Chapter 8 & 9 - Communicating Professionally, Working with an Individual Patient

*D:* Patients generally stop these behaviors when asked and should be reminded that these actions are inappropriate. The nurse then discusses the underlying need. If the behaviors continue, then setting limits can be stronger. Avoiding the patient without an explanation is incongruent with professionalism. Demands are ineffective and disrespectful. While a discussion concerning the behavior is appropriate, it is not the initial response.

A newly admitted patient continually touches the nursing staff members and makes sexual innuendoes when interactions are attempted. The initial therapeutic manner of managing such behavior is to: A. avoid the patient until the behaviors cease. B. demand firmly that the patient cease all inappropriate touching. C. ask the patient to explain why the sexual innuendoes occur. D. explain that the behavior is inappropriate and must stop.

*C:* Stopping to offer the patient a tissue allows the patient (and the nurse) to pause, think, and collect herself. Assessment initially may not be postponed; data forms the basis for the plan of care, and the nurse-patient interaction initiates or establishes the therapeutic relationship. Making the observation is therapeutic and validates support of the patient. "Why" questions are considered nontherapeutic and could engender anger and/or defensiveness.

A newly admitted patient is depressed and fears her husband will ask for a divorce. She begins to cry during the initial assessment interview. An effective nursing strategy would be to: A. postpone the assessment for later. B. avoid comment on her tears, and continue the assessment. C. stop and offer her a tissue. D. ask her why her husband wants to divorce her.

*C:* Initially the nurse acknowledges and respects the patient's experience while presenting reality and avoiding reinforcement of the hallucinations. Stating that there are no voices discounts and minimizes the patient's experience. It is nontherapeutic and may be argumentative. More teaching and support of the patient will be required before distraction can be implemented, and even then it may not be possible or realistic for the patient.

A patient experiencing a loss of reality believes in the angry voices in her head. The nurse will respond to a newly admitted patient who is experiencing auditory hallucinations. The nurse initially makes which response? A. "There are no voices in your head." B. "Try to ignore them by listening to your favorite music ." C. "I am not hearing those voices, but I understand that you do." D. "Just listen to my voice to distract yourself."

A nurse is communicating with a client who was just admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? A. Offering advice B. Reflecting C. Listening attentively D. Giving information

A. CORRECT: Offering advice to a client is a barrier to therapeutic communication that the nurse should avoid using. Advice tends to interfere with the client's ability to make personal decisions and choices. B. T he technique of reflection, directs the focus back to the client in order for the client to examine his feelings. C. T he skill of active listening is an important therapeutic technique to help the nurse hear and understand the information and messages the client is trying to convey. D. Giving information informs the client of needed information to assist in the treatment planning process.

A nurse in an acute mental health facility is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating

A. O ffering general leads allows the nurse to take the direction of the discussion. B. Summarizing enables the nurse to bring together important points of discussion to enhance understanding. C. F ocusing concentrates the attention on one single point. D. CORRECT: Restating allows the nurse to repeat the main idea expressed.

A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? A. Personal space B. Posture C. Eye contact D. Intonation

A. Personal space is a component of nonverbal communication. B. Posture is a component of nonverbal communication. C. Eye contact is a component of nonverbal communication. D. CORRECT: The nurse should identify intonation as a component of verbal communication. Intonation is the tone of one's voice and can communicate a variety of feelings.

A nurse caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. The nurse discusses the client's weight loss during a health care team meeting. B. The nurse examines her own personal feelings about clients who have anorexia nervosa. C. The nurse asks the client about her body image perception. D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents.

A. T he nurse's discussion of client information with members of the healthcare team is an example of small‑group communication. B. T he nurse's self‑assessment of feelings is an example of intrapersonal communication. C. CORRECT: The nurse's one‑on‑one communication with the client is an example of interpersonal communication. D. T he nurse's educational presentation to a large group of adolescents is an example of public communication.

A nurse is caring for the parents of a child who has demonstrated recent changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son's condition, which of the following responses should the nurse make? A. "I think your son is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically."

A. T his nontherapeutic response interjects the nurse's opinion and can cause the parents to withhold their thoughts and feelings. B. T his nontherapeutic response interjects the nurse's opinion and provides false reassurance which can cause the parents to withhold their thoughts and feelings. C. T his nontherapeutic response avoids addressing the parent's concerns directly and indicates disinterest by the nurse for wanting to discuss the concerns with the parents. D. CORRECT: This therapeutic response reflects upon, and accepts, the parents' feelings, and it allows them to clarify what they are feeling.

When the nurse formulates nursing diagnoses, it is necessary to be specific in describing dysfunctional behaviors in order to: a. select appropriate desirable behaviors for outcome criteria. b. analyze how the patient was feeling at the time of assessment. c. explore the context that precipitated the exacerbation of the illness. d. determine how the illness relates to the patient's total life experience.

ANS: A A goal or outcome specifies an adaptive behavior to replace one that is dysfunctional. The more specific the description of the dysfunctional behavior in the nursing diagnosis, the easier it is to specify an appropriate adaptive behavior. The other options are not relevant reasons for describing dysfunctional behaviors in nursing diagnoses.

A student grumbles to an instructor, "I do not see the value of process recordings." The best justification of a process recording the instructor can give is that it is a: a. tool for analyzing communication. b. verbatim record of a patient interview. c. legal document that becomes part of the medical record. d. note written at the time of a patient interview to provide information to team members.

ANS: A A process recording is a tool for the nurse to learn about the effectiveness of communication and interventions during an interpersonal interaction. It is more than a verbatim record. It is for use by the nurse, rather than the interdisciplinary team. It is not placed into the medical record.

A realistic outcome for a patient with situational low self-esteem who will have a short inpatient stay would be for the patient to: a. write a list of strengths, abilities, and talents. b. Role-play with others to improve social skills. c. replace a negative self-image with a positive one. d. respond with positive self-esteem in all encounters.

ANS: A A short-term goal is one that can be attained in 4 to 6 days. Option 1 is attainable within this time frame. The other options are long-term goals.

A patient shouts at a nurse who just entered the room, "You're an incompetent fool. Leave me alone." The nurse's response should be based on which rationale? a. The anger was created by a situation or significant person, not the nurse. b. The reaction likely results from transference and countertransference. c. The patient is probably reacting to fear of loss of emotional control. d. The patient has a right to openly express negative feelings.

ANS: A Anger toward the nurse is often displaced anger that has arisen from some situation or significant person in the patient's life. Nurses feel the brunt of the anger because they are "handy" and might be considered by the patient to be a safe object for the displacement. Knowing that the nurse is not the true object of the anger allows the nurse to plan a therapeutic strategy for helping the individual manage the emotion. None of the other options provides an accurate basis for planning intervention.

A nurse tells a patient, "I know how you feel. My spouse can be very insensitive too. I am also considering divorce." Analysis suggests that the nurse is: a. self-disclosing inappropriately. b. experiencing countertransference. c. using empathy to establish trust with the patient. d. encouraging the patient to express negative feelings.

