Chapter 20. Communication & Therapeutic Relationships

A young adult with a severe episode of asthma bronchoconstriction comes to the emergency department with signs of respiratory distress. When the nurse performs the admission assessment, she notes that the patient is not able to say where she is or the time. Which nursing diagnosis is probably most suitable for this patient? 1) Chronic Confusion 2) Acute Confusion 3) Impaired Verbal Communication 4) Readiness for Enhanced Communication

ANS: 2 This patient is experiencing Acute Confusion caused by lack of oxygen related to his respiratory distress. As a young adult with an acute episode of asthma, this patient would not likely have a history of confusion; therefore, without more data, Chronic Confusion is not an appropriate diagnosis for this patient. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia, but not with confusion. Readiness for Enhanced Communication is appropriate when the patient expresses willingness to enhance communication. PTS:1DIFgrinifficultREF:p. 474 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

A patient experiences expressive aphasia after a stroke. Which expected outcome is appropriate for this patient? 1) Uses alternative methods of communication 2) Communicates effectively using a translator 3) Interprets messages accurately 4) Follows commands when asked

ANS:1 An appropriate outcome for a patient with expressive aphasia is "uses alternative methods of communication." Expressive aphasia means the patient cannot verbalize his intended message, but the patient may be able to understand and to communicate in other ways. "Communicates effectively using a translator" is an appropriate outcome for a patient who is unfamiliar with the dominant language. "Interprets messages accurately" and "follows commands when asked" are appropriate outcomes for the patient with receptive, not expressive, aphasia. PTS:1DIF:ModerateREF:p. 475 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application

Which statement by the nurse manager demonstrates an assertive approach when communicating with the staff nurse about a patient care issue? 1) "You must assess and document pain status for every patient." 2) "Why haven't you been assessing and documenting pain for every patient?" 3) "Will you please assess and document pain status for every patient?" 4) "Explain why you haven't been assessing and documenting pain for every patient."

ANS:1 By stating that pain must be assessed and documented for every patient, the nurse manager is using an assertive approach. An assertive approach uses the statement of facts, not judgments. Asking why the nurse has not been assessing and documenting pain is judgmental and elicits a defensive response by the nurse. Asking the nurse whether she will assess and document pain for every patient invites a negative response and does not use an assertive approach. Asking the nurse to explain why she has not been assessing and documenting pain is also judgmental. PTS:1DIF:ModerateREF:pp. 470-471 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis

A patient comes to the emergency department complaining of severe, substernal chest pain. He is restless and anxious. Which statement by the nurse appropriately offers reassurance? 1) "I'll give you some medication to help relieve the pain." 2) "If you lie still and relax, you'll be fine in a little while." 3) "Please try not to think about the pain as best as you can." 4) "Don't worry; we're going to take good care of you."

ANS:1 By telling the patient that she is going to give him some medication to help relieve his pain, the nurse is offering him realistic reassurance. The other options offer false reassurance and minimize patient concerns. PTS:1DIF:ModerateREF:p. 479 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

.A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred for this patient? 1) Impaired Communication 2) Readiness for Enhanced Communication 3) Impaired Verbal Communication 4) Sensory Alteration

ANS:1 Impaired Communication is the preferred nursing diagnosis when the patient is unfamiliar with the dominant language. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia. Readiness for Enhanced Communication is appropriate when the patient expresses willingness to enhance communication. Sensory Alteration is appropriate when there is a change in the characteristics of the patient's incoming stimuli. PTS:1DIFgrinifficultREF:p. 474 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

The wife of an elderly patient begins crying after she is informed that he has a terminal illness. Which intervention by the nurse is best? 1) Sit quietly with the patient's wife while she composes her thoughts. 2) Inform his wife that a chaplain is available if she would like to speak to him. 3) Remind his wife that her husband has lived a long and happy life. 4) Tell his wife there are always options and suggest she not give up hope.

ANS:1 The nurse can intervene best by sitting quietly with the patient's wife, allowing her to compose her thoughts. Silence communicates acceptance. After processing the bad news, the wife can provide the nurse with further information, such as whether she would like to consult with a chaplain. Telling the wife there are always options offers false reassurance and would probably discourage her from further communication. PTS:1DIFgrinifficultREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

.A health center that is interested in purchasing IV infusion pumps organizes a group of nurses to evaluate pumps provided by a variety of vendors. Which type of group has been organized? 1) Short term 2) Ongoing 3) Self-help 4) Work-related social support

ANS:1 The organized group is a short-term group. Short-term groups focus on the task at hand, which in this case is evaluating infusion pumps. Ongoing groups address issues that are recurrent. Self-help groups are voluntary organizations composed of people with a common need. Work-related social support groups assist members of a profession to cope with the stress associated with their work. PTS:1DIF:ModerateREF:p. 473 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension

Which statement about communication is true? (Choose all that apply.) Communication is 1) Used to meet physical and psychosocial needs 2) Most basically described as talking and listening 3) The process of sending and receiving information 4) The basis for forming relationships

