Mental Health - Chapter 8 - Therapeutic Relationships
How does the nurse best engage in self-analysis that will benefit a specific nurse-patient relationship? 1 Asking, "What barriers exist that make it difficult for me to provide effective care for this patient?" 2 Avoiding conflict with the patient by seldom setting boundaries or disagreeing with his or her beliefs. 3 Refraining from expressing any negative feelings about a patient's behaviors. 4 Reporting to the nurse manager that, "I've tried but I just can't work therapeutically with this patient."
1 Asking, "What barriers exist that make it difficult for me to provide effective care for this patient?" Self-analysis is best reflected in the nurse's willingness to evaluate personal feelings about patients to first identify and then eliminate any barriers there may be to an effective therapeutic relationship. The nurse's role includes setting appropriate boundaries and exploring the possible causes of maladaptive or dangerous patient behaviors. Asking for a change in assignments should occur only when all other attempts to manage barriers have failed. The nurse's role includes setting appropriate boundaries and exploring the possible causes of maladaptive or dangerous patient behaviors.
A patient reports that her mother-in-law is very intrusive. The nurse responds, "I know how you feel. My mother-in-law is nosy too." The nurse is demonstrating 1 Countertransference 2 Empathy to establish trust 3 Self-disclosure in an appropriate way 4 To the patient permission to continue
1 Countertransference Countertransference refers to the stirring up of feelings in the nurse by the patient.
An action that is acceptable in a social relationship but not in a therapeutic relationship is 1 Giving advice 2 Listening actively 3 Clarifying feelings 4 Giving positive regard
1 Giving advice Giving and receiving advice is acceptable in a social relationship. In a therapeutic relationship, it is appropriate for the nurse to assist the patient in exploring alternative solutions to problems and in making his or her own decisions.
The nurse finds difficulty in communicating with a patient with a mental disorder. Upon interacting with the patient's family members, the nurse finds that the patient does not understand English. Which action should the nurse take next for an effective interaction with the patient? 1 Seek assistance from a translator. 2 Seek assistance from a family member. 3 Engage the patient in a therapeutic game. 4 Reinforce instructions in a low-pitched voice.
1 Seek assistance from a translator. Misunderstanding is most commonly observed when a nurse is caring for patients of the non-English community. Nurses make use of a professional translator while communicating with such patients. A translator is a person who conveys the instructions given by the nurse to the patient and the responses of the patient to the nurse. Reinforcing the instructions in a low-pitched voice is used when a patient has hearing disorders, especially in elderly patients. Therapeutic games are used by a nurse for assessing the health status of children. Seeking assistance from family members is not advisable as the information can be inaccurate or biased.
Which information will the nurse include when discussing confidentiality with a newly admitted patient? Select all that apply. 1 What confidential information will be shared with members of the patient's health care team. 2 Patient permission is required to allow family access to confidential information. 3 Who will have access to the patient's confidential information. 4 Information regarding self-harm or incidences of abuse will be shared only with patient permission. 5 Confidentiality is a patient's legal right as well as a nurse's legal responsibility.
1 What confidential information will be shared with members of the patient's health care team. 2 Patient permission is required to allow family access to confidential information. 3 Who will have access to the patient's confidential information. 5 Confidentiality is a patient's legal right as well as a nurse's legal responsibility. The patient has a right to know who else will be given the information shared with the nurse and that the information may be shared with specific people, such as a clinical supervisor, the health care provider, the staff, or other students in conference. The patient also needs to know that the information will not be shared with relatives, friends, or others outside the treatment team, except in extreme situations. Extreme situations include child or elder abuse, threats of self-harm or harm to others, or intention not to follow through with the treatment plan. Safeguarding the privacy and confidentiality of patients is not only an ethical obligation but a legal responsibility as well.
The nurse is caring for a patient with tuberculosis and finds that the patient has suicidal thoughts and feelings of helplessness. According to Peplau, which phase of the nurse-patient relationship does this indicate? 1 Working phase 2 Orientation phase 3 Termination phase 4 Preorientation phase
1 Working phase During the working phase, patients express their feelings, such as suicidal intentions. During this phase, the nurse identifies the patient's emotions, such as helplessness, anger, and self-hate. In the preorientation phase, the nurse does not identify the patient's feelings as the patient hesitates to interact with the nurse. In the orientation phase, the nurse establishes trust and understanding with the patient for an effective rapport. The termination phase is the final phase, when the patient is discharged from the hospital. The patient expresses feelings of sadness and loss but does not have suicidal ideation.