ANS: A Brief self-disclosure is used to help the patient clarify specific issues, to feel less vulnerable, or to feel more "normal." When used appropriately, self-disclosure benefits the patient. When used inappropriately, it benefits the nurse. In this case, the self-disclosure burdens the patient with the nurse's problems. Empathy focuses on the patient. Countertransference would result in different behaviors. Encouraging expression of negative feelings would be more direct.

The nurse caring for a hyperactive patient should be particularly concerned about assessing: a. physical safety. b. emotional trauma. c. manipulative behaviors. d. feelings about the relationship.

ANS: A Hyperactive patients are at high risk for injury and physical exhaustion, both of which compromise physical safety. Safety needs take priority over emotional needs.

What is the best analysis of this described nurse-patient interaction? Patient: I get discouraged when I realize I've been struggling with my problems for over a year. Nurse: Yes you have, but many people take even longer to resolve their issues. You shouldn't be so hard on yourself. a. The nurse has responded ineffectively to the patient's concerns. b. The patient is expressing lack of willingness to collaborate with the nurse. c. The patient is offering the opportunity for the nurse to revise the plan of care. d. The nurse is using techniques that are consistent with the evaluation step of the nursing process.

ANS: A In this response, the nurse has minimized the patient's feelings and problems, used clichés, and given advice—all considered ineffective responses. None of the other options provides an accurate assessment of the interaction.

During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best comment by the nurse to this nonverbal cue. a. "I notice you keep looking toward the door." b. "This is our time together. No one is going to interrupt us." c. "It looks as if you are eager to end our discussion for today." d. "If you are uncomfortable in this room, we can move someplace else."

ANS: A Making observations and encouraging the patient to describe perceptions are useful therapeutic communication techniques for this situation. The other responses are assumptions made by the nurse.

Which therapeutic intervention should the nurse suggest for a patient with panic attacks and problems with concentration? a. Occupational therapy b. Medication education c. Recreational therapy d. Group therapy

ANS: A Occupational therapists prescribe activities that can help the patient increase concentration and focus. The other activities are not designed to increase concentration and attention span.

A nurse working on a geropsychiatric unit designs new clinical protocols. Which potential problems have the highest priority? a. Risks for falls b. Cognitive errors c. Memory deficits d. Nutritional deficits

ANS: A Patients in geropsychiatric units have an especially high risk for falls. Safety is the nurse's priority concern.

A patient is withdrawn and avoids talking to the nurse. The best initial intervention for the nurse would be to: a. offer to listen and help. b. directly ask why the patient does not wish to talk. c. involve the patient in a group activity to decrease isolation. d. respect the patient's desire not to talk and leave the patient alone.

ANS: A Patients might be afraid or unable to approach nurses. Nurses must take the initiative to approach the patient, thus acknowledging the patient's worthiness and conveying acceptance. "Why" questions usually elicit rationalization. Leaving the patient alone does not foster trust. Decreasing isolation will not build trust in the nurse.

A patient with suicidal ideation is hospitalized. What is the priority intervention? a. Negotiating a no-harm contract. b. Facilitating attendance at groups. c. Administering a psychotropic drug. d. Determining the precipitating situation.

ANS: A Preservation of patient safety is of higher priority than any of the other interventions.

During the mental status examination, the nurse notes that a patient has very rapid-fire speech. The nurse should document this finding as: a. pressured speech. b. tangential speech. c. inappropriate affect. d. a short attention span.

ANS: A Pressured speech is sometimes called machine gun speech. It is rapid and explosive. Tangential speech is only marginally related to the topic. Inappropriate affect refers to emotional tone. Attention span is more related to concentration.

A nurse and patient agree on problems to be addressed during a brief hospital stay. Which inference is correct? a. The relationship is moving into the working stage. b. The nurse should reinforce messages about termination. c. The nurse needs to direct the patient to begin journaling. d. Management of emotions must be ensured before work can continue.

ANS: A Problems are defined and priorities for work are set as the nurse and patient collaborate during the orientation stage. This sets the stage for transition into the working stage. Management of emotions can occur during the working stage.

Objective data obtained in an initial assessment of a patient are of particular value when: a. the patient is too ill to participate. b. the patient's admission is involuntary. c. family members have admitted the patient. d. the patient has been transferred from a subacute setting.

ANS: A Some patients are too ill to participate in or complete the assessment interview. When this is the case, the interviewer uses objective data obtained from patient observation and the reports of family or others present at the time of admission. The other options do not reflect situations in which objective data have maximal value.

A patient has identified the need for better anger management and tells the nurse, "I'm afraid that someday I might explode." The best strategy for reducing this patient's fear of losing control is to: a. talk about these feelings openly and directly. b. discuss feelings in general without reference to the patient. c. avoid talking about the feelings until the patient feels comfortable. d. reassure the patient that expressing feelings is the first step to resolving them.

ANS: A Talking openly about feelings conveys the message that feelings are natural and can be handled. Once feelings can be discussed, the focus can shift to learning to cope more effectively with them. The other options are either avoidant or nontherapeutic.

Following the admission interview, a spouse of a patient asks the nurse, "Why did you ask my partner all those questions? Some of them had nothing to do with current problems." The nurse's best response is, "Those questions help us understand: a. the patient's current status." b. the complete family history." c. the patient's past experiences." d. what the patient's prognosis will be."

ANS: A The mental status examination (MSE) is designed to provide information about the patient's current level of functioning. Other specific information might be obtained that contributes to the overall picture. The MSE does not provide information relating to the other options.

Which diagnosis meets criteria for admission to a co-occurring inpatient unit? a. Bipolar disorder, manic phase, patient has abused alcohol daily to self-medicate b. Undifferentiated schizophrenia and hallucinations of angels playing harps c. Major depression, suicidal intent, and a highly lethal suicide plan d. Anorexia nervosa and 30% underweight

ANS: A The patient experiencing a bipolar episode and abusing alcohol would meet criteria for such a diagnosis unit, since its focus is on the treatment of substance abuse and mental illness in a psychiatric hospital setting. The other three patients require acute psychiatric care but do not meet the admitting criteria.

A patient says to the nurse, "I dreamed I could not breathe and was being attacked. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which comment would be appropriate if the nurse seeks to interpret? a. "It sounds as though you were uncomfortable with the content of your dream." b. "So you are saying that you were not able to breathe and felt in danger?" c. "I understand. Thank you for telling me about your bad dream." d. "So, you feel as though you had a poor night's sleep?"

ANS: A The technique of interpreting is therapeutic and helps the nurse examine meaning and importance of the experience. The distracters use other techniques

Effective use of the nursing process is dependent on communication that: a. is structured and goal-directed. b. meets the needs of both patient and nurse. c. is spontaneous and affords mutual self-disclosure. d. fosters emotional distance between patient and nurse.

