Prep U's - Therapeutic Communication - Chapter 8

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?

Self-disclosure on the nurse's part should benefit the client. 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.

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?

The nurse has inhibited therapeutic communication by giving advice. 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.

Proxemics is the study of distance zones between people during communication. Which of the following distance zones is acceptable to conversation between family and friends?

personal. Rationale: The personal zone is comfortable between family and friends who are talking. The social zone is the distance acceptable for communication in social, work, and business settings. The intimate zone is the amount of space that is comfortable for parents with young children. The public zone is an acceptable distance between a speaker and an audience.

A client is being counseled by the nurse about family conflict. The client asks the nurse, "Should I go home for the weekend?" Which response by the nurse would demonstrate using the reflection communication technique?

"Should you go home for the weekend?" Rationale: Reflection is a therapeutic communication technique used to redirect the idea back to the client for classification of emotional overtones, feelings, and experiences. The nurse's response, "Should you go home for the weekend?" is utilizing the reflection technique. The nurse's statement, "Let me see if I understand" is utilizing the validation technique. The nurse's statements, "Yes, so that you can talk to your family" and "I don't think you should, you might not be ready" is giving advice, which is a block in communication.

During the mental status assessment, the client expresses the belief that the CIA is stalking the client and plans to kidnap the client. Which would be the best response by the nurse?

"What kinds of things have been happening?" Rationale: When the nurse responds, "What kinds of things have been happening?" the nurse is seeking information. "That makes no sense at all," is inappropriate because it may make perfect sense to the client. "You can tell me about that after I finish asking these questions," shows that the nurse is not interested in what the client has to say. "Why would the CIA be interested in you?" feeds into the notion that the CIA is stalking the client.

A client is sitting alone, slouched, with eyes closed. The nurse approaches. Which statement is most likely to encourage the client to talk?

"You look like you are deep in thought." Rationale: Verbalizing what the nurse perceives can give a natural opening for the client to engage in dialogue. The nurse cannot presume the meaning of the client's behavior (i.e. that he or she is sleepy). Asking if something is wrong may put the client on the defensive. Asking why the client is sitting this way is a blunt question that may limit, rather than enhance, dialogue.

A psychiatric-mental health client tells the nurse, "The doctor hates me. The doctor promised to come check on me after dinner yesterday but never came." What is the nurse's most therapeutic response?

"I don't know why the doctor didn't check on you yesterday, but I think it's unlikely that the doctor hates you." Rationale: One therapeutic communication technique is to express doubt. This is appropriate when the client expresses a thought that stretches credibility. The nurse does not agree or disagree but does express skepticism, which encourages the client to reconsider. It would be inappropriate for the nurse to characterize the health care provider to the client as someone who "doesn't keep promises." The nurse cannot justifiably reassure the client that the health care provider will come as soon as she is able; the nurse cannot make commitments for the provider. Similarly, it would likely be inappropriate for the nurse to page the health care provider solely in response to the client's statement.

A client remarks, "You know, it's the same thing every time." The nurse should respond by stating:

"I'm not sure what you mean. Please explain." Rationale: Sometimes, words, phrases, or slang terms have different meanings and can be easily misunderstood. In this case, it is important for the nurse to clarify the meaning in order to avoid making assumptions. Stating that everyone is doing their best is a response that is based on an assumed meaning. Restating the client's statement will not necessarily provide clarification. Stating, "I understand" is simplistic and inaccurate because the nurse cannot claim to fully understand the client's situation.

A psychiatric-mental health nurse has been off of work for the past 4 days, as per the normal work schedule on the unit. On the nurse's first day back, a longterm client says, "I haven't seen you around here since Thursday. How was your time off?" What is the nurse's most appropriate response?

"I've been off for the past four days. What have you done since I last saw you?" Rationale: The nurse should avoid self-disclosure. Whenever possible, it is more therapeutic to redirect the conversation rather than setting an explicit boundary. Saying, "How do you like to spend your time when you're able to do whatever you like?" redirects the conversation but is less therapeutic because the nurse has ignored the client's question. Asking the client to speculate serves no therapeutic purpose.

A client diagnosed with a mental illness asks the nurse, "Does mental illness run in your family?". Which response to the client by the nurse would be therapeutic?