During a one-to-one session a patient is crying while telling the nurse of his or her father's recent death from a car accident. Which nursing response illustrates empathy? 1 "I know that you will get over this. It just takes time." 2 "That must have been such a hard situation to deal with." 3 "I'm so sorry. My father died two years ago, so I know how you are feeling." 4 "You need to focus on yourself right now. You deserve to take time just for you."
2 "That must have been such a hard situation to deal with." The statement "That must have been such a hard situation to deal with" reflects understanding of the patient's feelings, which is empathy. Feeling sorry for the patient represents sympathy, whereas not addressing the patient's concern belittles the patient's feelings of grief he or she is expressing by changing the subject. Telling the patient he or she will get over it does not reflect empathy and is closed-ended.
A community mental health nurse is relocating to another city. As the nurse ends the therapeutic relationship with a long-term patient, the patient gives the nurse a necklace made in arts and crafts group and says, "You have helped me so much. I hope this necklace will remind you of me." Select the nurse's best action. 1 Decline the necklace without comment. 2 Acknowledge the value of the relationship and the patient's consideration. Accept the necklace. 3 Explain to the patient that accepting gifts violates policies and procedures of the agency and decline the necklace. 4 Accept the necklace on behalf of the new nurse who will be working with this patient.
2 Acknowledge the value of the relationship and the patient's consideration. Accept the necklace. The nurse should consider the meaning of this gift. In this instance, the gift demonstrates a sincere expression of gratitude. Because the gift is inexpensive and given at the end of the relationship, the nurse should accept it graciously. The new nurse should establish a new relationship with this patient without respect to the departing nurse. Declining the necklace deprives the patient of an opportunity for healthy self-expression.
Which factor promoting patient growth refers to the nurse's ability to be open, honest, and authentic in interactions with patients? 1 Empathy 2 Genuineness 3 Positive regard 4 Countertransference
2 Genuineness Genuineness refers to the nurse's ability to be open, honest, and authentic in interactions with patients. Empathy occurs when the nurse attempts to understand the world from the patient's perspective. Positive regard implies respect; it is the ability to view another person as being worthy of caring and as someone who has strengths and achievement potential. Countertransference does not promote patient growth. It occurs when the nurse unconsciously displaces feelings related to significant figures in the nurse's past onto the patient.
The nurse establishes a rapport with the patient during which phase of the nurse-patient relationship? 1 Working 2 Orientation 3 Termination 4 Preorientation
2 Orientation The orientation phase of the nurse-patient relationship involves establishing rapport, specifying a contract, and explaining confidentiality. The working phase involves gathering further data, identifying problem-solving skills and self-esteem, providing education about the disorder, promoting symptom management, providing medication education, and evaluating progress. The termination phase involves summarizing the goals and objectives achieved in the relationship, discussing ways for the patient to incorporate into daily life any new coping strategies learned, reviewing situations that occurred during the nurse-patient relationship, and exchanging memories to help validate the experience. Preorientation involves reviewing the patient's chart, conducting research, consulting with staff, and exploring feelings about the first encounter.
A 43-year-old patient is being seen in the mental health clinic with depression. The patient states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which nursing diagnosis best describes the patient's comment? 1 Hopelessness 2 Spiritual distress 3 Ineffective coping 4 Risk for self-harm
2 Spiritual distress The patient is expressing distress regarding religion and spiritual well-being. The patient could be experiencing ineffective coping, but this does not directly relate to his or her comment. There is nothing in the patient's comment that would lead to the conclusion the patient is having thoughts of harming him- or herself. The patient's comment does not describe hopelessness.
The orientation phase of the nurse-patient relationship focuses on 1 The nurse identifying personal biases 2 The nurse and patient identifying patient needs 3 Overcoming resistance to changing behavior 4 Reviewing situations that occurred in previous meetings
2 The nurse and patient identifying patient needs The orientation phase is the first stage of the nurse-patient relationship and focuses on, among other things, the identification of patient needs.
A patient with epilepsy often becomes aggressive and refuses to take prescribed medicines. What is the nurse's approach to the patient? Select all that apply. 1 The nurse does not listen or talk to the patient. 2 The nurse demonstrates genuineness and concern. 3 The nurse speaks softly in a nonprovocative manner. 4 The nurse turns back with anger and leaves the room. 5 The nurse avoids the patient and cares for other patients.