ANS: A Therapeutic communication occurs with the purpose of helping patients. It is patient-centered, structured, and goal-directed. It is not expected to meet the needs of the nurse or to include mutual self-disclosure. These are characteristics of social communication. The nurse maintains objectivity, rather than emotional distance.

A patient tells the nurse, "I was raped a month ago. Since then, I've felt anxious and have been unable to talk normally to my husband. I've had frequent thoughts about cutting my wrists." What is the priority nursing diagnosis? a. Risk for violence, self-directed. b. Rape traumatic syndrome. c. Self-esteem, chronic low. d. Anxiety.

ANS: A This diagnosis is of highest priority because patient safety is involved.

The nurse believes that a patient is having emotional pain. Which remark is most therapeutic? a. "I hear how painful this is for you. I would like to help you deal with it." b. "I'm so sorry this has happened to you. You don't deserve it." c. "What would you like me to do to help you through this?" d. "I don't think this is as serious as you believe it is."

ANS: A This remark uses empathy to acknowledge the patient's feelings and then offers help. Using empathy tells the patient that his or her feelings are understood. Offering help implies hope for a positive resolution. Empathy, rather than sympathy, is a useful tool. Asking what to do for the patient implies helplessness on the part of the nurse. Minimizing the problem is demeaning to the patient.

A patient hospitalized for 6 days has made little progress toward outcomes written at the time of admission. The nurse decides that the lack of progress toward goals indicates that: a. needs for reassessment exist. b. discharge should be delayed. c. nursing diagnoses were incorrect. d. nursing interventions were inadequate.

ANS: A When the evaluation is made that goals are not being attained, reassessment should take place. Nursing diagnoses might need to be reformulated, more realistic outcomes identified, or nursing interventions changed, but none of these measures can be determined to be appropriate until the reassessment has been completed.

A patient is withdrawn, suspicious, and maintains physical distance from staff and other patients. Which intervention demonstrates appropriate use of touch with this patient? a. Refraining from touch b. Patting the patient's arm when fear is expressed c. Reaching out to shake the patient's hand as an initial greeting d. Placing an arm around the patient's shoulders while walking down the hall

ANS: A Withdrawn, suspicious patients often consider touch a violation of personal space or might misinterpret touch as being sexual or aggressive. Refraining from touching a suspicious patient is wise until there is evidence that the patient can tolerate touch. The more intimate or extensive the touching, the more threatening it might be to the patient.

A psychiatric aide asks, "Can you give me some examples of how we provide structure for patients?" The nurse should offer which suggestions? Select all that apply. a. Set limits on destructive behavior. b. Direct a patient to go to a quiet place. c. Sit with a withdrawn, isolated patient. d. Distract a patient who is hallucinating. e. Help a patient contemplate change.

ANS: A, B, C, D Providing structure means that staff members meet patient needs for organizing elements in the environment to produce specific outcomes. Contemplating change is the only option that would not be considered an example of structuring.

Assessment findings by the multidisciplinary team after a patient intake interview are used primarily to: a. confirm ongoing discharge planning. b. expand and confirm the initial assessment. c. verify the appropriateness of nursing diagnoses. d. analyze the patient's feelings about hospitalization.

ANS: B As members of the multidisciplinary team interact with the patient, their impressions might support or differ slightly from the initial assessment. The findings are synthesized and used in planning ongoing treatment. The other options have less relevance or are not applicable.

Which nursing intervention will initially be most helpful for trust building with a suspicious patient? a. Enforcing rules b. Keeping appointments and promises c. Agreeing not to document the patient's disclosures d. Openly challenging unclear statements by the patient

ANS: B Consistency and honesty regarding intentions are behaviors that promote patient trust. The other options are nontherapeutic.

During a mental status examination, a patient says, "I am a special messenger sent to provide the world a cure for cancer." The patient's statement indicates the presence of: a. a phobia. b. a delusion. c. hypervigilance. d. loose associations.

ANS: B Delusions are false beliefs. Grandiose delusions are beliefs that one possesses greatness or special powers. A phobia is an excessive fear. Hypervigilance refers to being hyperalert and suspicious. Loose associations refer to a thought disorder in which ideas are only loosely connected.

A patient at the crisis intervention clinic states, "When I got up this morning, I realized I could not go on any longer." Select the nurse's best response to facilitate analyzing the problem and making a nursing diagnosis. a. "How long have you been feeling this way?" b. "What is different about your feelings today?" c. "We are here to help you. I'm glad you decided to come to the center." d. "You said you felt like you could not go on. Tell me more about that."

ANS: B Encouraging comparison is a useful technique when the nurse wishes to analyze the problem and draw conclusions to facilitate establishing a nursing diagnosis. None of the other options would be as effective in encouraging the patient to analyze feelings

A nurse works in a geropsychiatric unit. Which intervention will be most helpful for patients experiencing confusion and disorientation? a. Door locks b. Environmental cues c. Community meetings d. Psychoeducational groups

ANS: B Environmental cues can be helpful to patients with cognitive impairment, such as signs with names or graphic images, orientation boards, and color-coding locations. These elements are usually present on dementia units and geropsychiatric units. Community meetings and psychoeducational groups may be helpful but may also overstimulate patients with dementia. Door locks help the staff rather than patients.

Which patient would benefit most from closed, process-oriented group therapy? a. Adult with disorganized schizophrenia admitted to an acute psychiatric unit b. Outpatient living independently with chronic low self-esteem and anxiety c. Patient receiving treatment in an assertive community treatment program d. Resident of a group home attending a partial hospitalization program

ANS: B Group therapy is seldom an option during short-term treatment. The individual with low self-esteem, anxiety, and living independently meets criteria for being able to develop plans for change and coping, and is able to attend group sessions long enough to benefit from group therapy's curative features. A patient in an assertive community program is someone who receives care from a team that seeks him or her out in the community. Group home residents might or might not be suitable for inclusion in group therapy sessions.

The nurse performing a mental status examination wants to assess for hallucinations. The nurse should ask: a. "Can you tell me where you are now?" b. "Do you hear or see things when others don't?" c. "Do your moods shift more than those of other people?" d. "What would you do if you found a stamped, addressed letter on the floor?"

ANS: B Hallucinations are false sensory perceptions. The correct answer directly inquires about possible hallucinations. The other options seek information about other aspects of the MSE.

During the community meeting a patient says, "I'm having problems in my sex life." The leader of the meeting will make which response? a. "Go on. We are here to listen." b. "That's a topic to discuss with your therapist today." c. "How does everyone else feel about discussing this topic?" d. "Perhaps you should leave the meeting until you are in better control."

ANS: B Individual problems are not dealt with in community meetings. It is suggested to patients that individual issues be discussed with one's therapist. The focus of community meetings is on matters of general concern to the group at large. When the patient is informed of when and where to address the individual problem, it should be done in a nonpunitive manner.

An adolescent has an autism spectrum disorder. Which psychoeducational group topic would best meet the patient's needs? a. Signs of relapse b. Interpersonal skills c. Anger management d. Medication management

ANS: B Individuals with autism spectrum disorders almost universally have impaired relationships and need help learning effective social skills to support relationships. Anger and medication management might or might not be needs of such individuals. Deficits are constant, so relapse is not an issue.

