Chapter 08: Therapeutic Relationships

A student nurse exhibits the following behaviors or actions while interacting with her patient. Which of these are appropriate as part of a therapeutic relationship? a. Sitting attentively in silence with a withdrawn patient until the patient chooses to speak. b. Offering the patient advice on how he could cope more effectively with stress. c. Controlling the pace of the relationship by selecting topics for each interaction. d. Limiting the discussion of termination issues so as not to sadden the patient unduly.

A

Amanda was raised by a rejecting and abusive father and had a difficult childhood. As an inpatient, she frequently comments on how hard her nurse, Jane, works and on how other staff members do not seem to care as much about their patients as Jane does. Jane finds herself agreeing with Amanda. Jane appreciates her insightfulness, and realizes that the other staff member do not appreciate how hard she works and take her granted. Jane enjoys the time she spends with Amanda and seeks out opportunities to interact with her. What phenomenon is occurring here, and which response by Jane would most benefit her and the patient? a. Amanda is experienced transference; Jane should should help Amanda to understand that she is emphasizing in Jane those qualities that were missing her father. b. Jane is idealizing Amanda, seeing in her strengths and abilities that Amanda does not possess; Jane should temporarily distance herself somewhat from Amanda. c. Amanda is overidentifying with Jane, seeing similarities that do not in reality exist; Jane should label and explore this phenomenon in her interactions with Amanda. d. Jane is experiencing countertransference in response to Amanda's meeting Jane's need for greater appreciation; Jane shoudl seek clinical supervision to explore these dynamics.

A

Which of the following actions best represents the basis or foundation of all other psychiatric nursing care? a. The nurse assesses the patient at regular intervals. b. The nurse administers psychotropic medications. c. The nurse spends time settings with a withdrawn patient. d. The nurse participates in team meetings with other professionals.

A

The nurse is finding it difficult to provide structure and set limits for a client. The nurse should self-evaluate for A. boundary blurring. B. value dissonance. C. covert anger. D. empathy.

A Boundary blurring is often signaled by the nurse being either too helpful or not helpful enough. REF: Page 133-134

One of the possible sources of boundary violations is placing the focus on A. meeting the nurse's needs. B. identifying client disturbances. C. assessing the client's ego strength. D. assessing the client's weaknesses.

A Boundary violations have two sources: (1) allowing the therapeutic relationship to slip into a social relationship, and (2) meeting the nurse's personal needs at the expense of the client's needs. REF: 133-134

You are admitting 32-year-old Louisa to the psychiatric unit. You pull up your chair and sit close to the patient, with your knees almost touching hers, and lean in close to her to speak. Louisa becomes visibly flustered and gets up and leaves the room. What is the most likely explanation for Louisa's behavior? A. You have violated Louisa's personal space by physically being too close. B. Louisa has issues with sharing personal information. C. You have not made the patient feel comfortable by explaining the purpose of the admission interview. D. Louisa is responding to the voices in her head telling her to leave.

A By sitting and leaning in so closely, you have entered into intimate space (0 to 18 inches), rather than social distance and the patient may feel uncomfortable with being so close to someone she does not know. All the other options lack evidence and jump to conclusions regarding the patient's behavior. Cognitive Level: Analyze (Analysis) Nursing Process: Assessment NCLEX: Psychosocial Integrity Text page: 161

With which client should the nurse make the assessment that not using touch would probably be in the client's best interests? A. A recent immigrant from Russia B. A deeply depressed client C. A Chinese American client D. A tearful client reporting pain

A Chinese Americans may not like to be touched by strangers. REF: Page 158-159

Two main principles that can guide the communication process during the nurse-client interview are A. clarity and giving recognition. B. personal and environmental factors. C. passive listening and cultural caution. D. interpreting and speculating on the client's meaning.

A Clarity refers to mutual understanding of communication, and giving recognition indicates awareness of change and personal efforts. Both are desirable. REF: 148

What is the focus during clinical supervision? A. The nurse's behavior in the nurse-client relationship B. Analysis of the client's motivation for transferences C. Devising alternative strategies for client growth D. Assisting the client to develop increased independence

A Clinical supervision helps the nurse look at his or her own behavior and determine more effective approaches to working with clients. REF: 162

The pre-orientation phase of the nurse-client relationship is characterized by the nurse's focus on A. self-analysis of strengths, limitations, and feelings. B. clarification of the nursing role. C. changing the client's dysfunctional behavior. D. incorporating coping skills into client's routine.

A During the preorientation phase the nurse prepares for a relationship with a client by engaging in self-examination. REF: Page 137-138

An action that is acceptable in a social relationship but not in a therapeutic relationship is A. giving advice. B. listening actively. C. clarifying feelings. D. giving positive regard.

A Giving and receiving advice is acceptable in a social relationship. In a therapeutic relationship, it is appropriate for the nurse to assist the client in exploring alternative solutions to problems and in making his or her own decisions. REF: 134-135

A client states "That nurse nevers seems comfortable being with me." The nurse can be described as A. not seeming genuine to the client. B. transmitting fear of clients. C. unfriendly and aloof. D. controlling.