"Mental illness does run in families. I've had a lot of experience caring for people with mental illnesses." Rationale: One of the most important principles of therapeutic communication for the nurse to follow is to focus the interaction on the client's concerns. Self-disclosure, telling the client personal information, generally is not a good idea. If the client asks the nurse personal questions, the nurse should elicit the underlying reason for the request. The nurse can then determine how much personal information to disclose, if any. Therefore, the nurse's response of "Mental illness does run in families. I've had a lot of experience caring for people with mental illnesses" would be therapeutic to say to the client. The nurse's responses of "Actually, my sister is being treated for schizophrenia. It's been hard on our whole family" and "I struggle with anxiety and depression at times. I have learned a lot from the group sessions here" are providing too much self-disclosure and are inappropriate in a therapeutic nurse-client relationship. The nurse's response of "That's not an appropriate question for me. Let's talk about something else" is giving disapproval and changing the subject, which are both nontherapeutic techniques for the client.

A client diagnosed with depression is being counseled by the nurse for cognitive distortions. The client says, "Bad things always happen to me." Which response by the nurse would be therapeutic?

"Tell me about a time when things went your way." Rationale: Clients diagnosed with depression may use communication styles such as overgeneralizations ("This always happens to me..., everything always turns out for the worse..."). The nurse can assist the client to be more specific, such as asking about a specific time or a specific exception. The client in the scenario is overgeneralizing; therefore, the nurse's response, "Tell me about a time when things went your way" would be therapeutic for the client. The nurse's responses, "Did you sleep last night?", and "Are you feeling more depressed today?" are changing the subject, which is not therapeutic. The nurse's response, "There must have been some good things in your life" is minimizing the client's feelings, which is not therapeutic.

The nurse is trying to obtain some information about family relationships from the client. Which statement is best?

"Tell me your feelings about your family situation." Rationale: This statement asks the client to describe or discuss family by expressing his or her feelings and perceptions. Asking if this is upsetting or whether the family is ready for the client to come home are closed-ended questions that elicit just a one-word answer. Asking "how is your family" does not address the nurse's focus, which is family relationships.

Which statement by the nurse reflects the use of a therapeutic statement?

"You look upset. Would you like to talk about it?" Rationale: The correct answer reflects validation of the client's feelings and further exploration. Asking about the client's children seeks more information, while discussing the death of the client's husband reveals personal information and a nonhelpful personal reflection by the nurse. Asking multiple questions may be confusing.

Which of the following statements would be an empathetic response in a client interaction?

"You must have been embarrassed when your father yelled at you in the grocery store." Rationale: This statement conveys the nurse's understanding of the client's feelings. Empathy is the ability to perceive the meanings and feelings of another person and to communicate that understanding to that person. Choices B, C, and D do not convey empathy.

A nurse has invited a client to sit down and have a conversation. The client takes the first seat. The nurse pulls up another chair to sit with the client. Approximately how far from the client should the nurse place her chair?

3-6 feet. Rationale: The therapeutic communication interaction is most comfortable when the nurse and client are 3 to 6 feet apart; 0 to 18 inches is comfortable for parents with young children, people who mutually desire personal contact, or people whispering; 2 to 3 feet is comfortable between family and friends who are talking; 4 to 12 feet is acceptable for communication in social, work, and business settings.

A nurse is engaged in a therapeutic relationship with a client. What should the nurse do in order to ensure therapeutic communication takes place?

A nurse engaged in therapeutic communication with a client should follow the principles of therapeutic communication: making the client the primary focus of the interaction; using self-disclosure cautiously and only when it serves a therapeutic purpose; maintaining client confidentiality; implementing interventions from a theoretic base; and avoiding the giving of advice.

The nurse and the client are using therapeutic communication skills. Which statements are true of concrete and abstract messages?

Abstract messages include figures of speech that are difficult to interpret; Concrete messages are clear, direct, and easy to understand. Rationale: Abstract messages include figures of speech that are difficult to interpret. Concrete messages are clear, direct, and easy to understand. Concrete (not abstract) messages are important for accurate information exchange. Abstract (not concrete) messages require the listener to interpret what the speaker says. Concrete (not abstract) messages are best used for persons who are anxious.

Which communication technique does a nurse use in establishing trust and developing empathy?

Acceptance. Rationale: Acceptance is the encouraging and receiving of information in a nonjudgmental and interested manner. It is used in establishing trust and developing empathy. A nurse uses confrontation when presenting a client with a different reality of the situation. Doubt is the expression or voicing of skepticism when a client relates a situation. Observation is the act of stating to the client what the nurse is observing.

