Chapter 9 Therapeutic Relationships

As the nurse performs an assessment on a client diagnosed with breast cancer, the client says, "I will discuss my illness, but you should not share the information with anyone." Which response by the nurse is appropriate for effective nurse-client interaction? "It is a part of the assessment, and you are required to inform me of your concerns." "I assure you that I will not share the information provided by you with anyone." "I cannot maintain your secrets, because I have to follow and abide by professional ethics." "I will be sharing the information provided by you with other health care professionals but no one else."

During the assessment the nurse should inform the client that the information provided by the client will be shared with the health care professionals. This action helps safeguard the confidentiality and privacy of the client. It also helps provide for continuity of care when the client is discharged from the hospital. The statement that the client should inform the nurse of all concerns may lead to angry feelings for the client and interfere with communication; therefore, this is not an appropriate response. The nurse should not give the client false assurance by saying that the information provided by the client will not be disclosed to anyone. The nurse should not rudely deny the client's request by saying that the client's confidential medical information cannot be kept secret. This may cause the client feel rejected and is not true. pp. 111-112

When conducting a clinical interview of a client, which techniques should the nurse implement to facilitate effective communication? Select all that apply. Maintaining silence to encourage the client to talk Making nonthreatening observations to initiate conversation Making value judgments about the client's behaviors Reassuring the client that everything will be all right Probing the client for relevant information Asking open-ended questions

Maintaining silence to encourage the client to talk Asking open-ended questions Making nonthreatening observations to initiate conversation Maintaining silence, making observations, and asking open-ended questions are effective therapeutic techniques. Maintaining silence when necessary gives the client time to recollect and think. Making observations and calling attention to the client's behavior helps start a conversation with a withdrawing client. Asking open-ended questions promotes long conversations and encourages the client to respond fully. Making value judgments prevents problem solving, and the client may get angry or dissatisfied. False reassurances will make the client feel unimportant. Probing the client may make him or her withdrawal if the nurse pushes for conversations the client is not ready to have. p. 120

Which behavior by the nurse most clearly demonstrates promoting a social relationship instead of a therapeutic nurse-client relationship? The nurse shares stories about his or her children. The nurse talks about favorite television shows with the client. The nurse confides in the client about a frustrating day at work. The nurses talks about a client with another nurse outside the workplace.

The nurse confides in the client about a frustrating day at work. In order to maintain a therapeutic nurse-client relationship, the nurse must remember to focus all interactions on the client and the client's needs. A nurse who talks about a frustrating day at work is focusing on his or her own needs, which imparts a social relationship rather than a therapeutic relationship. A nurse can share a brief story about his or her own personal life, as long as the conversation and interaction remains focused on the client. The nurse can be friendly with the client and talk about favorite television shows while still maintaining a therapeutic relationship. The nurse should not talk about clients outside of the workplace due to privacy issues, but this inappropriate nurse-to-nurse interaction does not necessarily affect the nurse's therapeutic relationship with the client. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. p. 110

Which statement made by a mental health nurse demonstrates the need for further education regarding therapeutic communication techniques? "When I use therapeutic silence, I'm giving the client time to think and reflect." "Sharing perceptions doesn't mean I tell the client how my experiences are similar to his or hers." "I generally find it helpful to ask the client why he or she blames others for the mistakes he or she has made." "It's not therapeutic to give the client suggestions as to what he or she needs to do to fix his or her problems."

"I generally find it helpful to ask the client why he or she blames others for the mistakes he or she has made." Asking why the client is behaving in a particular manner often is viewed as judgmental by the client. Presenting such an attitude would be a barrier to communication and thus nontherapeutic. Stating, "When I use therapeutic silence, I'm giving the client time to think and reflect" describes an effective use of silence. Sharing perceptions is used to clarify an understanding of what the client is thinking or feeling. Suggestions are therapeutic only when given as possible alternatives for the client to consider, not when given as advice. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so. p. 120

Which comment by the nurse would be appropriate when beginning a new nurse-client relationship? "Which of your problems is most serious?" "I want you to tell me about your problems." "I'm an experienced nurse. You can trust me." "What would you like to tell me about yourself?"