A patient says, "I'm like a wind-tossed leaf. My goal is to find meaning in life." The nurse should consider referring the patient to which group? a. Self-help b. Spirituality c. Reality orientation d. Psychoeducational

ANS: B Lack of meaning in one's life is a spiritual concern. Referral to a spirituality group has potential for helping the client. The other options do not address the patient's expressed concern.

A patient diagnosed with depression has a need for divisional activities. Which team member is best qualified to assess the patient's leisure needs and plan the interventions? a. Occupational therapist b. Recreational therapist c. Exercise physiologist d. Chaplain

ANS: B Recreational therapists are qualified to assist patients to find leisure interests that will enable the patient to learn to balance work and play. The other professionals do not have this focus.

A newly admitted female patient is depressed and has lost 20 pounds in 1 month. The patient also expresses suicidal thoughts related to the recent death of her spouse. What is the priority nursing diagnosis? a. Imbalanced nutrition: less than body requirements b. Risk for violence, self-directed c. Chronic low self-esteem d. Dysfunctional grieving

ANS: B Risk for suicide is the priority diagnosis when the patient has suicidal ideation. Imbalanced nutrition and chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as would a suicide attempt. The spouse's death is too recent for the grief to be labeled as dysfunctional.

A nurse wants to provide opportunities for a patient to try out new, more assertive behaviors. Which technique should the nurse use? a. Clarifying b. Role-playing c. Giving feedback d. Encouraging evaluation

ANS: B Role-playing permits the patient to practice new behaviors in a safe setting and to develop comfort with the use of the new behaviors. The nurse plays a particular role and provides coaching and feedback. The other techniques given as options do not encourage the patient to practice new behaviors.

Which outcome of hospital-based psychiatric care should the nurse consider a priority for a patient to achieve before discharge? a. Referral for vocational rehabilitation b. Safe level of functioning c. Medication stabilization d. Problem resolution

ANS: B Safe level of functioning is of paramount importance before a patient returns to the community. Work toward problem resolution and medication stabilization can continue in the community. Referral for aftercare might or might not be necessary, depending on a patient's needs.

Realistic short-term goals for a patient who is newly admitted to the hospital should be achievable in a. 1 to 2 days. b. 4 to 6 days. c. 1 to 2 weeks. d. 2 to 4 weeks.

ANS: B Short-term goals are those achievable in 4 to 6 days for hospitalized patients and somewhat longer for patients in other settings. One to 2 days allow too little time. The other options suggest longer times than necessary.

A large mental health facility has several specialized units. A patient admitted for alcohol withdrawal asks, "Will I be with patients who have schizophrenia or dementia while I'm here?" Select the nurse's best answer. a. "No. Patients with alcoholism often become violent and must be isolated from our general psychiatric population." b. "No. Patients with needs for alcohol detoxification are treated on our acute substance abuse unit." c. "Yes. Our patients often help each other, so they are all on the same unit." d. "Your question leads me to wonder if you're feeling frightened."

ANS: B Specialty units serve specific populations of patients. The patient in need of alcohol detoxification will receive care on an acute substance abuse unit. It's important to answer the patient's question. Afterward, the nurse can explore the patient's feelings. Violence is a risk during alcohol withdrawal, but the risk alone is not a reason to isolate the patient from others.

A patient diagnosed with schizophrenia, paranoid type, frequently gets up and walks away during interactions with a nurse. The nurse can best increase the patient's comfort level by: a. arranging the chairs side by side, about 2 feet apart. b. sitting at eye level across the table from the patient. c. standing a few feet away from where the patient sits. d. talking in the patient's room with the door closed.

ANS: B Suspicious patients require increased personal space. Sitting across the table provides that space. Being at the same eye level fosters communication. Side-by-side placement of chairs might not give the suspicious patient the ability to watch the nurse closely enough for comfort. Being in a closed room might be threatening to the patient.

Select the best description of therapeutic use of self to provide to a new psychiatric nurse. a. "Most nurses have caring personalities that equip them to be helpful to patients." b. "It's mostly about using good verbal and nonverbal communication, objectivity, genuineness, and empathy." c. "It means that you keep yourself at a distance so you are not affected by patients' problems and emotions." d. "The most important aspect of practice is when and how much to touch, as well as when to listen and give advice."

ANS: B The correct answer lists several of the components of therapeutic use of self. The other options provide less information for the new nurse to use to continue to develop skills.

A patient says, "I went out drinking only one time last week. At least I'm trying to change." The nurse responds, "I appreciate your effort, but you agreed to abstain from alcohol completely." The nurse is: a. using cognitive restructuring. b. preventing manipulation. c. showing empathy. d. using flooding.

ANS: B The correct comment prevents the nurse from being manipulated by the patient. The nurse should address what happened, along with the expectations.

What is the best way to support the need for physical activity when the patient moves from acute care into community-based care? a. Use video-based exercise programs on television. b. Enroll in a swim class at the community center. c. Attend outpatient psychoeducational groups. d. Join a social club.

ANS: B The key combination affords the patient physical exercise as well as opportunities for social interaction at a community center. Exercise on television is solitary. Psychoeducational and social interaction do not achieve the goal.

A nurse considers interventions for a diabetic patient who needs to change eating habits and lose weight. The nurse will base strategies on which principle? a. The nurse's primary responsibility is to encourage the change. b. Patient-initiated change is more successful than imposed change. c. For successful change, both the benefit and the risk to the patient must be high. d. Patients value advice from nurses because of the trusting dimensions of the relationship.

ANS: B The key indicates that the patient is invested in the change process. Nurses have multiple responsibilities in the change process, including education and reinforcement. Nurses should avoid giving advice.

When assessing a patient's social skills, which remark would serve the nurse best? a. "It sounds as if you need to develop some assertiveness skills." b. "Describe an example of a time when you felt uncomfortable in a social situation." c. "It is not easy to be assertive. We can role-play some situations to give you practice." d. "What do you plan to do the next time you find yourself in an uncomfortable social situation?"

ANS: B The nurse is seeking clarification, a therapeutic technique that is a useful assessment tool. Mention of assertiveness skill development indicates that the assessment has been made. Asking for the patient's plan would occur during problem solving rather than assessment.

A patient's plan of care includes this nursing diagnosis: Impaired verbal communication related to lack of assertiveness skills. To include the patient in prioritizing this problem, the nurse should say: a. "Who are the people with whom you are most passive?" b. "How important is it for you to become more assertive?" c. "Let's look at how we can address this problem together." d. "Are you interested in attending the assertiveness class?"

ANS: B The technique of encouraging evaluation is useful to the nurse who is attempting to interpret meaning and importance. It seeks the patient's view of the situation and provides a basis for setting priorities. The other options are not concerned with priority.