A client has been making sexual comments when communicating with the nurse. The nurse wants to spend some time talking to the client while respecting the client's right to privacy. Which setting would be the most appropriate setting for the nurse to talk with the client? A. In a quiet corner of the dayroom at least 4 feet away from others. B. At the nurse's station when other clients and visitors are less than 4 feet away. C. In the client's room when the client's roommate is present and 3 feet away. D. In an interview room in a remote section of the unit with the nurse 1 foot away from the client.

Answer: A Rationale: A quiet corner of the dayroom at least 4 feet away from others would allow the patientclient privacy while being to deter any inappropriate activity would be the most appropriate setting. Being in the patient'sclient's room when the patient'sclient's roommate is present and 3 feet away or at the nurse's station when other patientsclients and visitors are less than 4 feet away would not allow for the patient'sclient's privacy and may facilitate more inappropriate statements. An interview room in a remote section of the unit would not be a good choice as the area is too isolated and could exacerbate the problem. Additionally, the nurse should maintain a distance of more than 1.5 feet away from the patientclient as closer distances are within the intimate zone.

When a novice psychiatric nurse shares with the nurse manager that talking about sexual abuse with clients is very uncomfortable, which would be the most effective response from the nurse manager? A. "What specifically makes you uncomfortable?" B. "Have you ever been sexually abused?" C. "It would be great if you could attend an in-service on therapeutic communication." D. "I can take that client off of your assignment this shift."

Answer: A Rationale: It is important for the novice nurse to identify what it is about discussing sexual abuse that is anxiety producing so that those issues can be addressed and resolved. Asking this question will assist the novice nurse in engaging in self-reflection that can lead to a greater awareness of self and thus enhance the ability to be therapeutic. Suggesting the nurse have such abuse victims released from the nurse's care ignores the problem and minimizes the nurse's therapeutic effectiveness. Arranging for training is appropriate only if it is discovered that the problem relates to a lack of skills related to the nurse's therapeutic communication techniques. While prior sexual abuse may be the cause of the nurse's discomfort, it is not appropriate for the nurse manager to initiate this discussion in that manner.

Which would not be considered a goal of therapeutic communication? A. Self-exploration of feelings by the nurse. B. Guiding the client in problem solving. C. Active listening. D. Establishing rapport.

Answer: A Rationale: Self-exploration of feelings by the nurse is not considered a goal of therapeutic communication. Establishing rapport, active listening, and guiding the client in problem solving are goals of therapeutic communication.

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

Answer: A 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.

The nurse observes that a client has been pacing in the unit's common area in an agitated state for the past 15 minutes. Which is the nurse's priority action? A. Explore with the client to determine why they are displaying these behaviors. B. Encourage the client to participate in a group activity to provide a therapeutic distraction. C. Ask the client to sit down and perform deep breathing exercises. D. Redirect the client to an activity that will alleviate the client's agitation.

Answer: A Rationale: The nurse will attempt to have the client validate their feelings and must precede any interventions such as redirection, relaxation techniques, or group activities. The nurse should avoid presuming that the client's behavior is motivated by anxiety and must validate whether this is the case.

The client says to the nurse, "I wonder what's playing at the movies tonight." Which response by the nurse would be most therapeutic? A. "Are you telling me you would like to go to the movies?" B. "There's nothing worth watching." C. "We may have some DVDs available." D. "Why don't you look in the newspaper."

Answer: A Rationale: This nurse is restating or verbalizing the implied, which involves voicing what the client has hinted at or suggested. The nurse should apply this technique to confirm the implications of the client's statement before suggesting solutions to the presumed meaning.

A nurse is working with a client whose background is very different from the nurse. Which is a good question to ask to assure the nurse can be effective working with this client? A. "What experiences do I have with people with different backgrounds?" B. "Is this person going to be able to relate to me?" C. "Can this person understand me?" D. "Do I understand this client's expectations of me?"

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

A nurse is engaged in a therapeutic relationship with a client. What should the nurse do in order to ensure therapeutic communication takes place? Select all that apply. A. Ensure the client's confidentiality. B. Focus on the client during the interaction. C. Use self-disclosure frequently for empathy. D. Give the client advice about what to do. E. Employ theoretically based interventions.