A Hiding behind a role, using stiff or formal interactions, and creating distance between self and client suggest a nurse is lacking in genuineness, or the ability to interact in a person-to-person fashion. REF: Page 132-133

To help a client develop his or her resources, the nurse must first be aware of A. the client's strengths. B. negative transferences. C. countertransferences. D. resistances.

A Nurses work to bolster a client's strengths, to identify areas of dysfunction, and to assist in the development of new coping strategies. REF: 144-145

The use of empathy and support begins in the stage of the nurse-client relationship termed the A. orientation stage. B. working stage. C. identification stage. D. resolution stage.

A The use of empathy and support should begin in the orientation stage. These tools are helpful in building trust and furthering the relationship. REF: Page 139-140

Which of the following statements are true regarding the differences between a social relationship and a therapeutic relationship? (select all that apply): A. In a social relationship, both parties' needs are met; in a therapeutic relationship only the patient's needs are to be considered. B. A social relationship is instituted for the main purpose of exploring one member's feelings and issues; a therapeutic relationship is instituted for the purpose of friendship. C. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. D. In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship solutions are discussed but are only implemented by the patient. E. In a social relationship, communication is usually deep and evaluated; in a therapeutic relationship communication remains on a more superficial level, allowing patients to feel comfortable.

A, C, D The other options describe the opposite meanings of social and therapeutic relationships. Cognitive Level: Analyze (Analysis) Nursing Process: Implementation NCLEX: Psychosocial Integrity Text page: 132

Which of the following statements indicate a nontherapeutic communication technique? (select all that apply): A. "Why didn't you attend group this morning?" B. "From what you have said, you have great difficulty sleeping at night." C. "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" D. "If I were you, I would quit the stressful job and find something else." E. "I'm really proud of you for the way you stood up to your brother when he visited today." F. "You mentioned that you have never had friends. Tell me more about that." G. "It sounds like you have been having a very hard time at home lately."

A, C, D, E All these options reflect the nontherapeutic techniques of (in order) asking "why" questions; using excessive questioning; giving advice; and giving approval. The other options describe therapeutic techniques of restating, exploring, and reflecting. Cognitive Level: Apply (Application) Nursing Process: Implementation NCLEX: Psychosocial Integrity Text page: 155-157

A patient says, "Please don't share information about me with the other people." How should the nurse respond? a."I will not share information with your family or friends without your permission, but I share information about you with other staff." b."A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know." c."It depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others." d."I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us."

ANS:A A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse-patient contract is established, and suggest mutual problem solving. The relationship must be patient centered. See relationship to audience response question. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 133 | Page 140-141 TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. When a novice nurse begins work with this patient, what is the starting point for the relationship? a.Begin at the orientation phase. b.Resume the working relationship. c.Initially establish a social relationship. d.Return to the emotional catharsis phase.

ANS:A After termination of a long-term relationship, the patient and new nurse usually have to begin at ground zero, the orientation phase, to build a new relationship. If termination is successfully completed, the orientation phase sometimes progresses quickly to the working phase. Other times, even after successful termination, the orientation phase may be prolonged. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 137-141 TOP:Nursing Process: Planning MSC:Client Needs: Psychosocial Integrity

A patient says, "I've done a lot of cheating and manipulating in my relationships." Select a nonjudgmental response by the nurse. a."How do you feel about that?" b."I am glad that you realize this." c."That's not a good way to behave." d."Have you outgrown that type of behavior?"

ANS:A Asking a patient to reflect on feelings about his or her actions does not imply any judgment about those actions, and it encourages the patient to explore feelings and values. The remaining options offer negative judgments. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 143 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

Which statement shows a nurse has empathy for a patient who made a suicide attempt? a."You must have been very upset when you tried to hurt yourself." b."It makes me sad to see you going through such a difficult experience." c."If you tell me what is troubling you, I can help you solve your problems." d."Suicide is a drastic solution to a problem that may not be such a serious matter."

ANS:A Empathy permits the nurse to see an event from the patient's perspective, understand the patient's feelings, and communicate this to the patient. The incorrect responses are nurse- centered (focusing on the nurse's feelings rather than the patient's), belittling, and sympathetic. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 143 TOP:Nursing Process: Evaluation MSC:Client Needs: Psychosocial Integrity

A nurse explains to the family of a mentally ill patient how a nurse-patient relationship differs from social relationships. Which is the best explanation? a."The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient." b."The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented." c."The focus of the relationship is socialization. Mutual needs are met, and feelings are shared openly." d."The focus is creation of a partnership in which each member is concerned with growth and satisfaction of the other."

ANS:A Only the correct response describes elements of a therapeutic relationship. The remaining responses describe events that occur in social or intimate relationships. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 132-133 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse's best action? a.Recognize the effectiveness of the relationship and patient's thoughtfulness. Accept the card. b.Inform the patient that accepting gifts violates policies of the facility. Decline the card. c.Acknowledge the patient's transition through the termination phase but decline the card. d.Accept the card and invite the patient to return to participate in other arts and crafts groups.

