or physical needs. When functioning as an advocate, the nurse is acting on the client's behalf when he or she cannot do so.

19. The nurse assesses fine hand tremors in a patient with a history of heavy alcohol use. If the nurse understands that the tremors are a direct result of alcohol use, the nurse is using which pattern of knowing, according to Carper? A) Aesthetic knowing B) Ethical knowing C) Personal knowing D) Empirical knowing

Ans: D Feedback: Empirical knowing is obtained from the science of nursing. An example would be a client with panic disorder begins to have an attack. Panic attack will raise pulse rate. Personal knowing is obtained from life experience. An example would be a client's face shows the panic. Ethical knowing is obtained from the moral knowledge of nursing. An example is although the nurse's shift has ended, she remains with the client. Aesthetic knowing is obtained from the art of nursing. Although the client shows outward signals now, the nurse has sensed previously the client's jumpiness and subtle differences in the client's demeanor and behavior.

10. When preparing for the first clinical experience with patients on a forensic unit at a psychiatric hospital, the nursing instructor discusses students' beliefs and fears surrounding forensic patients. The primary reason for discussing personal beliefs is to A) practice reflective communication skills in a role-play situation. B) assign the most compatible patients to the students. C) assess the appropriateness of the setting for implementing nursing skills. D) become aware of possible barriers to developing therapeutic relationships.

Ans: D Feedback: Self-awareness allows the nurse to observe, pay attention to, and understand the subtle responses and reactions of clients when interacting with them. Nurses are responsible for caring for patients in all settings and build therapeutic relationship skills regardless of personal beliefs.

5. The nurse initiating a therapeutic relationship with a client should explain the purpose, which is to A) alleviate stressors in life. B) allow the client to know the nurse's feelings. C) establish relationships. D) facilitate a positive change.

Ans: D Feedback: The client who has unmet or unsatisfactorily met needs seeks to make changes; the nurse facilitates this desire to change. The focus of the therapeutic relationship is on the client's needs, not the nurse's. The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. During the orientation phase, the nurse establishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies the client's problems; and clarifies expectations.

23. One of the primary differences between social and therapeutic relationships is the A) amount of emotion invested. B) degree of satisfaction obtained. C) kind of information given. D) type of responsibility involved.

Ans: D Feedback: 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 primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task.

30. Which of the following occurrences is considered a breach of professional boundaries? A) Patient asking a nurse for her phone number B) Refusing a gift from a patient C) Changing the subject in response to a patient complement D) Having a lengthy social conversation with a patient

Ans: D Feedback: The nurse must maintain professional boundaries to ensure the best therapeutic outcomes. The nurse must act warmly and empathetically but must not try to be friends with the client. Social interactions that continue beyond the first few minutes of a meeting contribute to the conversation staying on the surface. This lack of focus on the problems erodes the professional relationship. The nurse is responsible for maintaining boundaries in the event of patient inappropriateness.

9. 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." The nurse should recognize this as A) confrontation. B) countertransference. C) incongruence. D) transference.

Ans: D Feedback: Transference occurs when the client unconsciously transfers to the nurse feelings he or she has 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 his or her past. Incongruence occurs when the communication content and process disagree.