"What would you like to tell me about yourself?" Asking the client what he or she wants to tell the nurse is an open-ended statement that gives the client control over the interview. It emphasizes the client-centered nature of the nurse-client relationship. The focus is on the client's ideas, experiences, and feelings. Evaluating the client's problems and goals comes later in the working phase of the nurse-client relationship. Bringing up problems right away is not an open-ended approach and can make the client uncomfortable. Bringing up the nurse's experience does not keep the focus on the client. p. 120

A nurse is interacting with a child during a home visit. The nurse learns that the child is depressed because of poor grades in school. When the nurse responds, the child says the nurse just doesn't understand. Which nontherapeutic response might the nurse have used to cause this reaction? "Why did you score low in your exams?" "What are you worried about?" "You must be feeling very upset." "What would you like to talk about?"

"Why did you score low in your exams?" The response, "Why did you score low on your exams?" is a nontherapeutic response because the nurse is probing a topic that is sensitive for the child. The nurse should strive to decrease the client's anxiety, and a question like this will likely increase it. The child may then feel that the nurse is unable to understand his or her feelings. The response, "What are you worried about?" is a therapeutic response. The child can then help the nurse understand and acknowledge his or her feelings. The response, "You must be feeling very upset" is a therapeutic response. The nurse has restated the child's feelings to seek clarification. The response, "What would you like to talk about?" is a therapeutic response. It is an example of broad opening in which the nurse encourages the child to share his or her feelings. p. 120

A nurse is interacting with a client who is diagnosed with human immunodeficiency virus (HIV). The nurse observes that the client appears depressed and avoids interacting whenever possible. What response should the nurse provide to encourage the client to acknowledge his or her feelings? "You look upset about something." "Don't worry about what others would say." "Are you thinking about your illness now?" "I feel you are not willing to interact with me."

"You look upset about something." Observing that the client looks upset invites a response while keeping the focus on the client's feelings. It makes the client feel that the nurse is concerned about him or her and encourages sharing feelings. The nurse should not be judgmental and come to a conclusion that the client is worried about what others would say. The nurse should avoid asking closed-ended questions such as, "Are you thinking about your illness?" It limits the conversation to a "yes" or "no" response and may interfere with further communication. It is unprofessional for the nurse to express his or her own feelings. p. 120

After work, a psychiatric nurse makes several comments to a family member. Which comment indicates that this nurse needs clinical supervision? "It seems like my work load is very heavy right now." "My supervisor announced plans for renovations to our offices." "I am taking care of a prominent political person from our community." "We have a new psychiatrist with expertise in working with troubled veterans."

"I am taking care of a prominent political person from our community." The correct response indicates that the nurse has attached an additional importance to care of one client (a politician). In some instances, this comment also could jeopardize the client's confidentiality. Supervision by a more experienced clinician or team member is essential to developing one's competence. Nurses should consistently practice self-care by sharing their own feelings with others; however, this sharing must respect professional boundaries. Indicating a work load is heavy, that a supervisor announced plans for renovation, or that there is a new expert for a given population are all acceptable comments to share with family members and do not warrant supervision. Test-Taking Tip: Look for answers that focus on the client or are directed toward feelings. p. 111

A client diagnosed with paranoid schizophrenia tells the nurse, "I'm here on a top secret mission for the President. Don't tell anyone I am here." Which response should the nurse provide to address the client's primary concern? "Let's talk about something other than your mission for the President." "Your admission papers do not list you as an employee of the President." "You have lost touch with reality, which is a symptom of your illness." "It sounds like you have some concerns about your privacy. You are safe here."