ANS:A The nurse must consider the meaning, timing, and value of the gift. In this instance, the nurse should accept the patient's expression of gratitude. See relationship to audience response question. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 133-135 (Table 8-1) TOP:Nursing Process: Evaluation MSC:Client Needs: Safe, Effective Care Environment

At what point in the nurse-patient relationship should a nurse plan to first address termination? a.During the orientation phase b.At the end of the working phase c.Near the beginning of the termination phase d.When the patient initially brings up the topic

ANS:A The patient has a right to know the conditions of the nurse-patient relationship. If the relationship is to be time-limited, the patient should be informed of the number of sessions. If it is open-ended, the termination date will not be known at the outset, and the patient should know that the issue will be negotiated at a later date. The nurse is responsible for bringing up the topic of termination early in the relationship, usually during the orientation phase. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 139-141 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

A nurse says, "I am the only one who truly understands this patient. Other staff members are too critical." The nurse's statement indicates: a.boundary blurring. c.positive regard. b.sexual harassment. d.advocacy.

ANS:A When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation the nurse is becoming over-involved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest positive regard or advocacy. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 134 (Table 8-1) | Page 135 (Table 8-2) TOP:Nursing Process: Assessment MSC:Client Needs: Safe, Effective Care Environment

A nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase? Select all that apply. a.Focus dialogues with the patient on problems that may occur in the future. b.Help the patient express feelings about the relationship with the nurse. c.Help the patient prioritize and modify socially unacceptable behaviors. d.Reinforce expectations regarding the parameters of the relationship. e.Help the patient to identify strengths, limitations, and problems.

ANS:A, B The correct actions are part of the termination phase. The other actions would be used in the working and orientation phases. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 141-142 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

A novice psychiatric nurse has a parent with bipolar disorder. This nurse angrily recalls feelings of embarrassment about the parent's behavior in the community. Select the best ways for this nurse to cope with these feelings. Select all that apply. a.Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. b.Recognize that these feelings are unhealthy. The nurse should try to suppress them when working with patients. c.Recognize that psychiatric nursing is not an appropriate career choice. Explore other nursing specialties. d.The nurse should begin new patient relationships by saying, "My own parent had mental illness, so I accept it without stigma." e.Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.

ANS:A, E The nurse needs support to explore these feelings. An experienced psychiatric nurse is a resource that may be helpful. The knowledge and experience gained from the nurse's relationship with a mentally ill parent may contribute sensitivity to compassionate practice. Self-disclosure and suppression are not adaptive coping strategies. The nurse should not give up on this area of practice without first seeking ways to cope with the memories. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 132-133 | Page 137 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

A nurse introduces the matter of a contract during the first session with a new patient because contracts: a.specify what the nurse will do for the patient. b.spell out the participation and responsibilities of each party. c.indicate the feeling tone established between the participants. d.are binding and prevent either party from prematurely ending the relationship.

ANS:B A contract emphasizes that the nurse works with the patient rather than doing something for the patient. "Working with" is a process that suggests each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, and premature termination is forbidden. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 139-141 TOP:Nursing Process: Planning MSC:Client Needs: Safe, Effective Care Environment

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents...so helpless." Which response is the nurse demonstrating? a.Transference c.Catastrophic reaction b.Countertransference d.Defensive coping reaction

ANS:B Countertransference is the nurse's transference or response to a patient that is based on the nurse's unconscious needs, conflicts, problems, or view of the world. See relationship to audience response question. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 134-137 TOP:Nursing Process: Assessment MSC:Client Needs: Psychosocial Integrity

An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion? a."This patient continues to deny problems resulting from drinking." b."My parents were alcoholics and often neglected our family." c."The patient cannot identify any goals for improvement." d."The patient said I have many traits like her mother."

ANS:B Countertransference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviors related to significant figures in the nurse's past. In this instance, the new nurse's irritability stems from relationships with parents. The distracters indicate transference or accurate analysis of the patient's behavior. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 134 (Table 8-1) | Page 135-136 (Table 8-2) TOP:Nursing Process: Assessment MSC:Client Needs: Psychosocial Integrity

A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: a.restate what the patient says. b.use congruent communication strategies. c.use self-revelation in patient interactions. d.consistently interpret the patient's behaviors.

ANS:B Genuineness is a desirable characteristic involving awareness of one's own feelings as they arise and the ability to communicate them when appropriate. The incorrect options are undesirable in a therapeutic relationship. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 139 | Page 142-143 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

A nurse wants to enhance growth of a patient by showing positive regard. The nurse's action most likely to achieve this goal is: a.making rounds daily. b.staying with a tearful patient. c.administering medication as prescribed. d.examining personal feelings about a patient.

ANS:B Staying with a crying patient offers support and shows positive regard. Administering daily medication and making rounds are tasks that could be part of an assignment and do not necessarily reflect positive regard. Examining feelings regarding a patient addresses the nurse's ability to be therapeutic. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 139-140 | Page 142-144 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

As a patient diagnosed with a mental illness is being discharged from a facility, a nurse invitesthe patient to the annual staff picnic. What is the best analysis of this scenario? a.The invitation facilitates dependency on the nurse. b.The nurse's action blurs the boundaries of the therapeutic relationship. c.The invitation is therapeutic for the patient's diversional activity deficit. d.The nurse's action assists the patient's integration into community living.