Answer: A, B, E Rationale: A nurse engaged in therapeutic communication with a client should follow the principles of therapeutic communication: making the client the primary focus of the interaction; using self-disclosure cautiously and only when it serves a therapeutic purpose; maintaining client confidentiality; implementing interventions from a theoretic base; and avoiding the giving of advice.

Effective communication involves the process of giving and receiving of information that includes which of the following? Select all that apply. A. A sender B. The environment C. The feedback D. The message E. The receiver

Answer: A, C, D, E Rationale: Effective communication involves the process of giving and receiving of information that includes a sender, a receiver, the message, and feedback. While the environment may affect communication, it is not included in this list.

A client has learned about defense mechanisms. Which behavior of the client would demonstrate the effective use of sublimination defense mechanism? A. The client notices their feelings and informs their friend of their feelings. B. When the client is angry about their boss, they go to a boxing class. C. The client reaffirms what they want to with social activities. D. The client views one friend as being perfect and views another friend as evil.

Answer: B Rationale: Sublimination defense mechanism is channeling potentially maladaptive feelings or impulses into socially acceptable behavior. When the client goes to a boxing class when they are angry about their boss, this demonstrates the sublimination defense mechanism. The example of the client viewing one friend as being perfect and viewing another friend as evil is demonstrating the splitting defense mechanism. The example of the client reaffirming what they want to with social activities is the self-assertion defense mechanism. The example of the client noticing their feelings and informing their friend of their feelings is demonstrating the self-observation defense mechanism.

The nurse observes the parent of a child client holding the child close on the lap during the initial assessment. Which distance zone is the parent exhibiting for people who mutually desire personal contact? A. Social B. Intimate C. Public D. Personal

Answer: B Rationale: The intimate zone is the amount of space that is comfortable for parents with young children and those who desire personal contact. The social zone is the distance acceptable for communication in social, work, and business settings. The personal zone is comfortable between family and friends who are talking. The public zone is an acceptable distance between a speaker and an audience.

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

Answer: B 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 is caring for a client in a severe anxiety state. What is an important nursing consideration while communicating with the client experiencing anxiety? A. teaching the client coping skills. B. using short and simple statements or questions. C. increasing concentration on the task. D. increasing environmental stimulation for distraction.

Answer: B Rationale: While communicating with clients, it is important for the nurse to consider an individual's mental health challenges when selecting specific communication strategies. For example, clients with increased levels of anxiety may have poor concentration, requiring the nurse to use shorter and simpler statements or questions. Therefore, an important nursing consideration while communicating with the client experiencing anxiety includes using short and simple statements or questions. Teaching the client coping skills is important, but after the client's anxiety level is lower. Increasing concentration on the task would not be appropriate because the client has poor concentration while feeling anxious. Increasing environmental stimulation for distraction would not be appropriate because it would increase the client's anxiety.

The nurse understands that clients send simultaneous messages, and active listening and observation are used to understand these messages. Which action(s) represents these principles? Select all that apply. A. process charting this information. B. using care not to interrupt the client. C. asking the client to explain when unclear. D. noting how the client is sitting and moving. E. sitting facing a client during a conversation.

Answer: B, C, D, E Rationale: To receive the sender's simultaneous messages, the nurse must use active listening and active observation. Active listening means refraining from other internal mental activities and concentrating exclusively on what the client says. Active observation means watching the speaker's nonverbal actions as they communicate. Processing how to chart the information from the conversation does not allow for focusing on the client exclusively.

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

Answer: B, E 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.

The nurse is talking with a client that states, "I am so sad today. It is the anniversary of my parent's death." Which response by the nurse may impede the communication process between the nurse and client? A. "It's okay to feel sad about your parents." B. "I am sorry you feel sad. Would you like to talk?" C. "You will feel better tomorrow." D. "I will sit here with you for a while."

Answer: C Rationale: Although the nurse is not intentionally impeding the communication process and intending for the client to feel better, using a statement like "You will feel better tomorrow" is dismissive and nontherapeutic. It does not allow the client to talk about the sadness or feel the nurse is empathetic to the client. Allowing the client to talk about it, giving permission to grieve, or just giving of self are therapeutic responses to the statement.

