Chapter 9: The Nurse-Client Relationship

Factors that Promote Client Growth:

a.Communicating genuineness b. Expressing empathy c. Having positive regard for client

During which phase of the nurse--client relationship may the client express ambivalence about the relationship? A. Orientation B. Working C. Resolution D. Debriefing

ANS: C Rationale: During the resolution phase, the client may express ambivalence about the relationship and its termination. During the orientation phase, the client seeks assistance and client needs are identified. During the working phase, there is a discussion of problems that have underlying needs. A debriefing phase does not occur in the nurse--client relationship.

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. How should the nurse begin to apply this method? A. Emphasize the importance of adhering to the prescribed drug regimen. B. Review the benefits of the client's treatment to this point. C. Validate the client's ability to make decisions and effect change. D. Teach the client about the concept of recovery and the likelihood of setbacks.

ANS: C 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.

While interviewing a client, the nurse puts herself into the client's situation and tries to imagine what it would be like and how it would feel. The nurse is demonstrating which aspect of communication? A. Empathy B. Self-awareness C. Projection D. Rapport

ANS: A 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 in their feelings. The nurse need not have had the experience, but has to be able to imagine the feelings associated with it. 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. Self-awareness is the process of understanding one's own beliefs, thoughts, motivations, biases, and limitations, and recognizing how they affect others. Projection is a defense mechanism in which a person falsely attributes to another one's own unacceptable feelings, impulses or thoughts.

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

ANS: A, C, E 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.

The 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 in denial about the severity of her illness B. The client is testing the parameters of the relationship C. The client's illness is being treated by another clinician D. The client mistrusts the nurse's ability to promote recovery

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

ANS: B Rationale: The TRM is most applicable for clients 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 clients is currently undergoing this transition from inpatient care to community care.

In a nontherapeutic relationship, the nurse and client both feel very frustrated and keep varying their approach with each other in an attempt to establish a meaningful relationship. A deteriorating relationship starts with which phase? A. Ignoring B. Avoiding C. Withholding D. Struggling with and making sense of

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

A psychiatric--mental health nurse recognizes the importance of reflecting thoughtfully and critically on the feelings experienced when interacting with clients. This practice of self-reflection will most likely produce what benefit? A. Enhanced protection of the client's right to confidentiality B. Hastening of the transition to the working phase of the nurse-client relationship C. Reduced likelihood of developing empathic linkages D. Maintenance of professional boundaries in the nurse's relationships with clients

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

In a nurse--client relationship, the client may exhibit "testing behaviors." During which stage of the relationship does the client typically use these behaviors? A. Working B. Resolution C. Orientation D. Transference

ANS: C Rationale: During the orientation phase, the client begins to test the relationship in order to become convinced that the nurse will truly accept him or her. Typical "testing behaviors" include forgetting a scheduled session, or arriving late. Testing behaviors typically do not occur in the working or resolution phase. Transference is not a phase of the nurse--client relationship; it is the unconscious assignment to others of the feelings and attitudes that the client originally associated with important figures.

During the orientation phase of the nurse--client relationship, the client is involved with which element? A. Expresses ambivalence about the relationship B. Discussing underlying needs C. Seeking assistance D. Testing new ways to solve problems

ANS: C Rationale: During the orientation phase, the client seeks assistance, identifies needs, and commits to a therapeutic relationship; the client begins to test the relationship later in this phase. The client discusses underlying needs and tests new ways to solve problems in the working phase. The nurse is responsible for establishing boundaries during the orientation phase.

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

ANS: D 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.

A nurse is communicating with a client who is highly anxious. During the conversation, the nurse notices that her speech is matching the fast pace of the client's speech and her heart rate is increasing. The nurse identifies this as which aspect of communication? A. Rapport B. Boundary violation C. Empathetic linkage D. Defense mechanism

Ans: C Rationale: It is important for the nurse to be aware of empathic linkages, the direct communication of feelings 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 if the anxiety was communicated interpersonally, or if 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-5 as mechanisms that mediate the client's reaction to emotional conflicts and to external stressors.

Termination Phase:

a. Summarize the goals achieved. b. Discuss new coping strategies. c. Review situations that occurred during the relationship. d. Exchange memories and validate experiences of the relationship to promote closure.

Working Phase:

a. Maintain client relationship b. Share information and gather further data. c. Promote clients problem solving skills. d. Facilitate behavioral change. e. Evaluate problems and goals. f. Evaluate problems and goals. g. Promote practices and expression of alternative adaptive behaviors.

Orientation Phase:

a. Rapport and trust are established. b. The nurse's role is clarified, and all roles are defined. c. Confidentiality is established. d. The terms of termination are introduced. e. The nurse becomes aware of transference and countertransference issues. f. Client problems are articulated, and mutually agreed-upon goals are established.