ANS:B The invitation creates a social relationship rather than a therapeutic relationship. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 134 (Table 8-1) TOP:Nursing Process: Evaluation MSC:Client Needs: Psychosocial Integrity

Which descriptors exemplify consistency regarding nurse-patient relationships? Select all that apply. a.Encouraging a patient to share initial impressions of staff b.Having the same nurse care for a patient on a daily basis c.Providing a schedule of daily activities to a patient d.Setting a time for regular sessions with a patient e.Offering solutions to a patient's problems

ANS:B, C, D Consistency implies predictability. Having the same nurse see the patient daily and provide a daily schedule of patient activities and a set time for regular sessions will help a patient predict what will happen during each day and develop a greater degree of security and comfort. Encouraging a patient to share initial impressions of staff and giving advice are not related to consistency and would not be considered a therapeutic intervention. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 142-143 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

A novice nurse tells a mentor, "I want to convey to my patients that I am interested in them and that I want to listen to what they have to say." Which behaviors will be helpful in meeting the nurse's goal? Select all that apply. a.Sitting behind a desk, facing the patient b.Introducing self to a patient and identifying own role c.Maintaining control of discussions by asking direct questions d.Using facial expressions to convey interest and encouragement e.Assuming an open body posture and sometimes mirror imaging

ANS:B, D, E Trust is fostered when the nurse gives an introduction and identifies his or her role. Facial expressions that convey interest and encouragement support the nurse's verbal statements to that effect and strengthen the message. An open body posture conveys openness to listening to what the patient has to say. Mirror imaging enhances patient comfort. A desk would place a physical barrier between the nurse and patient. A face-to-face stance should be avoided when possible and a less intense 90- or 120-degree angle used to permit either party to look away without discomfort. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 139-140 | Page 142-144 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

Which behavior shows that a nurse values autonomy? The nurse: a.suggests one-on-one supervision for a patient who has suicidal thoughts. b.informs a patient that the spouse will not be in during visiting hours. c.discusses options and helps the patient weigh the consequences. d.sets limits on a patient's romantic overtures toward the nurse.

ANS:C A high level of valuing is acting on one's belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. Autonomy or self-determination is not the issue in any of the other behaviors. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 137 TOP:Nursing Process: Evaluation MSC:Client Needs: Safe, Effective Care Environment

As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response? a."Accepting gifts violates the policies and procedures of the facility." b."I'm glad you feel so much better now. Thank you for the beautiful necklace." c."I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope." d."Helping people is what nursing is all about. It's rewarding to me when patients recognize how hard we work."

ANS:C Accepting a gift creates a social rather than therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patient's gesture of appreciation, but the gift should not be accepted. See relationship to audience response question. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 133-134 (Table 8-1) TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: a.self-responsibility and autonomy. c.rapport and trust with the nurse. b.a greater sense of independence. d.resolved transference.

ANS:C Development of rapport and trust is necessary before the relationship can progress to the working phase. Behaviors indicating a greater sense of independence, self-responsibility, and resolved transference occur in the working phase. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 137-141 TOP:Nursing Process: Outcomes Identification MSC:Client Needs: Psychosocial Integrity

During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? a.Preorientation c.Working b.Orientation d.Termination

ANS:C During the working phase, the nurse strives to assist the patient in making connections among dysfunctional behaviors, thinking, and emotions and offers support while alternative coping behaviors are tried. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 141 TOP:Nursing Process: Planning MSC:Client Needs: Psychosocial Integrity

A patient says, "I'm still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?" What is the nurse's best response? a."Why are you asking me when you're able to speak for yourself?" b."I will be glad to address it when I see your doctor later today." c."That's a good topic for you to discuss with your doctor." d."Do you think you can't speak to a doctor?"

ANS:C Nurses should encourage patients to work at their optimal level of functioning. A nurse does not act for the patient unless it is necessary. Acting for a patient increases feelings of helplessness and dependency. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 134 (Table 8-1) TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

Which issues should a nurse address during the first interview with a patient with a psychiatric disorder? a.Trust, congruence, attitudes, and boundaries b.Goals, resistance, unconscious motivations, and diversion c.Relationship parameters, the contract, confidentiality, and termination d.Transference, counter transference, intimacy, and developing resources

ANS:C Relationship parameters, the contract, confidentiality, and termination are issues that should be considered during the orientation phase of the relationship. The remaining options are issues that are dealt with later. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 131-132 | Page 137-138 TOP:Nursing Process: Planning MSC:Client Needs: Psychosocial Integrity

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? a.The patient's reactions toward the nurse seem realistic and appropriate. b.The patient states, "Talking to you feels like talking to my parents." c.The nurse feels unusually happy when the patient's mood begins to lift. d.The nurse develops a trusting relationship with the patient.

ANS:C Strong positive or negative reactions toward a patient or over-identification with the patient indicate possible countertransference. Nurses must carefully monitor their own feelings and reactions to detect countertransference and then seek supervision. Realistic and appropriate reactions from a patient toward a nurse are desirable. One incorrect response suggests transference. A trusting relationship with the patient is desirable. See relationship to audience response question. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 133-137 TOP:Nursing Process: Evaluation MSC:Client Needs: Psychosocial Integrity

Termination of a therapeutic nurse-patient relationship has been successful when the nurse: a.avoids upsetting the patient by shifting focus to other patients before the discharge. b.gives the patient a personal telephone number and permission to call after discharge. c.discusses with the patient changes that happened during the relationship and evaluates outcomes. d.offers to meet the patient for coffee and conversation three times a week after discharge.