The nurse educator is teaching the class about communication. Which statement by the student nurse best describes the basic elements of communication? A. "The basic elements of communication include sender, receiver, flow and message." B. "The basic elements of communication include message, sender, feedback, and gesture." C. "The basic elements of communication include feedback, sender, receiver, and messages." D. "The basic elements of communication include receiver, feedback, flow, and expression."

Answer: C Rationale: Communication includes the elements of sender delivers the message, messages are the content of the communication, receiver receives and decodes the message, and feedback is the message returned by the receiver and indicates whether the sender's message was understood. Flow, expression, and gesture are not included in the basic elements of communication.

A psychiatric-mental health nurse approaches a new client sitting in the dayroom to establish a relationship. The nurse notes that the client's facial expression and body posture appear guarded. Applying an understanding of proxemics, the nurse chooses which zone of physical space between themselves and the client? A. public B. personal C. social D. intimate

Answer: C Rationale: The intimate zone (0-18 in. between people) and personal zone (18-36 in.) is the amount of space that is comfortable for people who mutually desire personal contact. The client and the nurse do not know each other and invasion of these zones is likely to produce anxiety. A social zone (4-12 ft) is acceptable for communication in social, work, and business settings. The nurse and client are in the dayroom and the purpose of the communication is to greet each other and begin to establish a relationship. Choosing a distance based on the public zone (12-25 ft), which is an acceptable distance between a speaker and an audience in an inpatient dayroom, is likely to make the client feel that the nurse is afraid of them and will not contribute to the development of a therapeutic relationship.

After a client makes a statement, a nurse responds by saying, "Let me see if I understand what you are saying." Which communication technique is the nurse using? A. reflection B. doubt C. validation D. confrontation

Answer: C Rationale: The nurse is using validation, which reflects the nurse's attempt to understand a situation the client is trying to describe. Doubt is used when the nurse wants to guide a client toward other explanations, different from what the client stated. Confrontation is used to redefine a client's reality. Reflection is used to redirect an idea back to the client to classify important emotional overtones, feelings, and experiences.

The nurse is caring for a client with depression who states he cannot stop thinking about his dead wife. Which is the best example of self-disclosure the nurse may provide to the client? A. "My father passed away recently. I can understand your problem." B. "I just had a divorce; I can understand how it would feel to be without a partner." C. "I can understand your situation; my brother too lost his wife two months back." D. "I can understand your situation. Medication could be of great help to relieve your depression."

Answer: C Rationale: The nurse should express sympathy through the use of self-disclosure examples. The examples should consist of day-to-day situations and should not be related to the nurse's concerns or painful experiences. Stating that the nurse's father passed away recently could be extremely painful for the nurse. Stating that the nurse recently got divorced would also be painful. Stating that medication could be of great help to relieve the client's depression is not indicative of a self-disclosure example.

A nurse is conducting an initial interview with a client who is experiencing problems with anxiety. Which question would the nurse likely use to begin the interaction? A. "Are you feeling anxious right now?" B. "Do you want help dealing with your anxiety?" C. "Can you tell me what is happening with you?" D. "Are you having problems with anxiety?"

Answer: C Rationale: When beginning an initial interview, it is best to use open-ended statements that encourage the client to respond with more than a yes or no. Asking the client to tell the nurse what is happening with them provides this opportunity. Asking if the client is having problems with anxiety or wanting help with anxiety would elicit a yes or no response and not address the client's feelings. Asking if the client is feeling anxious right now might be appropriate later in the interview based on what the nurse observes.

The nurse is caring for a client who is very confused. In addition to verbal communication with the client, which intervention should the nurse use? A. providing instructions to the client for feeding oneself. B. speaking louder so that the client can hear. C. using gentle touch during activities of daily living. D. displaying a flat affect so the client will not misinterpret the nurse.

Answer: C Rationale: The nurse should supplement verbal communication with therapeutic nonverbal communication, including gentle touch, to reinforce caring feelings for the confused client. Providing instructions for feeding oneself and speaking louder are aspects of verbal communication and, in addition, would not be helpful. Displaying a flat affect is not an aspect of therapeutic nonverbal communication.

The nurse is performing a morning assessment on a client. When asked how they are feeling, the client hesitantly responds in a slow rate of speech "I think I am okay, is that alright?" Which response is appropriate for this speech pattern? A. "You're speaking slowly today; did you get enough sleep?" B. "Take a deep breath and try again." C. "Everything is alright." D. "You sound confused. Is that how you are feeling?"