"It sounds like you have some concerns about your privacy. You are safe here." The correct response focuses on the client's perception and feelings that it is important no one knows where he or she is. Reassuring the client of his or her privacy also offers a safe environment. Changing the subject takes the focus of the interview off the client's feelings and minimizes his or her experiences. It is important not to challenge the client's beliefs by noting the admission papers or saying the client has lost touch with reality, even if the beliefs are unrealistic. Challenging undermines the client's trust in the nurse. The nurse should try to understand the underlying feelings or thoughts that the client's message conveys rather than focusing on the accuracy of the unrealistic statement itself. Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in one to two minutes. p. 120

A client is hospitalized after making a suicide attempt when his or her spouse asks for a divorce. Which comment by the nurse is therapeutic for this client? "Don't you think your life is more valuable than an unhappy marriage?" "You should forget about your marriage and move on with your life." "Let's consider ways other than suicide to cope with your feelings." "I understand your depression. When I got divorced, I was overwhelmed too."

"Let's consider ways other than suicide to cope with your feelings." Considering coping mechanisms other than suicide demonstrates one of the working phase tasks of promoting practice of alternative adaptive behaviors. It also keeps the focus on the client's perception and feelings. Questioning the client's values is nontherapeutic. Telling the client to forget the divorce is unrealistic and minimizes the client's feelings. Bringing up the nurse's own divorce takes the focus off the client. Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation). p. 116

How should the nurse respond to a client who reports thinking of dropping out of college because it is too stressful? "Don't let them beat you! Fight back!" "School is stressful. What do you find most stressful?" "I know just what you are going through. The stress is terrible." "You have only two more semesters. You will be glad if you stick it out."

"School is stressful. What do you find most stressful?" This response acknowledges the client's perception of school as difficult and asks for further information, keeping the interview focused on the client and his or her feelings. This response suggests the nurse is listening actively and is concerned. The nurse should avoid attacking the target of the client's anxiety. Saying the nurse knows what the client is going through minimizes the client's experience. Saying "the stress is terrible" is an interpretation that should be avoided; this takes the focus off the client's perception. The nurse should also avoid giving advice or false reassurance. p. 120

A pregnant client with a history of three successive miscarriages is worried and says, "I'm afraid I may miscarry again, and my husband would be disappointed." What is the most therapeutic response by the nurse? "I feel so sorry for you." "You shouldn't talk like that." "Don't be upset; it is all going to be fine." "You are worried about having a miscarriage."

"You are worried about having a miscarriage." Clients are encouraged to share their feelings. Therefore, restating that the client is worried about having a miscarriage is reflective listening that encourages the client to talk more. Feeling sorry for the client is a sympathetic response and limits the client's response. Telling the client not to do something would make her feel ignored. Telling the client that all will be fine may limit the conversation and is a false reassurance. p. 121

A military wife tearfully tells a nurse about her husband's deployment to an active war zone. This client cries daily and says to the nurse, "I am so worried that he will never come home." What response by the nurse addresses the need to identify the client's perception of the problem? "Your husband is safe. You should be proud of him rather than absorbed in worry." "Let's talk about whether crying and the feelings you describe are normal in this situation." "You will eventually get back to normal. Start doing the things that used to be fun for you." "When you find yourself starting to cry or feel sad, distract yourself by getting busy with an activity."

Asking the client to elaborate on her feelings focuses on the client's perception. This aids the client in considering other persons and events from the perspective of the client's own set of values. Telling the client her husband is safe is a false reassurance the nurse cannot know to be true. Telling the client to distract herself does not address her feelings. p. 120

The nurse is caring for a geriatric client receiving dialysis three times a week. The client frequently discusses family disputes with the nurse and often becomes verbally aggressive. Which countertransference reaction is the nurse most likely to experience toward this client? Rescue Boredom Helplessness Overinvolvement

Boredom. Due to the client's behavior, the nurse is at risk to experience a variety of countertransference reactions. If the client gives repeated uninteresting information and uses an offensive style of communication, the nurse may develop boredom and become uninterested in talking to and interacting with the client. The nurse may develop a rescue reaction (a countertransference reaction) when the client shares his or her secrets with the nurse. The nurse may develop feelings of helplessness when the treatment goals are not achieved and if the client does not participate in the treatment effectively. Overinvolvement is experienced by the nurse if the client's behavior reminds him or her of someone who is close to the nurse or of past clients. p. 112