ANS:C Summarizing and evaluating progress help validate the experience for the patient and the nurse and facilitate closure. Termination must be discussed; avoiding discussion by spending little time with the patient promotes feelings of abandonment. Successful termination requires that the relationship be brought to closure without the possibility of dependency-producing ongoing contact. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 141-142 TOP:Nursing Process: Evaluation MSC:Client Needs: Safe, Effective Care Environment

A nurse caring for a withdrawn, suspicious patient recognizes development of feelings of anger toward the patient. The nurse should: a.suppress the angry feelings. b.express the anger openly and directly with the patient. c.tell the nurse manager to assign the patient to another nurse. d.discuss the anger with a clinician during a supervisory session.

ANS:D The nurse is accountable for the relationship. Objectivity is threatened by strong positive or negative feelings toward a patient. Supervision is necessary to work through countertransference feelings. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 132-137 TOP:Nursing Process: Evaluation MSC:Client Needs: Psychosocial Integrity

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship? a."I don't have any problems." b."It is so difficult for me to talk about problems." c."I don't know how it will help to talk to you about my problems." d."I want to find a way to deal with my anger without becoming violent."

ANS:D Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial is often seen in the orientation phase. It is common early in the relationship, before rapport and trust are firmly established, for a patient to express difficulty in talking about problems. Stating skepticism about the effectiveness of the nurse-patient relationship is more typically a reaction during the orientation phase. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 141 TOP:Nursing Process: Evaluation MSC:Client Needs: Safe, Effective Care Environment

A patient says, "People should be allowed to commit suicide without interference from others." A nurse replies, "You're wrong. Nothing is bad enough to justify death." What is the best analysis of this interchange? a.The patient is correct. b.The nurse is correct. c.Neither person is correct. d.Differing values are reflected in the two statements.

ANS:D Values guide beliefs and actions. The individuals stating their positions place different values on life and autonomy. Nurses must be aware of their own values and be sensitive to the values of others. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 135-137 TOP:Nursing Process: Evaluation MSC:Client Needs: Psychosocial Integrity

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you." The nurse should: a.invite the interrupting patient to join in the session with the current patient. b.say to the interrupting patient, "I am not available to talk with you at the present time." c.end the unproductive session with the current patient and spend time with the interrupting patient. d.tell the interrupting patient, "This session is 5 more minutes; then I will talk with you."

ANS:D When a specific duration for sessions has been set, the nurse must adhere to the schedule. Leaving the first patient would be equivalent to abandonment and would destroy any trust the patient had in the nurse. Adhering to the contract demonstrates that the nurse can be trusted and that the patient and the sessions are important. The incorrect responses preserve the nurse-patient relationship with the silent patient but may seem abrupt to the interrupting patient, abandon the silent patient, or fail to observe the contract with the silent patient. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 135 (Table 8-2) | Page 142-143 TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

A male patient frequently inquires about the female student nurse's boyfriend, social activities, and school experiences. Which of the following initial responses by the student best addresses the issue raised by this behavior? a. The student requests assignment to a patient of the same gender as the student. b. She limits sharing personal information and stresses the patient centered focus of the conversation. c. She tells him that she will not talk about her professional life. d. She explains that if he persists in focusing on her, she cannot work with him.

B

When a nurse and client meet informally or have an otherwise limited but helpful relationship, the relationship is referred to as a(n) A. crisis intervention. B. therapeutic encounter. C. autonomous interaction. D. preorientation phenomenon.

B A therapeutic encounter is a short but helpful interaction between the nurse and client. REF: 132-133

During what stage of the therapeutic nurse-client relationship is a formal or informal contract between the nurse and client established? A. Preorientation B. Orientation C. Working D. Termination

B Contracting is part of the orientation phase of the relationship. Establishing the operational "rules" provides a foundation for the relationship. REF: 139-140

A nurse should perceive an intense, highly emotional communication style as culturally appropriate for a client who is A. African American. B. Hispanic American. C. Asian American. D. British American.

B Highly emotional verbal communication accompanied by dramatic body language when describing emotional problems is a style associated with persons of Hispanic culture. French and Italian Americans also demonstrate animated facial expressions and expressive hand gestures during communication. REF: 157-158

What therapeutic communication technique is the nurse using by asking a newly admitted patient, "Can you tell me what was happening to you that led to your being hospitalized here?" A. Using a minimal encourager B. Using an open-ended question C. Paraphrasing D. Reflecting

B Open-ended questions require more than one-word answers. REF: 153-154

You are caring for William, a 55-year-old patient who recently came to the United States from England on a work visa. He was admitted for severe depression following the death of his wife from cancer 2 weeks ago. While telling you about his wife's death and how it has affected him, William shows little emotion. Which of the following explanations is most plausible? A. William did not love his wife. B. William's response may reflect cultural norms. C. William's response may reflect guilt. D. William may have an antisocial personality, which would explain his lack of feeling.