Answer: D Rationale: Clients' rate and quality of speech are useful assessment data for interpreting client mood, level of orientation, and cognitive processes. This client's slow rate of speech, hesitancy, and indirect answer to the question can indicate that the person is depressed, confused, searching for the correct words, or having difficulty finding the right words to describe an incident. It is important for the nurse to validate these nonverbal indicators rather than to assume that they know what the client is thinking or feeling. Asking the client about sleep does not give the client the opportunity to clarify their thinking. Telling the client to take a deep breath is recommended if the nurse assesses anxiety; this client's slow rate of speech would be incongruent if feeling anxious. Telling the client that everything is alright is nontherapeutic because it falsely reassures the client.

A psychiatric-mental health nurse has received an in-service education about defense mechanisms. Which statement made by the nurse regarding defense mechanisms would indicate a need for further teaching? A. "Defense mechanisms become maladaptive when the use interferes with the client's ability to function." B. "Defense mechanisms can be conscious or unconscious to the client." C. "Some defense mechanisms may be either maladaptive or adaptive depending on the context in which they occur." D. "Defense mechanisms indicate that the client is in a problematic mental state."

Answer: D Rationale: Defense mechanisms, also known as coping styles, are psychological mechanisms that help an individual respond to and cope with difficult situations, emotional conflicts, and external stressors. Although defense mechanisms might seem to indicate the existence of problematic mental state, this is not true; therefore, the nurse's statement of "Defense mechanisms indicates that the client is in a problematic mental state" indicates a need for further teaching.. Healthy individuals in many different contexts use defense mechanisms. The use of defense mechanisms may be conscious or unconscious and some defense mechanisms may be either adaptive or maladaptive depending on the context in which they occur. The use of defense mechanisms becomes maladaptive when its persistent use interferes with the person's ability to function and quality of life.

The nurse must be alert to the nonverbal expressions of the client. Because the meaning attached to nonverbal behavior is subjective, it is important for the nurse to ... A. Investigate the source of nonverbal behavior. B. Increase the client's awareness of nonverbals. C. Validate the client's feelings. D. Validate the meaning of the nonverbals.

Answer: D Rationale: It is essential to validate the meaning of nonverbal behavior (rather than assuming what it means) before proceeding with anything else.

A client with a diagnosis of schizophrenia has confided in the nurse that he has the ability to manipulate the exchange rates between foreign currencies. What is the nurse's most appropriate action? A. Ask the client about the way that he is able to achieve this difficult task. B. Dialogue with the client about the complex mechanisms involved in foreign currency markets. C. Document the fact that the client is experiencing autistic fantasy. D. Recognize that the client is exhibiting omnipotence and choose interventions accordingly.

Answer: D Rationale: The client's statement suggests the defense mechanism of omnipotence.Asking the client about how he does this inadvertently validates the delusion. Autistic fantasy is characterized by excessive daydreaming. The nurse should avoid trying to convince the client that this is not possible by explaining the complexities involved.

A client says to the nurse, "I have done something terrible." The nurse replies, "I would like to hear about it. It's okay to discuss it with me." Which therapeutic communication technique is the nurse utilizing? A. interpretation B. open-ended statements C. restatement D. acceptance

Answer: D Rationale: The therapeutic technique of acceptance involves encouraging and receiving information in a nonjudgmental and interested manner. The statement from the nurse of "I would like to hear about it. It's okay to discuss it with me" demonstrates the use of the acceptance therapeutic communication technique. The technique of interpretation is putting into words what the client is implying or feeling. The open-ended statements technique introduces an idea and lets the client respond. The restatement technique repeats the main idea expressed and lets the client know what was heard. The techniques of restatement, open-ended statements, and interpretation are not utilized with the nurse's statement.

Which goal of therapeutic communication would the nurse strive to attain first?

Establish a therapeutic nurse-client relationship. Rationale: Establishing a therapeutic relationship is one of the most important responsibilities of the nurse when working with clients. It is foundational to each of the other listed nursing actions so it must be established first.

A client has been making sexual comments when communicating with the nurse. The nurse wants to spend some time talking to the client while respecting the client's right to privacy. Which setting would be the most appropriate setting for the nurse to talk with the client?

