PrepU Chapter 8: Communication

A nurse touches the client's hand while discussing the client's diagnosis. This action is:

a communication channel. Explanation: A communication channel is a carrier of the message; touch can be a channel. Communication is a dynamic process, but simply touching one's hand is not. Touch is not translation--converting a message from one form to another--but is a channel for the message. Touch is a tactile, not auditory, channel.

Which is an open-ended question?

"Why did the health care provider prescribe this medication for you?" Explanation: Open-ended questions (e.g., "Why was this medication prescribed for you?") give the client an opportunity to express what the client understands and prevent the client from answering with just "yes" or "no" or some other one-word response. The other three responses require only a one-word response (e.g., "yes" or "no") and so are closed-ended questions.

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate Explanation: Clients with hearing impairment pose unique challenges for communication. Assessing how the client communicates best is important. For example, if a deaf client can read and write, writing can facilitate communication. If the client knows sign language, the nurse could use a person trained in sign language. Using hand gestures and exaggerated facial movements does not allow for adequate acquisition of knowledge.

A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase?

Examine goals of the relationship to determine whether they were achieved Explanation: In the termination phase, the nurse and client examine the goals of the nurse-client relationship for indications of their attainment or evidence of progress toward them. If goals were not attained, the nurse should help the client establish a relationship with a new nurse. Making formal introductions and making a contract regarding the relationship occur in the orientation phase. Providing assistance to achieve goals occurs in the working phase.

It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy?

Identifying with the client's feelings Explanation: Empathy is the ability to identify with client feelings. Congruence refers to feelings that match the expressions of the client. Positive regard means conveying genuine care to clients without passing any negative judgment on them.

Each of the following facilitates a therapeutic nurse-client relationship except:

closed-ended questions. Explanation: Rephrasing, reflection, and active listening are essential for accurate assessment and interventions.

A client was recently diagnosed with metastatic lung cancer. The nurse finds the client crying in the room. Which statement made by the nurse best demonstrates the use of empathy?

"I see you are upset. Would you like to talk?" Explanation: Nurses use empathy, an intuitive awareness of what a client is experiencing, to perceive the client's emotional state and need for support. Acknowledging the client's state, "I see you are upset" and asking the open-ended question, "would you like to talk" best demonstrates the use of empathy and helps the nurse become effective at providing for the client's needs while remaining compassionately detached. Sympathy, such as saying sorry, is not supportive and asking a closed question does not allow the client to express his or her concerns or fears. An offer to call someone is an example of avoidance, and makes the nurse appear uncaring. Telling the client not to worry is an example of giving false reassurance and is nontherapeutic and can give the client false hopes and expectations.

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"What did your health care provider tell you about your need to be admitted?"

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.

-"Do you smoke cigarettes?" -"Is there any chance you might be pregnant?" -"Are you ready to get out of bed?" Explanation: The closed-ended question provides the receiver with limited choices of possible responses and might often be answered by one or two words: "yes" or "no." Closed-ended questions are used to gather specific information from a client and to allow the nurse and client to focus on a particular area. Closed-ended questions are often a barrier to effective communication. Asking what the client does for fun or what the client's future plans are facilitates communication between the client and the nurse.

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

-The nurse maintains eye contact with the client. -The nurse shows patience with the client and gives the client time to respond. -The nurse keeps communication simple and concrete. Explanation: There are several nursing actions that would be appropriate to facilitate. The nurse would maintain eye contact with the client. The nurse shows patience and gives the client time to respond. The nurse keeps communication simple and concrete. The nurse would not communicate in a busy environment because this could be distracting to the client. The nurse would not give lengthy explanations to the client regarding the care to be given. The nurse would repeat the information if no response was shared by the client.

The nursing supervisor is giving a performance evaluation to an employee. Which communication technique by the nursing supervisor sends the message of disinterest in the employee?

Avoiding eye contact Explanation: Nonverbal communication must be conveyed in a positive manner. Avoiding direct eye contact sends a message of disinterest. Clarifying goals is a communication technique that assists in verifying the message is understood. Restating comments is another way to verify the message was understood. Upright posture sends the nonverbal message of interest.

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique?

Encouraging elaboration Explanation: Encouraging elaboration involves making simple statements that indicate active listening and comprehension on the part of the nurse and that prompt the client to continue talking. This technique helps the client to describe more fully the concerns or problems under discussion. Clarification involves asking a follow-up question about a statement made by the client to clear up some point that the nurse is not sure about or to elicit more specific details. Reflection and restatement involve the nurse repeating back to the client a comment made by the client to ensure that the nurse has correctly heard or understood the client.