Who determines the content and direction of the clinical interview? Nurse Client Health care provider Health care team

Client. The client should always be able to take the lead and determines the content and direction of the clinical interview, although the nurse may gently guide it by discouraging social conversation or intrusive personal questioning. The therapeutic relationship is consistently focused on the client's problem and needs. The nurse, health care provider, and health care team may take part in assisting the client's progress, but the client ultimately determines the focus of the interview. p. 110

A client diagnosed with prostate cancer is undergoing chemotherapy but, due to financial conditions, is unable to afford it. What is the most appropriate action by the nurse? Organize a fundraiser to pay the bills. Refer the client to another hospital or facility. Enroll the client in the financial assistance program. Educate the client about the financial assistance program.

Educate the client about the financial assistance program. It is the nurse's responsibility to help and encourage clients to use available resources. In a situation in which the client has financial issues, the nurse should inform the client about the financial assistance program. A nurse does not act for a client unless absolutely required. Paying the bill by raising funds indicates overinvolvement. Referring the client to another hospital will not solve the client's problem. By enrolling the client in the financial assistance program, the nurse would facilitate dependency. pp. 110-111

Which action by the nurse may acceptable in a social relationship but not in a therapeutic relationship? Giving advice Listening actively Clarifying feelings Giving positive regard

Giving advice. Giving and receiving advice is acceptable in a social relationship, but it is not in a therapeutic relationship. In a therapeutic relationship, it is appropriate for the nurse to assist the client in exploring alternative solutions to problems and in making his or her own decisions. Actively listening is imperative for a therapeutic relationship so this is incorrect. Clarifying feelings is appropriate, as is giving positive regard. p. 110

While assessing a client diagnosed with sickle cell anemia, the nurse tries to develop trust and establish rapport with the client. Which nursing intervention is appropriate for this phase of nurse-client interaction? Promote problem-solving skills. Teach alternative ways of expressing feelings. Inform the client about the scheduled meeting. Share the feelings of helplessness with colleagues and health care provider.

Inform the client about the scheduled meeting. During the orientation phase, the nurse tries to develop trust and establish rapport with the client. The nurse schedules an interview and informs the client of the time, date, and duration of the meeting. During the working phase, the nurse promotes problem-solving skills and teaches alternative ways to express feelings. Working with the client to accommodate his or her schedule indicates the concern of the nurse toward the client and encourages the client to express his or her thoughts and feelings to the nurse. In the preorientation phase, the nurse takes the advice of colleagues and the health care provider before interacting with the client. pp. 115-116

Which intervention will assist the nurse in improving his or her communication and interviewing skills? Observing other clinicians during interviews. Reviewing written records of the nurse-client session. Interacting with multiple clients. Asking each client more questions.

Reviewing written records of the nurse-client session. The best way to improve skills is to review clinical interactions exactly as they occurred. Written records of a nurse-client session are called process recordings. These records help in reviewing clinical interactions with the client and help the student nurse identify patterns in communication. Process recordings consist of both verbal and nonverbal communication between the client and the nurse. Having an observing clinician can distract the concentration of both the client and the nurse. Interacting with multiple clients can help to some extent, but without proper documentation and analysis of patterns, the student nurse will not learn as much as he or she would from the process recordings. Asking too many questions of the client will make the client annoyed and is not good practice for effective communication and interviewing. p. 121

A client telephones the nurse at the mental health center daily, giving lengthy details about multiple somatic complaints and relationship problems. Which limit-setting strategy should the nurse employ? Suggest the client call other people in the community. Say to the client, "I can talk to you for 15 minutes twice a week." Use the telephone's caller identification to screen calls from the client. Tell the client, "You should discuss these concerns with your personal physician rather than me."