A patient scheduled to attend various group sessions complains, "I'm really mad about having to attend all those groups. No one else spends all day in a circle in a little room." Select the nurse's best response. a. "Why are you upset?" b. "I can hear that you are upset. Let's talk about it." c. "Just go along with the plan, even if you do not agree." d. "The groups are carefully planned by staff to benefit patients."

ANS: B This remark exemplifies therapeutic listening. It acknowledges the patient's negative feelings and the nurse's willingness to listen as the patient offers his concerns. It implies a willingness to assist with problem solving. "Why" questions are not therapeutic, because they often elicit rationalization. Justification is defensive and closes off communication.

A newly admitted patient asks the nurse, "Can you hear those people laughing at me? They are making fun of me." Select the nurse's best response. a. "You are mistaken. No one is laughing at you." b. "I know the sound of laughter is real to you, but I don't hear it." c. "Your mind is playing tricks on you, making you think you hear laughter." d. "When people are mentally ill, they often experience things that others cannot relate to."

ANS: B This reply acknowledges the patient's perceptions and gently casts doubt on the reality of the patient's conclusions through the use of an "I" statement. It is not argumentative or accusative.

A patient cries as the nurse explores the patient's feelings about the death of a close friend. The patient sobs, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse facilitate communication? Select all that apply. a. "Why do you think you are so upset?" b. "I can see that you feel sad about this situation." c. "The loss of your friend is very painful for you." d. "Crying is a way of expressing the hurt you're experiencing." e. "Let's talk about something else, since this subject is upsetting you."

ANS: B, C, D Reflecting and giving information are therapeutic techniques. "Why" questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication

A nurse plans to teach a group of patients the basics of the change process. How should the elements be sequenced for the presentation? a. Assess the success of new behaviors. b. Observe to gain awareness. c. Draw conclusions about the problem. d. Test new behaviors. e. Determine that change is necessary.

ANS: B, C, E, D, A This sequence proceeds logically from assessment of the problem to analysis of the problem to determining that change is necessary to testing new behaviors and evaluating their efficacy.

Which techniques are therapeutic when interacting with a patient? Select all that apply. a. Avoiding direct questions b. Validating and clarifying c. Using empathy sparingly d. Assuming an attending posture e. Maintaining constant eye contact

ANS: B, D Using validation and clarification ensures that the nurse understands what the patient is saying. Using an attending posture conveys the message that the nurse is interested in what is being communicated. Giving feedback appropriately conveys interest and understanding. The other options are ineffective behaviors.

Which statement by a patient would the nurse interpret as willingness to collaborate in the nurse-patient relationship? a. "I know you are here to help me, and will do whatever you tell me to do." b. "I didn't want to deal with this at first, but I'm glad you made me face it." c. "I realize that I have some issues that I need help resolving." d. "I will do anything to get out of this hospital."

ANS: C Collaboration takes place when patients recognize problems and the need for assistance. The other responses suggest coercion or simple compliance.

Complete this goal statement for a newly admitted patient. "By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate: a. greater independence." b. increased self-responsibility." c. trust and rapport with two staff." d. ability to problem-solve one issue."

ANS: C Establishing trust is the primary task of the orientation stage of the nurse-patient relationship. The other options are too ambitious for this early stage.

A common mistake nurses make when developing therapeutic communication techniques is: a. using too many different techniques during an interaction. b. allowing patients to become too anxious before responding. c. giving advice rather than encouraging patients to solve problems. d. focusing on what patients say rather than on communication techniques.

ANS: C Giving advice is a common pitfall for nurses who are unsure of how to encourage patients to become involved in analyzing and problem solving. The other options are incorrect, because most novice nurses tend to rely heavily on direct questions, avoid anxiety-producing topics, and focus on communication techniques.

A patient has difficulty expressing anger appropriately. The nurse encourages the patient to set realistic goals by stating: a. "You seem to have problems expressing anger in a nonaggressive way." b. "I thought you sounded angry when I told you it was time for group." c. "What do you think needs to change about how you express anger?" d. "What bothers you about your actions when you get angry?"

ANS: C Goal-setting is most directly related to the technique of asking patients to decide on the type of change needed. The distracters demonstrate making observations and exploring.

During a mental status examination, what data is most relevant to determining a patient's mood? a. Answers to judgment questions. b. Observations about the patient's sensorium. c. Facial expression and statements about feelings. d. Level of cooperation or resistance to the interview.

ANS: C Mood is the patient's self-report of his or her prevailing emotional state. Facial expression is often congruent with mood and can provide the nurse with clues, even when the patient is unable to supply information about mood. Judgment, sensorium, and cooperation are elements not considered closely related to mood.

A new nurse says, "I have more important things to do than play games with patients. These activities are not a worthwhile use of my time." Select the nurse manager's best response. a. "Games are part of the therapeutic milieu." b. "Patients need a break from intensive individual therapy." c. "Informal activities help patients develop social skills and take risks." d. "Please review material on the psychotherapeutic management model."

ANS: C Nurses who engage in therapeutic activities with patients recognize that each encounter with patients is part of an overall therapeutic picture. Patients discuss real problems and solutions and practice skills needed in real-life situations. These encounters offer opportunities for assessment, for patients to process feelings, and for validation and feedback, as well as for tension relief. The correct answer is the most global response. The distracters do not educate the new nurse about the purpose of informal activities.

During the initial interview with a patient, the nurse uses a depression self-rating scale. The primary reason for using a rating scale is to: a. document the patient's need for treatment. b. define pretreatment concerns and ideation. c. provide a baseline for documentation of progress. d. give the patient a participative role in the interview.

ANS: C Patient self-rating scales are self-assessment tools. They might provide information about a patient's perception of problems and the effect of the problem on current functioning. This information can be compared with information obtained near the time of discharge to evaluate progress. The other options are not the primary reason for use.

Which treatment setting would necessitate the most restrictive environment? a. Partial hospitalization b. Geropsychiatric unit c. Forensic hospital d. Group home

ANS: C Patients in forensic hospitals have mental illness as well as conviction or charges for criminal activity. These settings must be therapeutic but also confine patients from society. Rules, regulations, and restrictions have similarities to those of prisons.

A patient playing pool with another patient throws down the pool cue and begins swearing. The nurse should initially intervene by: a. asking other patients to leave the room. b. calling for assistance to restrain the patient. c. suggesting a time-out in the patient's room. d. restating rules of the milieu related to swearing.

ANS: C Suggesting a time-out in the patient's room is often an effective initial strategy because it permits the patient to go to an area with fewer stimuli. It also removes the patient from other patients who are at risk for injury if the patient's behavior escalates. Restating the rules of the milieu does not help the patient diffuse the anger. Removing other patients is unnecessary unless the patient's behavior escalates.

As the nurse plans care for a newly admitted patient, identification of dysfunctional behaviors will provide the focus for: a. evaluation. b. nursing diagnosis. c. nursing interventions. d. outcome identification.