The client is an 18-month-old in the pediatric intensive care unit. The client is scheduled to have a subgaleal shunt placed tomorrow, and the client's mother is quite nervous about the procedure. The nurse tells the client's mother, "The surgeon has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication?

False reassurance Explanation: False reassurance minimizes the client's concerns and feelings and is providing assurance not based on fact. Rescue feelings occur when a nurse feels a strong urge to personally try to fix the client or family member's problem. The nurse is not giving advice or being moralistic in this scenario.

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?

Working phase Explanation: During the working phase, the nurse and client explore and develop solutions that are enacted and evaluated in subsequent interactions. The orientation phase involves making introductions and establishing client goals. The termination phase involves evaluating client progress toward goals and concluding the relationship. There is no evaluation phase in the nurse-client relationship.

A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should:

allow the client to set the pace. Explanation: It would be ineffective to rush through a list of questions when obtaining a nursing history; it is more effective to let the client set the pace. Let the client know at the beginning of the interaction if time is limited so that the client does not feel that you are rushing because of a lack of concern or personal interest. Open-ended questions do not apply to "yes or no" answers. The client should be the person answering the questions unless unable to.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not often performed wound care on a complex wound. Using effective intrapersonal communication, this nurse should:

tell oneself to "remain calm" and remember that the nurse was trained to perform this skill. Explanation: Intrapersonal communication, or self-talk, is communication within a person. This communication is crucial because it affects the nurse's behavior and can enhance or detract from positive interactions with the client and family. Understanding the importance of intrapersonal communication can also help the nurse work with clients and families whose negative self-talk affects their health and self-care abilities. Speaking directly to the client, a UAP, or charge nurse is interpersonal communication, not intrapersonal. This duty cannot be delegated to an UAP. The nurse should not ask the charge nurse to change the assignment but could ask for help in dealing with the complex wound.

A pregnant client presents to the emergency department with vaginal bleeding. A transvaginal ultrasound is performed, and the health care provider informs the client that there are normal fetal heart tones noted. The client begins to tear-up and has a worried appearance. To facilitate therapeutic communication, what statement would the nurse make after observing the client's nonverbal communication?

"Take your time and tell me how you are feeling. I have plenty of time to answer your questions and discuss any thoughts or feelings with you." Explanation: Nurses often rely on verbal and nonverbal cues from clients to verify whether client objectives or goals have been achieved. It is therapeutic to allow for a pause in the communication by giving the client time to think about the situation and what has happened. Rescuing, false reassurance, and moralistic judgement are not therapeutic and could lead to client disappointment, minimizing the client's concerns, or inference on what is the "right" way to feel.

What nursing care behavior by the nurse engenders a client's trust in the nurse?

A nurse answers the client's questions about an upcoming test in a calm gentle voice while making eye contact with the client. Explanation: It is important to remember that helping relationships are professional relationships. Telling a client not to worry about the test because others have not had problems with it undermines trust by belittling the client's concerns. A nurse that answers the client's questions while documenting or defers the questions to the oncoming nurse gives the impression that the client's questions or concerns are not important. Answering the client's questions while making eye contact instils trust by showing that the nurse is competent to answer the questions and cares about the client in their care.

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?

The working phase Explanation: There are three phases of a helping relationship: the orientation phase, the working phase, and the termination phase. The introduction phase is not a valid phase, yet the nurse introduces oneself during the orientation phase. The scenario defines characteristics of the working phase, during which the nurse and client work together to meet the client's physical and psychosocial needs. During the orientation phase, the nurse and client establish the tone and guidelines for the relationship . The termination phase occurs when the nurse and client acknowledge that they have met the goals of the initial agreement or that the client would be better served by another nurse or health care provider.

The nurse is caring for a client at the end stage of life. The client is crying and states to the nurse, "I just cannot believe I am going to be leaving my children without a parent. I am not ready to go." What response by the nurse demonstrates the expression of empathy to the client?

"It sounds as though you are most concerned about how your children will feel." Explanation: The nurse is demonstrating empathy when reiterating what the client is saying. This helps the nurse become effective at providing for the client's emotional needs while maintaining detachment. The other responses indicate that the nurse is feeling sympathy for the client, which includes feeling as emotionally distraught as the client. While this may be an unavoidable response, it may not help the client move through the grieving process as effectively.