B Showing little emotion while in distress may be a cultural phenomenon. Some cultures, such as the British and German cultures, tend to value highly the concept of self-control and may show little facial emotion in the presence of emotional turmoil. There is no evidence to suggest the patient did not love his wife, and this would be jumping to conclusions. There is also nothing in the scenario to suggest guilt and there is no evidence in the scenario to suggest antisocial personality disorder. Cognitive Level: Analyze (Analysis) Nursing Process: Assessment NCLEX: Psychosocial Integrity Text page: 150-151

The content and direction of the clinical interview is determined by the A. nurse. B. client. C. physician. D. health care team.

B The client always takes the lead and determines the content and direction of the clinical interview, although the nurse may discourage social conversation or intrusive personal questioning. REF: 159-160

The orientation phase of the nurse-client relationship focuses on A. the nurse identifying personal biases. B. the nurse and client identifying client needs. C. overcoming resistance to changing behavior. D. reviewing situations that occurred in previous meetings.

B The orientation phase is the first stage of the nurse-client relationship and focuses on, among other things, the identification of client needs. REF: Page 139-140

Client reactions of intense hostility or feelings of strong affection toward the nurse are common forms of A. resistance. B. transference. C. counter transference. D. emotional abreaction.

B The stirring up of feelings in the client by the nurse is referred to as transference. REF: Page 134

The preferred seating arrangement for a nurse-client interview is with A. the nurse behind a desk and the client in a chair in front of the desk. B. the nurse and client sitting at a 90-degree angle to each other. C. the client sitting in a chair and the nurse standing a few feet away. D. the nurse and client sitting facing each other

B This arrangement allows the nurse to observe the client but places no barriers between the principals. The two are at the same height, so neither is in an inferior position. Face-to-face seating is a more confrontational arrangement and therefore more anxiety producing. REF: 160

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

B This response acknowledges the speaker's perception of school as difficult and asks for further information. This response suggests the nurse is listening actively and is concerned. REF: Page 152

Bethany, a nurse on the psychiatric unit, has a past history of alcoholism. She has weekly clinical supervision meetings with her mentor, the director of the unit. Which statement by Bethany to her mentor would indicate the presence of countertransference? A. "My patient, Miranda, is being discharged tomorrow. I provided discharge teaching and stressed the importance of calling the help line number should she become suicidal again." B. "My patient, Laney, has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" C. "My patient, Jack, started drinking after 14 years of sobriety. We are focusing on his treatment plan of attending AA meetings five times a week after discharge." D. "My patient, Gayle, is an elderly woman with depression. She calls me by her daughter's name because she says I remind her of her daughter."

B This statement indicates countertransference; Bethany may be overidentifying with the patient because of her own past history of alcoholism. She is providing adamant advice to the patient that, besides being nontherapeutic, may be more relevant to her own past than to the patient's. The discharge teaching for a patient being discharged and focusing on the treatment plan for the alcoholic patient are appropriate and show no signs of countertransference. The patient calling the nurse by her daughter's name is transference rather than countertransference. Cognitive Level: Analyze (Analysis) Nursing Process: Evaluation NCLEX: Psychosocial Integrity Text page: 134

Emily is a 28-year-old nurse on the psychiatric unit. She has been working with Jenna, a 27-year-old who was admitted with depression. Emily and Jenna find they have much in common, including each have a 2-year-old daughter and each have graduated from the same high school. Emily and Jenna discuss getting together for lunch with their daughters after Jenna is discharged. This situation reflects: a. Successful termination b. Promoting interdependence c. Boundary blurring d. A strong therapeutic relationship

C

The nurse would NOT address which of the following goals in attempting to establish a therapeutic nurse-client relationship? A. Assisting the client with self-care needs when appropriate. B. Helping the client identify self-defeating behaviors. C. The role of the inpatient nurse on a Behavioral Health Unit encompasses Providing the client with opportunities to socialize. D. Facilitating the client's communication of disturbing feelings or thoughts. E. Encouraging the client to make decisions when appropriate.

C Addressing the client's need to socialize is not one of the goals of establishing a therapeutic relationship. The other options are goals addressed in a therapeutic relationship. REF: 132-133

You enter the room of Andrea, a patient on the psychiatric unit. Andrea is sitting with her arms crossed over her chest and her left leg rapidly moving up and down, and she has an angry expression on her face. When you approach her, she states harshly, "I'm fine! Everything's great." Which of the following is true regarding verbal and nonverbal communication? A. Verbal communication is always more accurate than nonverbal communication. B. Verbal communication is more straightforward, whereas nonverbal communication does not portray what a person is thinking. C. Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. D. Nonverbal communication is about 10% of all communication, and verbal communication is about 90%.

C Communication is roughly 10% verbal and 90% nonverbal, so nurses must pay close attention to nonverbal cues to accurately assess what the patient is really feeling. The other options are all untrue of verbal and nonverbal communication and are actually the opposite of what is believed of communication. Cognitive Level: Understand (Comprehension) Nursing Process: Implementation NCLEX: Psychosocial Integrity Text page: 150

A client 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 A. self-disclosure in an appropriate way. B. to the client permission to continue. C. countertransference. D. empathy to establish trust.