2 The nurse demonstrates genuineness and concern. 3 The nurse speaks softly in a nonprovocative manner. Talking in a calm and low tone of voice reduces anxiety levels and calms down aggressive behavior. Good interpersonal contact reduces aggression; therefore, the nurse has to demonstrate genuineness and concern. The patient may get more irritated if he or she is not given proper attention. Turning back with anger or avoiding the patient is not a good nursing behavior and causes patient withdrawal.
When a nurse and patient meet informally or have an otherwise limited but helpful relationship, the relationship is referred to as a(n) 1 Crisis intervention 2 Therapeutic encounter 3 Autonomous interaction 4 Preorientation phenomenon
2 Therapeutic encounter A therapeutic encounter is a short but helpful interaction between the nurse and patient.
After work, a psychiatric nurse makes these comments to a family member. Which comment indicates that this nurse needs clinical supervision? 1 "It seems like my work load is very heavy right now." 2 "My supervisor announced plans for renovations to our offices." 3 "I am taking care of a very prominent political person from our community." 4 "We have a new psychiatrist with expertise in working with troubled veterans."
3 "I am taking care of a very prominent political person from our community." The correct response indicates that the nurse has attached an additional importance to care of one patient (a politician). In some instances, this comment also could jeopardize the patient's confidentiality. Supervision by a more experienced clinician or team 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.
A mental health nurse shares with a friend that, "I have this one patient who can be difficult. The other nurses are just so hard on her because they don't know her like I do. It can be difficult to always be nice to my patients but I always try. I've never been told that I am an ineffective or uncaring nurse. But I know that some of the nurses don't always agree with my nursing style. I guess that the staff just wishes they could be as attuned to their patients as I am to mine. It's really a good feeling to know that my patients really love me for what I do for them." Which statement by the nurse indicates a possible problem with self-boundaries and countertransference? Select all that apply. 1 "I've never been told that I am an ineffective or uncaring nurse." 2 ""It can be difficult to always be nice to my patients but I always try." 3 "The other nurses are just so hard on her because they don't know her like I do." 4 "It's really a good feeling to know that my patients really love me for what I do for them." 5 "I guess that the staff just wishes they could be as attuned to their patients as I am to mine."
3 "The other nurses are just so hard on her because they don't know her like I do." 4 "It's really a good feeling to know that my patients really love me for what I do for them." 5 "I guess that the staff just wishes they could be as attuned to their patients as I am to mine." There may be a problem with boundaries or countertransference when the nurse feels that others are too critical of their patients, that he or she is the only one capable of understanding a patient, and when the nurse feels satisfaction from not only the appreciation of the patient but loves them. Stating "I've never been told that I am an ineffective or uncaring nurse" or "It can be difficult to always be nice to my patients but I always try" may identity attempts at deflecting a sense of guilt but these are not examples of countertransference or inappropriate boundaries.
The nurse brings new clothes and flowers to a patient who is a victim of sexual assault. The nurse manager observes that the nurse comes to the hospital early and leaves late. What advice does the nurse manager give to the nurse? 1 "You seem to be very dedicated; I appreciate it." 2 "I understand your feelings toward the patient." 3 "You should establish firm treatment goals." 4 "You should be very supportive with the patient."
3 "You should establish firm treatment goals." Overinvolvement is one of the countertransference reactions (blurring of role) that the nurse experiences when the patient's behavior or situation reminds him or her of a relative or a previous patient. The experienced professionals should help the nurse avoid overinvolvement by suggesting the nurse establish realistic treatment goals. Appreciating the nurse by saying "You seem dedicated" will not help the nurse identify the countertransference. The nurse must be advised against overinvolvement rather than acknowledging the feelings of the nurse. The nurse should not be advised to be supportive with the patient. It promotes dependency of the patient on the nurse and the patient may lose his or her problem-solving ability. The nurse should be advised to guide the patient instead of being very supportive with the patient.
According to Rogers, a synonym for genuineness is 1 Respect 2 Empathy 3 Congruence 4 Positive regard
3 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.
The use of empathy and support begins in the stage of the nurse-patient relationship termed the 1 Working stage 2 Resolution stage 3 Orientation stage 4 Identification stage
3 Orientation stage The use of empathy and support should begin in the orientation stage. These tools are helpful in building trust and furthering the relationship.