The client confronts the nurse, stating, "No one has come into my room to give me the pain medication I requested 2 hours ago. I am in pain!" Which response by the nurse indicates the nurse is using a "defending" communication technique?

"I have been busy with other clients that required my immediate attention." Explanation: The nurse is demonstrating defending behaviors and statements when attempting to justify the reason for not returning with a client's pain medication. This response places the client in the defensive stance as well. The nurse demonstrates belittling when indicating that the client is not feeling the degree of pain reported. The nurse is disagreeing with the client's statement which is nontherapeutic communication techniques. A more appropriate technique for the nurse to use would be to acknowledge the client's pain and administer the medication as prescribed. The nurse is not acknowledging the client's report of pain as valid when stating that "That's not true" which is inappropriate and will be detrimental to the nurse-client relationship. Informing the client that they should have reminded the nurse about the pain medication is not the client's responsibility.

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

"I understand you have four kids; how many times have you actually been pregnant?" Explanation: The use of the clarifying question or comment allows the nurse to gain an understanding of a client's comment. In this scenario, the nurse is asking how many times the client has been pregnant. Gravida refers to the number of pregnancies, whereas para refers to the total number of live births. Confirming the client has four children is a form of validating what the client said. The age and/or term of the children does not clarify the original question asked by the nurse.

A nurse has developed strong rapport with the spouse of a client who has been receiving rehabilitation following a debilitating stroke. The spouse has just been informed that the client is unlikely to return home and requires care that can only be provided in a facility with constant nursing care. The client's spouse tells the nurse, "I can't believe it's come to this." How should the nurse best respond?

"This must be very difficult for you to hear. How do you feel right now?" Explanation: Acknowledging the difficulty of the situation for the spouse is empathetic, and asking the spouse to elaborate on feelings may be therapeutic as well as provide insight into the spouse. Asking about the reasons underlying the care team's recommendation is less likely to be of benefit and may encourage the spouse to find fault with the recommendation. Attempting to redirect the spouse to a positive outlook at this early point is insensitive. Pointing out that the health care team has the client's best interest at heart might come across as defensive, and questioning what would help the spouse accept the situation is dismissive of the spouse's feelings and discourages the spouse from sharing feelings.

A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, "I do not know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening?

"You seem unsure. Tell me your concerns about your surgery." Explanation: To understand the client's perspective, the nurse uses therapeutic communication techniques to encourage verbal expression. The use of active listening facilitates therapeutic interactions. "You seem unsure" demonstrates that the nurse was actively listening and has decoded the content and feelings of the client. "Tell me your concerns about your surgery" is an open-ended statement which will allow the client to express themselves. Giving clients the opportunity to be heard helps them organize their thoughts and evaluate their situation more realistically. "I understand you are confused" and "I understand that you are not sure" are examples of rescue feelings on behalf of the nurse. Saying I understand implies the nurse has the knowledge to fix the problem, especially followed by an explorative statement. Asking the client what he or she thinks he or she should do or why the surgery is not needed will put the nurse in the position to judge the response. "Please let me know if you decide to postpone the surgery until you are no longer unsure" suggests that the client should postpone the surgery and is an example of giving advice. The nurse should not give opinions, attempt to sway a client's opinion, or avoid an uncomfortable discussion.

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?

"You're worried about how you will tolerate the pain associated with labor." Explanation: Reflecting or paraphrasing confirms that the nurse is following the conversation and demonstrates listening, thus allowing the client to elaborate further. False reassurance may initially relieve the client's anxiety, but it actually closes off communication by trivializing the client's unique feelings and discourages further discussion. Using clichés provides worthless advice and curtails exploring alternatives.

A nurse and an older adult client with chronic back pain are beginning to communicate. What activity should the nurse focus on at this point?

Being sensitive to the client's emotional barriers Explanation: The nurse should try to establish a good rapport with the client and use therapeutic communication. In doing so, the nurse should be sensitive to all needs of the client-including physical and emotional. The degree to which clients are physically comfortable influences their ability to communicate. Once rapport is established, the nurse and client can communicate about pain management options, although perhaps not in great detail, as the client may not be able to tolerate lengthy explanations. The nurse sharing the nurse's own family and personal history of back pain takes the focus off of the client and is not sensitive to the client's needs. Telling the client that back surgery will likely alleviate pain completely is providing false assurance, as this is not necessarily true.