ANS: C The nurse recognizes that dysfunctional behaviors are behaviors that would benefit the patient to change. These dysfunctional behaviors are written as defining characteristics in the nursing diagnosis. Nursing interventions are formulated that address changing dysfunctional behaviors to more adaptive behaviors. The focus of evaluation is patient progress; the focus of nursing diagnosis is patient problems; the focus of outcome identification is adaptive behaviors.

A psychotic patient tells the nurse, "Get away from me or I'll hit you. You're sucking the thoughts out of my head." The nurse should: a. direct the patient to a chair. b. deny taking the patient's thoughts. c. increase the distance between self and patient. d. tell the patient, "You will be restrained if you hit me."

ANS: C The nurse should do as the patient requests when the request is reasonable. Patients perceiving alterations in reality often need increased personal space to feel less anxious. Denials, touching, and threatening are likely to promote escalation of violent behavior.

A patient is hospitalized for severe depression. Knowing that the patient will be discharged after a short stay, what is the nurse's first priority? a. Maximize the benefits of milieu management. b. Immediately begin to explore acute patient issues. c. Develop a goal-directed, problem-centered relationship. d. Choose a specific theoretical model as the basis for care.

ANS: C Therapeutic relationships are planned, patient-centered, and goal-directed. This is of particular importance if progress is to be made when the duration of the relationship will be brief. The other options are not the priority. Exploration of patient issues requires trust development before it can proceed.

Select the best outcome for a nurse to include in the care plan for a withdrawn patient who says, "I would like to have more friends." Within 3 days, the patient will: a. be more outgoing. b. develop greater independence. c. participate in one group activity. d. increase socialization with others.

ANS: C This outcome is behavioral, measurable, and related directly to the problem of social isolation. The other outcomes are neither measurable nor relevant to socialization.

An inpatient says, "Last time I was here, a primary nurse talked with me every day. This time, different nurses work with me. How can I make progress?" Select the nurse's best response. a. "Your comments are interesting. With your permission I will share them with the treatment team." b. "We are using a new system because of managed care requirements. We are hopeful it will be effective." c. "Shift reports, care plans, and progress notes help different nurses work with every patient toward their individual goals." d. "It sounds like you are feeling dissatisfied with your care. After you are discharged, you will receive a form to provide feedback."

ANS: C This reply explains how many nurses are able to share responsibility and accountability for the care of patients. Good communication enables the nurses to be on the same page when it comes to working toward the achievement of patient-centered goals that are appropriate for each stage of the nurse-patient relationship. The other options fail to provide the information the patient needs to understand the current practices.

A nurse says, "What step would you like to take next to resolve this issue?" The patient stands up and shouts, "You are so controlling! You want me to do everything your way." What is the likely basis of the patient's behavior? a. Projection b. Dissociation c. Transference d. Emotional catharsis

ANS: C Transference involves a patient's emotional reaction to the nurse that is actually based on an earlier relationship or experience. In this case, the transference is negative and might be related to an earlier experience with an authority figure. Although projection is a possibility, it is less obvious. Dissociation and emotional catharsis do not apply.

As a patient and nurse move into the working stage of a therapeutic relationship, the nurse's most beneficial statement is: a. "I want to be helpful to you as we explore your problems and the way you express feelings." b. "A good long-term goal for someone your age would be to develop better job-related skills." c. "Of the problems we have discussed so far, which ones would you most like to work on?" d. "When someone gives you a compliment, I notice that you become very quiet."

ANS: C With this remark, the nurse seeks patient collaboration and offers the opportunity to set priorities for the work toward change that will be undertaken. The distracters relate to the orientation stage.

A nurse realizes that the comment just made to a patient was inconsiderate. Select the nurse's most therapeutic statement in this situation. a. "How do you feel about what I just said?" b. "See, even nurses say stupid things sometimes." c. "Sorry about that. Let's continue where we left off." d. "That was an insensitive remark. I'm sorry if it hurt you."

ANS: D Acknowledging insensitivity and apologizing for it will usually repair damage. Patients usually evaluate the nurse on overall caring rather than on one single comment. None of the other options includes both acknowledgment and apology.

A plan of care includes the desired outcome, "Patient will sleep a minimum of 5 hours nightly by May 31." On June 1, review of sleep data for the past week showed that the patient slept about 4 hours nightly and took a nap daily. Which evaluation is correct? The outcome: a. should be revised. b. has been achieved. c. was unreasonable. d. was not achieved.

ANS: D Although the patient is sleeping 5 or more hours daily, the total is not in one uninterrupted session at night. Therefore the outcome must be evaluated as never demonstrated. The outcome is reasonable and clinically sound, so it does not need revision.

What is the primary purpose of a community meeting? a. Making assignments for patients' chores for the day b. Determining patients' eligibility for increases in privileges c. Encouraging patients to share their feelings and individual problems d. Providing a forum for patients to have input into daily program operations

ANS: D An emphasis of community meetings is on democratic aspects of unit life. The meeting serves as a forum for patients to voice opinions about the environment and to initiate discussion of community concerns. Making assignments and sharing are only some of the issues addressed in a community meeting. Privilege eligibility would not be discussed in a community meeting.

A patient says to the nurse, "My family was mean to me when they visited today. They have no right to treat me like that." Select the nurse's best initial response. a. "Why do you think they were mean?" b. "Perhaps you overreacted to what they said." c. "How do you feel about your family treating you that way?" d. "Describe what happened when your family visited you today."

ANS: D Before proceeding, the nurse needs to have a better understanding of what happened in the interaction between the patient and family. The correct option seeks that clarification, whereas none of the other options takes that approach.

Which patient behavior would require the most immediate limit setting? a. The patient makes self-deprecating remarks. b. At a goal-setting meeting, the patient interrupts others to express delusions. c. During dinner, a patient manipulates an older adult patient to obtain a second dessert. d. A patient shouts at a roommate, "You are perverted! You watched me undress."

ANS: D Behaviors that require the most immediate limit setting are verbal and physical aggression, self-destructive behavior, fire setting, alcohol or drug use, manipulation, inappropriate sexual behaviors, and attempts to leave the hospital without consent. In this case, the verbal aggression toward the roommate requires immediate intervention to prevent further escalation.

When observing and interpreting a patient's nonverbal communication, which nursing consideration is important? a. Patients are usually aware of their nonverbal cues. b. Verbal responses are more important than nonverbal cues. c. Nonverbal cues have obvious meaning and are easily interpreted. d. Nonverbal cues provide significant information but must be validated.

ANS: D Body language has meaning, but meaning cannot be globally ascribed. Validation with the individual is necessary to accurate interpretation. The other options are incorrect.

A new patient tells the nurse, "The voices are bothering me." The nurse should first: a. ignore the patient's reference to voices. b. distract the patient from the hallucinations. c. tell the patient that the voices do not exist. d. seek a description of the voices and identify themes.