In a quiet corner of the dayroom at least 4 feet away from others. Rationale: A quiet corner of the dayroom at least 4 feet away from others would allow the patient privacy while being to deter any inappropriate activity would be the most appropriate setting. Being in the patient's room when the patient's roommate is present and 3 feet away or at the nurse's station when other patients and visitors are less than 4 feet away would not allow for the patient's privacy and may facilitate more inappropriate statements. An interview room in a remote section of the unit would not be a good choice as the area is too isolated and could exacerbate the problem. Additionally, the nurse should maintain a distance of more than 1.5 feet away from the patient as closer distances are within the intimate zone.

A nurse enters the room of a client who has been on the unit for several weeks. The client states, "I haven't seen you for a while. How were your days off?" What is the nurse's most appropriate response?

It's important to get a break from time to time. How have the last few days been for you? Rationale: Making a noncommittal and nonspecific statement like "it's important to get a break" and then redirecting the conversation to the patient is the best way to avoid self-disclosure and maintain a therapeutic relationship. Overtly stating that he or she cannot talk about personal matters threatens the rapport between the nurse and patient. The nurse should avoid specifying that he or she spent time with family on days off. Asking the patient to guess about the nurse's activities is of no benefit.

A teenager is mad at the teenager's parents about not being able to drive the father's car. The teenager begins to stay out late with friends after curfew. What defense mechanism is the teenager using?

acting out. Rationale: The teenager is acting out. Acting out is using actions rather than reflections or feelings during periods of emotional conflict. Denial is refusing to acknowledge some painful aspect of external reality or subjective experience that is apparent to others. Displacement is the transference of a feeling about (or a response to) one object onto another (usually less threatening) substitute object. Devaluation is attributing exaggerated negative qualities to the self or others.

The nurse is talking with the client and demonstrates concern for the way the client is feeling by using verbal affirmations and paraphrasing to show understanding. What communication techniques are being used by the nurse?

active listening. Rationale: Active listening is refraining from other internal mental activities and concentrating exclusively on what the client says. Self disclosure, empathetic linkages and self awareness are not communication techniques. Empathetic linkages are the communication of feelings. Self-awareness is having a clear perception of your personality, including strengths, weaknesses, thoughts, beliefs, motivation and emotions. Self-disclosure is communication by which one person reveals information like thoughts, feelings, aspirations, goals, failures, successes, fears and dreams, as well as one's likes, dislikes and favorites.

A nurse is caring for a client who is crying and describes an argument that they had with their spouse. The client expressed that after the argument with the partner, the client turned to their friend for emotional support. Which defense mechanism will the nurse document that the client is using?

affiliation. Rationale: The defense mechanism, affiliation, is turning to others for help or support (sharing problems with others without implying that someone else is responsible for them). The client turning to their friend for emotional support after the argument is demonstrating affiliation. Anticipation is experiencing emotional reactions in advance or anticipating consequences of possible future events and considering realistic, alternative responses or solutions. Acting out is using actions rather than reflections or feelings during periods of emotional conflict. Dissociation is experiencing a breakdown in the usually integrated functions of self or the environment, or sensory and motor behavior.

A psychiatric-mental health nurse must perform a physical examination on a newly admitted client. What is the nurse's priority action before entering the client's personal space for the examination?

asking for the client's permission. Rationale: Physical boundaries are those established in terms of physical closeness to others, such as who we allow to touch us or how close we want others to stand near us. When boundaries are infringed upon, the client feels threatened and responds to the perceived threat. Before implementing interventions that invade the client's personal space, the nurse must elicit permission from the client. Therefore, the priority intervention by the nurse is to ask for the client's permission before conducting a physical examination on the client. Assessing the client's mental status and emotional state is important to conduct, but the priority action is to ask the client's permission before conducting an examination on the client. Asking the client's family for permission would not be appropriate if the client is able to give permission for themselves.

The nurse wears a cross and has a Facebook page displaying pictures of the family, home and updates on what the nurse is currently doing. These actions are examples of what?

self-disclosure. Rationale: The most important principles of therapeutic communication is to focus the interaction on the patient's concerns. Self-disclosure is telling the client personal information. The nurse can determine how much personal information, if any, to disclose. In revealing personal information, the nurse should be purposeful and have identified therapeutic outcomes. Self-awareness, social zone and exploitation are not principles of therapeutic communication.