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance Explanation: False reassurance means giving reassurance that is not based on the real situation. It is an attempt to alleviate the client's concerns about a situation by confidently saying that everything will be fine when, in fact, the nurse has no grounds for making such a statement. It minimizes the client's feelings and could cause the client to have false hope, be disillusioned when difficulties arise, and ultimately lose trust in the nurse. Seeking clarification means asking follow-up questions or making follow-up statements to clarify or gain more specific information about something the client has said. Giving information involves sharing accurate information about the client's health and well-being in a timely manner. Encouraging elaboration is a technique used to help the client describe more fully the concerns or problems being discussed.

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?

Orientation phase Explanation: During the orientation phase, the nurse discusses with the client when visits will occur and how long they will last. The working phase is usually the longest phase of the nurse-client relationship. During this phase, the nurse works together with the client to meet the client's physical and psychosocial needs. Interaction is the essence of the working phase. The termination phase occurs when the nurse and client acknowledge that the agreement on which the relationship is based is concluding. There is no evaluation phase of the nurse-client relationship (evaluation is the final step in the nursing process).

The nurse makes a contract with the client during which phase of the nurse-client relationship?

Orientation phase Explanation: The orientation phase of the relationship represents the first phase of therapeutic work and involves signing of formal contracts. Formal contracts in this setting are a therapeutic tool to help a client develop more insight and control over the client's own behavior. The working phase is when the nurse assists clients in this process by helping them to describe and clarify their experiences, to plan courses of action and try out the plans, and to begin to evaluate the effectiveness of their new behavior. The termination phase is the final phase and the period when a client's goals are assessed and the relationship comes to an end. There is no intimate phase.

A nurse is caring for a client in a semi-private room. How will the nurse prepare a private environment to discuss the client's plan of treatment?

Pull the curtain dividing the two beds. Explanation: It might not always be possible to carry on conversations alone with the client in a room, but every effort should be made to provide privacy and to prevent conversations from being overheard by others. Sometimes merely drawing the curtains around the bed in a hospital or long-term care facility, or sitting in a corner of the waiting room or lounge, can provide the sense of privacy that is so important in most interactions. It is not appropriate to ask the client in the other bed or any visitors to leave the room. Personal information should not be discussed in public thoroughfares.

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:

aggressive. Explanation: Aggressive behavior involves asserting one's rights in a negative manner that violates the rights of others. Comments such as "do it my way" or "that's just enough out of you" are examples of aggressive verbal statements. In this scenario, the preceptor is neither nurturing the new nurse nor being passive. Assertive behavior is the ability to stand up for oneself and others using open, honest, and direct communication.

Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice?

analysis Explanation: Empathy, positive regard, and a comfortable sense of self were among the key ingredients. Empathy is an objective understanding of the way in which a client sees his or her situation, identifying with the way another person feels, putting yourself in another person's circumstances, and imagining what it would be like to share that person's feelings. Communication is crucial because it affects the nurse's behavior and can enhance or detract from positive interactions or regard with the client and family. Comfortable sense of self is part of the nursing confidence in caring for clients. Analysis is part of the nursing process and not the key elements of therapeutic communication.

A nurse has been working on a telemetry unit for 6 months. The nurse arrives at work in the morning and overhears a night shift nurse talking about the new nurse. The night shift nurse is heard saying, "That new nurse is only here to meet a doctor and get married." The best response by the new nurse would be to:

ask to speak to the night shift nurse in private and explain how the comment made the new nurse feel. Explanation: Assertive behavior is the ability to stand up for oneself and others using open, honest, and direct communication. The focus is on the issue and not the person. Assertive behaviors, which are one hallmark of professional nursing relationships, are very different from aggressive (i.e., harsh, injurious, or destructive) behaviors. They also differ greatly from avoidance or acquiescent behaviors. The key to assertiveness is expressing feelings and beliefs in a non-defensive manner. "I" statements-"I feel . . ." and "I think . . ."-play an important role in assertive statements. "You" statements are defensive and close lines of communication. The comment should not be ignored or the lateral violence--or displaced hostility toward a peer--will continue. It would be inappropriate to contact hospital security; the matter should be dealt with directly by the new nurse.

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:

eliminate as many distractions as possible. Explanation: Factors that distort the quality of a message can interfere with communication at any point in the process. These distractors might be from the television, or from pain or discomfort experienced by the client. Visitors may remain in the room as long as the mother agrees and they do not interfere with the education session. It may also be beneficial for others to learn the care in the event that they too will be caregivers for the infant. For this reason, it is best for the client's partner to remain in the room.