ANS: D Early assessment of hallucinations is based on the content of the messages. Content often reveals the dynamics of the patient's symptoms and typically revolves around a theme such as powerlessness, hate, guilt, or loneliness. Ignoring the reference is nontherapeutic and thwarts assessment. Distraction is a possible strategy after the nurse understands the content of the hallucinations. Saying that the voices do not exist negates the patient's experience. Saying you do not hear them is preferable.

A nurse and patient who developed a therapeutic relationship enter the termination phase. An important nursing intervention for this stage is for the nurse to: a. provide structure and intensive support. b. inform the patient of the progress made. c. encourage the patient to describe goals for change. d. discuss feelings about termination with the patient.

ANS: D Healthy closure is facilitated when the patient discusses his or her reactions to termination and the feelings that she or he might be experiencing. The nurse serves as a role model during termination. Providing structure is related more to the orientation and working stages. Informing the patient of progress is paternalistic. The process of termination is facilitated by collaborative work. Describing goals takes place with passage from the orientation to the working stage.

The nurse writing a discharge summary for a patient should include achievements as well as: a. care plan updates. b. a list of patient strengths. c. effective nursing interventions. d. outcomes that still need to be addressed.

ANS: D Information included in discharge summaries includes outcomes attained, outcomes still to be attained, discharge instructions, medication instructions, and follow-up appointments. The other items are not part of a discharge summary.

A nurse assessing a new patient asks, "What is meant by the old saying, 'You can't teach an old dog new tricks'?" Which aspect of the mental status evaluation is the nurse primarily assessing? a. Mood b. Attention c. Speech patterns d. Intellectual function

ANS: D Interpretation of proverbs gives assessment information regarding the patient's intellectual function, including ability to abstract, an aspect of cognition. While the nurse may obtain some information about speech patterns, that is not the focal intent of the question. Mood and attention span are assessed in other ways.

A patient has a history of noncompliance with the medication regime. In which part of the plan of care should a nurse record this item? "Encourage patient to attend one psychoeducational group daily." a. Assessment b. Analysis c. Outcome Identification d. Implementation e. Evaluation

ANS: D Interventions are the nursing prescriptions used to achieve the outcomes. Interventions should be specific.

To determine the integrity of a patient's judgment, which question should the nurse ask during the mental status examination? a. "Do you ever hear voices?" b. "On a scale of 1 to 50, how stressed are you?" c. "Do your thoughts ever seem to be all jumbled up?" d. "If you found a stamped, addressed envelope on the street, what would you do?"

ANS: D Judgment involves making constructive, adaptive decisions. The correct option most clearly addresses this ability, but the other options are unrelated.

The nurse tells a patient, "I noticed that you frowned when we discussed your relationship with your family." Which communication technique is the nurse using? a. Clarifying b. Interpreting c. Giving information d. Making observations

ANS: D Making observations is defined as commenting on what is seen or heard to encourage discussion. The nurse's statement cannot be interpreted as using any of the other techniques listed.

The priority treatment goal for a patient with severe and persistent mental illness being treated in a community-based facility will be to: a. form new relationships. b. self-administer medications. c. participate in community activities. d. independently attend to activities of daily living.

ANS: D Priority outcomes for community treatment focus on the individual being able to function at his or her optimal level by attending to activities of daily living. The other options have a lower priority or can be managed by others.

A patient says, "Aliens from another galaxy invaded my home and tried to kill me." There is little emotional reaction coupled with the comment even though a person facing such a threat would usually have anger or fear. How should the nurse document the patient's affect? a. Labile. b. Elated. c. Congruent. d. Flat or blunted.

ANS: D Reporting significant events with little emotion suggests blunted or flattened affect. Lability refers to rapid changes in affect. Elated refers to an overly happy or high affect. Congruent refers to the agreement of two elements, such as affect and verbalizations.

A patient states, "I'm tired of all these therapy sessions. It's just too much for me." Using supportive confrontation, the nurse should reply: a. "It will get better if you just keep trying." b. "You are doing fine. Don't be so hard on yourself." c. "Tell me more about how the therapy sessions are too much." d. "I know you find this difficult, but I believe you can get through it."

ANS: D Supportive confrontation is a technique in which the nurse acknowledges the difficulty in changing, but pushes for action. The other options clarify or give reassurance.

Which documentation of a hospitalized patient's behavior best communicates the nurse's observations? a. "Patient calm but refused group activities. Ate well at all meals." b. "Patient remains delusional. Needs frequent redirection from staff." c. "Patient is isolated and withdrawn. Dozed frequently. Vital signs are stable." d. "Patient wore layered clothing and stated, 'I need protection from demon spirits.'"

ANS: D The medical record is a legal document. Documentation should be specific. The distracters offer vague comments.

During an interview with a depressed patient, the nurse sits with folded arms and fidgets when long silences occur. When the patient expresses hopelessness about getting better, the nurse replies, "You will feel better when your medication takes effect." This interaction: a. shows therapeutic use of limit-setting. b. is minimally therapeutic but effective. c. evidences therapeutic use of self. d. is nontherapeutic and ineffective.

ANS: D The nurse is demonstrating a closed posture, suggesting lack of interest in the interaction. Fidgeting suggests boredom or lack of comfort during the interaction. The quoted response minimizes the patient's problem and sounds short. Cumulatively, these indicate that the nurse's behaviors are nontherapeutic and ineffective.

A patient with a history of self-mutilation says to the nurse, "I want to stop hurting myself." What is the initial step of the problem-solving process to be taken toward resolution of a patient's identified problem? a. Deciding on a plan of action b. Determining necessary changes c. Considering alternative behaviors d. Describing the problem or situation

ANS: D The nurse learns how well the patient understands the problem by asking for a detailed, in-depth description of situations, thoughts, feelings, and behaviors relevant to the identified problem. This step must be completed before moving through the problem-solving process. The other actions are premature.

A nurse working in an intensive inpatient psychiatric unit should place emphasis on which area of care? a. Behavior modification principles b. Personality restructuring and insight c. Improving interpersonal relationships d. Symptom stabilization and daily living skills

ANS: D The nurse will emphasize symptom stabilization and daily living skills, because the length of stay will be short. Behavior modification principles are not used in all settings. Developing insight, restructuring personality, and improving interpersonal relationships are lengthy endeavors.

A patient with schizophrenia says to the nurse, "I feel really close to you. You're the only true friend I have." Select the nurse's most therapeutic response. a. "We are not friends. Our relationship is a professional one." b. "I feel sure there are other friends in your life. Can you name some?" c. "I am glad you trust me. Trust is important for the work we are doing together." d. "Our relationship is professional, but let's explore ways to strengthen friendships in your life."

ANS: D The patient's remarks call for the nurse to remind the patient of the parameters of their relationship and take the opportunity to discuss the issue of friends. Only this option incorporates both desired elements.

Which skill is most important for a nurse preparing to work in the psychiatric setting? a. Helpful transference b. Sympathetic listening c. Supportive confrontation d. Therapeutic communication

ANS: D Therapeutic communication provides the basis for effective use of each stage of the nursing process, as explained by the authors. The other options are skills basic to effective use of the nursing process.