C Counter transference refers to the stirring up of feelings in the nurse by the client. REF: Page 134

According to Rogers, a synonym for genuineness is A. respect. B. empathy. C. congruence. D. positive regard.

C 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. REF: 139-140

The primary difference between a social and a therapeutic relationship is the A. type of information exchanged. B. amount of satisfaction felt. C. type of responsibility involved. D. amount of emotion invested.

C In a therapeutic relationship the nurse assumes responsibility for focusing the relationship on the client's needs, facilitating communication, assisting the client with problem- solving, and helping the client identify and test alternative coping strategies. REF: Page 5-6

Of the following environments, which would be most conducive to a therapeutic session? A. The nurses' station B. A table in the coffee shop C. A quiet section of the day room D. The utility room

C Of the options provided, a quiet corner of the day room offers the safest, quietest, most private environment for a therapeutic encounter. REF: 160

During a therapeutic encounter the nurse remarks to a client, "I noticed anger in your voice when you spoke of your father. Tell me about that." What communication techniques is the nurse using? A. Giving information and encouraging evaluation B. Presenting reality and encouraging planning C. Clarifying and suggesting collaboration D. Reflecting and exploring

C Reflecting conveys the nurse's observations of the client when a sensitive issue is being discussed. Exploring seeks to examine a certain idea more fully. REF: Page 153

When the client sits about 5 feet away from the nurse during the assessment interview, the nurse interprets that the client views the nurse as a A. safe person to interact with. B. new friend. C. stranger. D. peer.

C Social distance (4-12 feet) is reserved for strangers or acquaintances. This is often the client's perception of staff during the initial phase of relationship-building. REF: Page 161

When determining the appropriateness of touching a psychiatric client, the nurse should A. follow his or her instincts concerning touching individual clients. B. touch the elderly but avoid touching the young. C. check the facility's policy on the acceptability of touch. D. perceive touch as a gesture of warmth and friendship that fosters a relationship.

C Students are urged to check the policy manual of their facilities, because some facilities have a no-touch policy, particularly with adolescents and children who may have experienced inappropriate touch and would not know how to interpret the touch of the health care worker. REF: 158-159

When considering the interaction between verbal and nonverbal communication, what is the best word to complete this analogy: Verbal communication relates to content as nonverbal communication relates to A. touch. B. conflict. C. process. D. double messages.

C The verbal message is sometimes referred to as the content of the message, and the nonverbal behavior is called the process of the message. REF: 150-151

Your patient, Emma, is crying in your one-to-one session while telling you of her father's recent death from a car accident. Which of the following responses illustrates empathy? A. "Emma, I'm so sorry. My father died two years ago, so I know how you are feeling." B. "Emma, you need to focus on yourself right now. You deserve to take time just for you." C. "Emma, that must have been such a hard situation to deal with." D. "Emma, I know that you will get over this. It just takes time."

C This response reflects understanding of the patient's feelings, which is empathy. Feeling sorry for the client represents sympathy, whereas not addressing the patient's concern belittles the patient's feelings of grief she is expressing by changing the subject. Telling the patient she will get over it does not reflect empathy and is closed-ended. Cognitive Level: Understand (Comprehension) Nursing Process: Implementation NCLEX: Psychosocial Integrity Text page: 143

When a nurse is biased against a client, those feelings will likely make it difficult to A. assess the client's symptoms. B. assess boundary issues with the client. C. view the client with positive regard. D. engage in values clarification with the client.

C Whenever a nurse harbors negative feelings about a client, these feelings stand in the way of objectivity and reduce his or her ability to give the client positive regard. REF: 134-135

After a client discusses her relationship with her father, the nurse asks, "Tell me if I'm correct that you feel dominated and controlled by him?" The nurse's purpose is to A. elicit more information. B. encourage evaluation. C. verbalize the implied. D. clarify message.

D Clarification helps the nurse understand and correctly interpret the client's message. It gives the client the opportunity to correct misconceptions. REF: Page 152

When discussing her husband, a client shares that "I would be better off alone. At least I would be able to come and go as I please and not have to be interrogated all the time." What therapeutic communication technique is the nurse using when responding, "Are you saying that things would be better if you left your husband?" A. Focusing B. Restating C. Reflection D. Clarification

D Clarification verifies the nurse's interpretation of the client's message. REF: Page 152

Recent immigrants to the United States from which country would find direct eye contact a positive therapeutic technique? A. Korea B. Mexico C. Japan D. Germany

D Eye contact conveys interest to most northern European individuals. Eye contact would be considered intrusive to the others. REF: Page 158

Which communication techniques should the nurse use with a client who has been identified as having difficulty expressing thoughts and feelings? A. Using emotionally charged words and gestures B. Offering opinions and avoiding periods of silence C. Asking closed-ended questions requiring "yes" or "no" answers D. Asking open-ended questions and seeking clarification

D Open-ended questions give the client the widest possible latitude in answering. Also, the client can take the lead in the interview. Seeking clarification helps the client clarify his or her own thoughts and promotes mutual understanding. REF: 153-154

Which statement by the nurse reflects the process occurring in the clinical interview? A. "Give me an example of something your wife does that 'drives you nuts.'" B. "What makes you think your doctor will give you a pass?" C. "When is your child custody hearing going to be held?" D. "You are frowning. What are you feeling?"