While the nurse and client are in a therapy session, the nurse says to the client, "You become very anxious when we start talking about your drinking." Which technique is the nurse using?

making an observation. 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 (seeking to verbalize client's feelings that he or she expresses only indirectly), nor is the nurse verbalizing the implied (voicing what the client has hinted at or suggested). The nurse is elaborating on an observation, not addressing an implied statement by the client.

A nurse is interviewing a client who is describing difficulties with their family. The client begins crying and says, "I don't want to talk about this anymore." What boundary would the nurse be mindful to avoid crossing with the client?

psychological. Rationale: Boundaries are the defining limits of individuals, objects, or relationships. Boundaries mark territory, distinguishing what is "mine" from what is "not mine". Humans have many different types of boundaries. Material boundaries, such as fences or property, artificially imposed state lines, and bodies of water, define territory as well as provide security and order. Personal boundaries include physical, psychological, and social dimensions. Physical boundaries are those established in terms of physical closeness to others, such as who we allow to touch us or how close we want others to stand near us. Psychological boundaries are established in terms of emotional distance from others, such as how much of our innermost feelings and thoughts we want to share. Social boundaries, such as norms, customs, and roles, help us establish our closeness and place within the family, culture, and community. Therefore, the client in the scenario is establishing physiological boundaries that the nurse must be careful not to cross. Physical, social, or material boundaries are not at risk being crossed in the scenario.

The nurse is conducting a presentation on the importance of medication compliance to a community group. Which zone is an acceptable distance between a speaker and an audience?

public. Rationale: The public zone is an acceptable distance between a speaker and an audience. The intimate zone is the amount of space that is comfortable for parents with young children and people who mutually desire personal contact. The personal zone is the distance comfortable between family and friends who are talking. The social zone is the distance acceptable for communication in social, work, and business settings.

Which is often considered the most difficult yet most effective communication technique?

silence. Rationale: Although restating, reflecting, and clarifying are effective therapeutic communication techniques, one of the most difficult but often most effective communication techniques is the use of silence during verbal interactions. By maintaining silence, a nurse allows the client to gather thoughts and to proceed at his or her own pace.

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:

reflect critically on the student's own life experiences, perspectives, and characteristics. 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.

A nurse is caring for a client on the unit who is attempting to manipulate the staff. Which description of the client made by a nurse demonstrates strength-based communication?

resourceful. Rationale: Strength-based communication should be supportive, focusing on the client's strengths instead of potential deficits. Language that promotes acceptance and respect should be favored over language that distracts from acceptance of the person. For example, instead of perceiving a client to be "manipulative," an alternative consideration is that the client is "resourceful and trying to get help." Therefore, the client being described as resourceful by the nurse is utilizing strength-based communication. Being described as aggressive, noncompliant, or argumentative is not utilizing strength-based communication.

The nurse is talking with a married client just diagnosed with syphilis. The nurse talks with the client about disclosing the information to the spouse and/or any other sexual partners. The client cries and asks the nurse, "Have you ever had an affair?" The nurse states, "Yes, it usually doesn't turn out well." The nurse proceeds to answer other questions about the affair. By answering these personal questions, the nurse is divulging what?

self-disclosure. Rationale: Self-disclosure is letting the client know personal information. The conversation should focus on the client, and not the nurse. On revealing personal information the nurse should be purposeful and have identified therapeutic outcomes. Rapport, empathetic linkages, and self-awareness are not included in self-disclosure.

Which form of nonverbal communication would be least effective for the nurse to engage in to demonstrate interest in and acceptance of the client?

sitting behind a desk. Rationale: Sitting behind a desk imposes a barrier between the nurse and the client and is therefore the least effective technique listed here. Therapeutic nonverbal communication uses positive body language, such as sitting at the same eye level as the client with a relaxed posture that projects interest and attention. Leaning slightly forward also helps engage the client. Generally, the nurse should not cross the arms or legs during therapeutic communication because such postures erect barriers to interaction; uncrossed arms and legs project openness and a willingness to engage in conversation.

The nurse is caring for a client who is very confused. In addition to verbal communication with the client, which intervention should the nurse use?

using gentle touch during activities of daily living. Rationale: The nurse should supplement verbal communication with therapeutic nonverbal communication, including gentle touch, to reinforce caring feelings for the confused client. Providing instructions for feeding oneself and speaking louder are aspects of verbal communication and, in addition, would not be helpful. Displaying a flat affect is not an aspect of therapeutic nonverbal communication.