Say to the client, "I can talk to you for 15 minutes twice a week." Telling the client that the nurse can be available for 15 minutes twice a week sets a clear, absolute limit that cannot be misinterpreted. Suggesting the client call other people does not address the nurse's boundaries in the relationship. Using caller identification to avoid the client does not communicate a limit. Unless the client's concerns are out of the nurse's scope, it is unnecessary for the nurse to defer to the physician. p. 111

Of what must the nurse first be aware in order to help a client develop his or her resources? Resistance Countertransference The client's strengths Negative transference

The client's strengths. Nurses work to bolster a client's strengths, to identify areas of dysfunction, and to assist in the development of new coping strategies. While being aware of a client's resistance, countertransference, and negative transference is important, the first step is identifying the client's strengths. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 119

Which seating arrangement appropriately supports communication during a nurse-client interview? The nurse behind a desk and the client in a chair in front of the desk The nurse and client sitting at a 90-degree angle to each other The client sitting in a chair and the nurse standing a few feet away The nurse and client sitting in chairs while facing each other

The nurse and client sitting at a 90-degree angle to each other Sitting at a 90-degree angle to each other is less intense and allows the client and nurse to look away from each other without discomfort. In these positions, the two are at the same height, so neither is in an inferior position. The nurse should avoid placing a barrier like a desk between him- or herself and the client. If the nurse stands while the client sits, this may be threatening to the client. Face-to-face seating is a more confrontational arrangement and therefore can produce anxiety. p. 119

A nurse plans to interview a hospitalized client who is lying supine with the head elevated at 45 degrees. Which initial action by the nurse will most enhance the probability of achieving a therapeutic interaction? The nurse should transfer the client to a chair near the door if the client is able to move. The nurse should stand during the interview to establish professional credibility. The nurse should select a chair or stool that positions the nurse at about the same level as the client. The nurse should maintain the room arrangement without alteration to enhance the client's comfort.

The nurse should select a chair or stool that positions the nurse at about the same level as the client. The nurse should arrange the setting to maximize communication. In all settings, chairs should be arranged so that conversation can take place in normal tones of voice and so that eye contact can be comfortably maintained or avoided. Seating should use the same height whenever possible to support the therapeutic relationship. Placing the client near the door may jeopardize the nurse's safe exit if it should become necessary. The nurse should not stand or otherwise be positioned above the client, because this may make the client feel uncomfortable or inferior. The nurse should change the arrangement of the furniture if necessary to maximize the therapeutic value of the visit. p. 119

A client diagnosed with major depressive disorder has been socially isolated. The nurse invites the client to a staff luncheon to honor the supervisor. Which analysis best applies to this scenario? The invitation supports development of the client's self-esteem. The nurse's action blurs the boundaries of a therapeutic relationship. The nurse's invitation exposes the client to a therapeutic social activity. The invitation provides an opportunity for the client to practice interactions with others.

The nurse's action blurs the boundaries of a therapeutic relationship. The nurse-client relationship should be conducted within appropriate and clear boundaries. In this scenario, the nurse's invitation blurs those boundaries by adding a social dimension. Supporting the client's self-esteem, exposing the client to a therapeutic social activity, and providing the client an opportunity to interact with others move the relationship toward a social, rather than therapeutic, one. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. p. 110

When a nurse and client meet and have a limited but helpful relationship, what can the relationship be called? Crisis intervention Therapeutic encounter Autonomous interaction Preorientation phenomenon

Therapeutic encounter A therapeutic encounter is a short but helpful interaction between the nurse and client. Crisis intervention, autonomous interaction, and preorientation phenomenon are not instances of a nurse and client meeting informally or having an otherwise limited but helpful relationship. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 112

According to Rogers, which term is a synonym for genuineness? Respect Empathy Congruence Positive regard

Congruence Genuineness refers to self-awareness of one's feelings as they arise within the relationship and the ability to communicate them when appropriate. It is the ability to meet others person-to-person without hiding behind roles. Rogers uses the word "congruence" to signify genuineness. Respect, empathy, and positive regard may not work in tandem with genuineness, but they are not synonyms for genuineness. pp. 117-118