A patient asks, "Who will be at the community meeting?" The nurse responds: a. "Patient representatives and staff" b. "Members of the mental health team" c. "All patients and the nurse manager" d. "All patients, nursing staff, and students"

ANS: D Typically, all patients, students assigned to the unit, and all nursing staff attend community meetings. Members of other disciplines might or might not attend.

A patient tells the nurse, "I want to have sex with you." Which nursing responses are appropriate? Select all that apply. a. "I will forget you said that." b. "Your suggestion frightens me." c. "You must keep your distance." d. "Sex is not part of our relationship." e. "We are here to work on your problems."

ANS: D, E The correct responses provide information to the patient about the purpose of the relationship and recognize the underlying need. The other options are ineffective.

A person checks the pantry and finds there is no sugar, flour, or oil. The person purchases the items, restocks the pantry, bakes a cake, and then serves it to guests. The guests eat the cake and comment how delicious it was. The guests' comments correlate with which step of nursing process? a. Assessment b. Analysis c. Outcome identification d. Implementation e. Evaluation

ANS: E This scenario offers an analogy. The guests' comment give feedback on the endeavor, indicating it was successful.

*A:* Countertransference usually consists of feelings related to persons other than the patient but transferred to the patient. This range of both positive and negative feelings may interfere with the ability to be therapeutic. Reporting a patient's attempt at arranging a social interaction or the need to manage a patient's maladaptive behavior are appropriate occurrences to report to the team but do not demonstrate countertransference. Crying is not associated with countertransference.

During a team meeting the RN who is experiencing a countertransference reaction to a patient would state: A. "He reminds me so much of my sweet uncle." B. "That patient asked me out to dinner." C. "I think the team needs to discuss how best to manage the patient's manipulative behaviors." D. "I believe it's okay to cry."

*C:* Thanking the patient and acknowledging the value of the experience offers respect and support to the patient while validating the importance of the relational opportunity for the nurse. Termination is always appropriate and necessary therapeutically. Wishing the patient "good luck" is not therapeutic but instead is casual and informal. Termination should not be rushed, and—depending upon the length of time in the relationship—planning and discussion of termination for the patient and nurse are important.

The new RN is experiencing difficulty knowing how to terminate a relationship with a patient. The preceptor states: A. "If the relationship has been short, termination may not be necessary." B. "Just say good-bye and good luck." C. "Thank the patient for working with you, and say how you valued the experience." D. "Try to move through the termination phase as quickly as possible."

*B:* The establishment and maintenance of objectivity and goal-directedness is crucial in therapeutic relationships. Assessing patient needs in preparation for discharge demonstrates therapeutic intentions. Offering to visit the patient following discharge is an example of blurring boundaries and the risk of unprofessional conduct that may come as a result. Inappropriate social requests should not be ignored but should be discussed with the team for decision-making purposes. Crying and feeling sad in response to a patient's condition may suggest a potential for a boundary violation as an example of countertransference.

The nurse practicing with therapeutic intentions versus social ones will: A. offer to visit the patient following discharge. B. assess the patient's needs for discharge. C. ignore the patient's requests for a date while on the unit. Incorrect D. feel sadness and cry in response to the patient's depression.

*A:* The nurse concentrates on nursing approaches in a particular phase, depending on the status and needs of individual patients. For example, approaches used in the orientation phase have priority when the patient is highly suspicious, because a need exists to develop trust with the patient. The distrustful patient will require additional interventions associated with the orientation phase. For the patient with good insight and motivation such as the young mother and the middle-aged adult, approaches in the working phase are most important because they concentrate on problem solving and change. If the patient is to be admitted for only 3 days, then approaches used in the termination phase are critical because of the need for formalizing plans for follow-up care and referrals to other services along the continuum of care.

The nurse will probably spend more time on the orientation phase of the nurse-patient relations with which patient? A. The highly distrustful teenager who ran away from an abusive home situation B. The young mother who wants to return home to her young children C. The older adult who is admitted for 3 days for adjustments to his medication regime D. The middle-aged adult who voluntarily admitted himself for drug detox treatment

*C:* If the patient acknowledges hearing something that the nurse cannot hear, the nurse can then ask, "Tell me what you hear." Moving the patient to a low-stimuli area will not serve to help control the voices. The voices from the television are not likely to serve as a distraction. Reassuring the patient that staff will keep him safe is not necessarily inappropriate, but the need for safety cannot be determined until it is known what the patient is hearing.

What is the initial intervention when a patient acknowledges to the nurse that he is hearing voices? A. Minimizing stimulation by moving the patient to an area that is quiet and dimly lighted B. Seating the patient in front of the television so the program can serve as a distraction from the voices C. Asking the patient to describe what the voices are saying D. Reassuring the patient that the staff will keep him safe

*D:* Empathy is an objective understanding of the way in which patients see their situation. It can also convey hope for improvement. Sympathy, by contrast, is the nurse having the same feelings as the patient, and objectivity is therefore lost. Sympathy often leads to comforting, reassuring, or pitying patients.

Which statement demonstrates empathy on the part of the nurse responding to a patient who is angry about the death of her child? A. "I lost a child too, so I know how you feel." B. "It is a pity that someone so young was taken from you." C. "You have a right to be angry, losing a child is so unfair." D. "It's normal to be angry, but let's talk about how to handle that anger."

*B:* A self-disclosure should be planned, patient-centered, and goal-directed. The disclosure guides the conversation toward the exploration of patient problems, issues, and needs. Such disclosures help the patient clarify issues and feel less vulnerable and more normal. Therapeutic self-disclosure facilitates comfort, honesty, openness, and risk taking but never burdens patients with the nurse's problems. Directing the conversation to possible triggers is the best example of self-disclosure, since it opens the topic and divulges very general personal information. Sharing a family history of depression, the fact that the nurse was once prescribed antidepressant medication, and that suicide was once considered constitute personal information that is inappropriate to share and burdensome to the patient.

Which statement made by the nurse best demonstrates the technique of self-disclosure when discussing a depressed patient? A. "Depression runs in my family. Does any family member of yours have depression too?" B. "Feeling lonely can make me depressed. What kinds of things make you feel depressed?" C. "Medication helped me when I was depressed. Have you ever been prescribed an antidepressant medication?" D. "I was so depressed once, I actually thought about suicide. Have you ever thought about hurting yourself?"

*C:* The nurse should not give the patient advice to leave but rather help the patient solve her own problems. The nurse encourages short-term, realistic, and achievable goals that have been made by the patient. Asking the patient to consider timelines, praising the patient for positive changes, and helping with the identification of triggers are all appropriate nursing interventions that focus on the promoting of change.

Which statement made by the nurse indicates a need for additional instructions concerning the nursing role in promoting a change in a patient's behavior? A. "How long do you think it will take for you to stop smoking?" B. "You should be very proud of the way you handled your anger today." C. "I think you will be much happier when you leave your abusive partner." D. "What do you think you can do to avoid the triggers that cause you to abuse alcohol?"