The phase of the nurse-patient relationship that may cause anxieties to reappear and past losses to be reviewed is the 1 Working phase 2 Orientation phase 3 Termination phase 4 Preorientation phase
3 Termination phase Termination, a stage in which the patient must face the loss or ending of the therapeutic relationship, often reawakens the pain of earlier losses.
A patient asks a nurse a personal question during a teaching session on contraceptive methods. What is the response of the nurse? 1 "I shall answer this later." 2 "You should concentrate on your illness." 3 "We are not supposed to discuss personal issues." 4 "It is time to focus on your concerns."
4 "It is time to focus on your concerns." It is better to make the patient refocus on the topic if the nurse decides not to answer, so the nurse asks the patient to refocus on the discussion. Inability to answer the question may make the patient feel rejected. Telling the patient to concentrate on the illness may offend the patient. Telling the patient that nurses are not supposed to discuss their personal issues may sound polite, but the patient may feel ignored.
A male patient says to a female nurse, "You are the best looking nurse on the entire staff." Which initial response by the nurse best addresses the issue raised by this comment? 1 "Thanks for the compliment but I have heard that comment from other patients." 2 "I prefer that you maintain a professional demeanor regarding our relationship." 3 "I cannot work with you if you continue to try to engage in a personal relationship." 4 "Thank you for the compliment; however, let's focus on your problems and concerns."
4 "Thank you for the compliment; however, let's focus on your problems and concerns." The nurse should acknowledge hearing the patient's comment but stress a patient-centered focus to the conversation. The nurse needs to set clear limits on expected behavior. Frequently restating the nurse's role throughout the relationship can help maintain boundaries. If the patient does not stop, the nurse might postpone interaction with the patient to provide an opportunity for the patient to reflect and gain control.
The nurse observes that some of the patients are leaving the room without completing the task during group therapy. What intervention does the nurse implement for the next session to ensure that patients will participate? 1 Avoid giving mathematical tasks to the patients during group therapy. 2 Avoid giving instructions in a firm voice to patients during group therapy. 3 Avoid maintaining eye contact with patients during group therapy. 4 Avoid interacting with staff and other patients not in group therapy.
4 Avoid interacting with staff and other patients not in group therapy. The nurse should not feel helpless when patients do not participate in a group activity or if they walk out before completing the given work. The nurse should motivate the patients by interacting and effectively communicating with them. Interacting with the staff and other patients not in group therapy may make the patients feel rejected. Giving mathematical tasks like simple addition and subtraction helps improve the patients' problem-solving ability. Giving instructions in a firm voice helps patients understand the instructions properly and follow them. Maintaining eye contact with the patients while giving instructions helps the patients develop trust that the nurse is there to help them.
In the process of trying new values, which step shows the highest commitment to the value? 1 Cherishing the value 2 Publicly stating affirmation of the value 3 Choosing a stand consistent with the value from among several alternatives 4 Consistently acting in ways that repeatedly affirm the value
4 Consistently acting in ways that repeatedly affirm the value Values clarification theory puts acting consistently on one's belief as the highest level of the process, after prizing and choosing.
Which nursing diagnosis for a psychiatric patient is structured and worded correctly? 1 Hopelessness related to severe chronic depression 2 Defensive coping related to lack of insight associated with illicit drug use 3 Spiritual distress as evidenced by the patient stating, "God has abandoned me because I'm a bad person" 4 Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating"
4 Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating" The diagnosis "Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting 'I'm not worthy of eating'" contains all the required components: problem statement, the etiology, and supporting data.
A patient states, "That nurse never seems comfortable being with me." The nurse can be described as 1 Controlling 2 Unfriendly and aloof 3 Transmitting fear of patients 4 Not seeming genuine to the patient
4 Not seeming genuine to the patient Hiding behind a role, using stiff or formal interactions, and creating distance between self and the patient suggest a nurse is lacking in genuineness, or the ability to interact in a person-to-person fashion.
A patient tells the nurse "I really feel close to you. You are like the friend I never had." The nurse can assess this statement as indicating the patient may be experiencing 1 Congruence 2 Empathetic feelings 3 Countertransference 4 Positive transference
4 Positive transference Transference involves the patient experiencing feelings toward a nurse that belong to a significant person in the patient's past.