D Process refers to nonverbal behavior. Nonverbal behavior is often a more accurate gauge of client feelings than what is being verbalized. REF: Page 150

During a clinical interview the client falls silent after disclosing that she was sexually abused as a child. The nurse should A. quickly break the silence and encourage the client to continue. B. reassure the client that the abuse was not her fault. C. reach out and gently touch the client's arm. D. allow the client to break the silence.

D Silence is not a "bad" thing. It gives the speaker time to think through a point or collect his or her thoughts. REF: Page 151-152

The outcome of the nurse's expressions of sympathy instead of empathy toward the client often leads to A. enhanced client coping. B. lessening of client emotional pain. C. increased hope for client improvement. D. decreased client communication.

D Sympathy and the resulting projection of the nurse's feelings limits the client's opportunity to further discuss the problem. REF: Page 143-144

The phase of the nurse-client relationship that may cause anxieties to reappear and past losses to be reviewed is the A. preorientation phase. B. orientation phase. C, working phase. D. termination phase.

D Termination, a stage in which the client must face the loss or ending of the therapeutic relationship, often reawakens the pain of earlier losses. REF: 141

You are working with Allison on the inpatient psychiatric unit. Which of the following statements reflect an accurate understanding during which phase of the nurse-patient relationship the issue of termination should first be discussed? A. "Allison, you are being discharged today, so I'd like to bring up the subject of termination—discussing your time here and summarizing what coping skills you have attained." B. (to fellow nurse): "I haven't met my new patient Allison yet, but I am working through my feelings of anxiety in dealing with a patient who wanted to kill herself." C. "Allison, now that we are working on your problem-solving skills and behaviors you'd like to change, I'd like to bring up the issue of termination." D. "Allison, now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge."

D The issue of termination is brought up first in the orientation phase. All the other options describe other phases of the nurse-patient relationship—the termination phase, the preorientation phase, and the working phase. Cognitive Level: Analyze (Analysis) Nursing Process: Implementation NCLEX: Psychosocial Integrity Text page: 141

Willis has been admitted to your inpatient psychiatric unit with suicidal ideation. He resides in a halfway house after being released from prison, where he was sent for sexually abusing his teenage stepdaughter. In your one-to-one session he tells you of his terrible guilt over the situation and wanting to die because of it. Which of the following responses you could make reflects a helpful trait in a therapeutic relationship? A. "It's good that you feel guilty. That means you still have a chance of being helped." B. "Of course you feel guilty. You did a horrendous thing. You shouldn't even be out of prison." C. "The biggest question is, will you do it again? You will end up right back in prison, and have even worse guilt feelings because you hurt someone again." D. "You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living."

D This response demonstrates suspending value judgment, a helpful trait in establishing and maintaining a therapeutic relationship. Although it is difficult, nurses are more effective when they don't use their own value systems to judge patients' thoughts, feelings, or behaviors. The other options are all judgmental responses. Judgment on the part of the nurse will most likely interfere with further explorations of feelings and hinder the therapeutic relationship. Cognitive Level: Analyze (Analysis) Nursing Process: Implementation NCLEX: Psychosocial Integrity Text page: 144

You enter the room of Andrea, a patient on the psychiatric unit. Andrea is sitting with her arms crossed over her chest and her left leg rapidly moving up and down, and she has an angry expression on her face. When you approach her, she states harshly, "I'm fine! Everything's great." Which of the following responses would be therapeutic? A. "Okay, but we are all here to help you, so come get one of the staff if you need to talk." B. "I'm glad everything is good. I am going to give you your schedule for the day and we can discuss how the groups are going." C. "I don't believe you. You are not being truthful with me." D. "It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?"

D This response uses the therapeutic technique of clarifying; it addresses the difference between the patient's verbal and nonverbal communication and encourages sharing of feelings. The other options do not address the patient's obvious distress or are confrontational and judgmental. Cognitive Level: Analyze (Analysis) Nursing Process: Implementation NCLEX: Psychosocial Integrity Text page: 152-153

A client 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 client may be experiencing A. congruence. B. empathetic feelings. C. countertransference. D. positive transference.

D Transference involves the client experiencing feelings toward a nurse that belong to a significant person in the client's past. REF: Page 134

In the process of trying new values, which step shows the highest commitment to the value? A. Cherishing the value B. Publicly stating affirmation of the value C. Choosing a stand consistent with the value from among several alternatives D. Consistently acting in ways that repeatedly affirm the value

D Values clarification theory puts acting consistently on one's belief as the highest level of the process, following prizing and choosing. REF: 137-138

During a therapeutic encounter, the nurse makes an effort to ensure the use of two congruent levels of communication. What is the rationale for this? A. The mental image of a word may not be the same for both nurse and client. B. One statement may simultaneously convey conflicting messages. C. Many of the client's remarks are no more than social phrases. D. Content of messages may be contradicted by process.

D Verbal messages may be contradicted by the nonverbal message that is conveyed. The nonverbal message is usually more consistent with the client's feelings than the verbal message. REF: Page 151