ANS:1, 3, 4 People use communication to fulfill basic human needs at all levels: physical, psychosocial, emotional, and spiritual needs. Communication is a process of sending and receiving messages. It forms the basis for sharing meaning and building effective relationships among individuals, families, and the healthcare team. Communication involves more than just talking and listening. And simply because messages are verbalized does not mean listening and understanding are achieved. PTS:1DIF:EasyREF:pp. 463-464 KEY:Nursing process: N/A |Client need: PSI | Cognitive level: Recall

Which intervention by the nurse first helps to establish a trusting nurse-patient relationship? 1) Avoiding topics that may provoke emotional responses from the patient 2) Listening to the patient while performing care activities 3) Performing care interventions quietly and respectfully 4) Greeting the patient by name whenever entering the patient's room

ANS:4 The nurse can establish a trusting nurse-patient relationship by always greeting the patient by name, listening actively, responding honestly to the patient's concerns, providing explanations for care interventions, and providing care competently and consistently. PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

The nurse must insert a nasogastric (NG) tube into a patient with a bowel obstruction. Before inserting the tube, the nurse must explain the procedure to the patient. Which explanation by the nurse is best, assuming that all provide correct information? 1) "I'm going to insert an NG tube and connect it to low Gomco to keep your stomach empty." 2) "I'm going to insert a tube through your nose into your stomach to prevent you from vomiting." 3) "I'm going to insert an NG tube through your nares to suction your secretions and prevent emesis." 4) "Lie still, please; I need to elevate the head of the bed and insert this tube."

ANS:2 Because patients are typically confused by medical terminology, the nurse should use language that the patient can understand. "NG tube," "Gomco," "suction secretions," "nares," and "emesis" are all medical jargon that the patient might not understand. Moreover, the nurse should explain all procedures before performing them to help minimize the patient's anxiety. "Lie still, please . . . " offers no explanation of why the NG tube is being inserted, and it conveys that the nurse is impatient. PTS:1DIF:ModerateREF:p. 465 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

A patient newly diagnosed with breast cancer tells the nurse, "I'm worried I won't live to see my children grow up." Which response by the nurse best conveys concern and active listening? 1) "There have been many advances in breast cancer treatment; hope for the best." 2) "Breast cancer is a serious disease; I can understand why you're worried." 3) "You're strong and have youth on your side to fight the breast cancer." 4) "I'd be worried, too; I've seen a lot of patients die from breast cancer."

ANS:2 Restating the patient's concern by saying, "Breast cancer is a serious disease; I can understand why you're worried" conveys concern and active listening. Stating that there have been many advances in breast cancer treatment minimizes the patient's concern. Stating that the patient is young and should have no trouble surviving breast cancer minimizes the patient's concern and offers false reassurance. Stating that the nurse has seen a lot of patients die from breast cancer could frighten the patient and cause emotional harm. PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

When using the SBAR model to communicate with a physician, what information does the nurse offer first? 1) Statement of the problem and its probable cause 2) Nurse's name, patient's name, and reason for the communication 3) History of information related to and leading up to the situation 4) A solution to the problem or what is needed from the physician

ANS:2 SBAR is an acronym for Situation, Background, Assessment, and Recommendation. The nurse's name, and so forth, are part of the Situation. Statement of the problem and cause are the Assessment. History of the factors leading up to the current situation make up the Background. What the nurse thinks will correct the problem is categorized under Recommendation. PTS: 1 DIF: Difficult REF: p. 471 KEY:Nursing process: Implementation | Client need: PSI | Cognitive level: Application

The nurse is preparing a patient for a computed tomography (CT) scan of the abdomen. Which statement by the nurse is best (all contain correct information)? 1) "You will need to remain NPO for the 4 hours prior to your CT scan." 2) "You cannot have anything to eat or drink for 4 hours before your test." 3) "You will need to be NPO and drink this contrast media before your test." 4) "You may need to void before you go down to the department for your CT scan

ANS:2 Telling the patient that he cannot have anything to eat or drink for a specific time before his test is the best statement. It uses terms that the patient can understand. The other options use medical jargon that many patients may not understand. PTS:1DIF:ModerateREF:p. 465 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

A patient being admitted in hypertensive crisis informs the nurse that he stopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best? 1) "You're lucky you didn't have a stroke; you really need to take your medication." 2) "Tell me more about your experience with your high blood pressure medication." 3) "Why did you stop taking your high blood pressure medication?" 4) "It's very important to take your blood pressure medication."

ANS:2 The nurse can gather more information about the patient's reasons for stopping his blood pressure medication by asking him to tell her more about his experience with the medication. Telling the patient he is lucky he did not have a stroke suggests criticism. Asking the patient why he stopped taking his high blood pressure medication may cause the patient to become defensive and halt further communication. Telling the patient that it is very important to take his blood pressure medication is patronizing and also suggests criticism; at the very least, it fails to elicit more communication from the patient. PTS:1DIF:ModerateREF:pp. 477-478 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? 1) Small group 2) Interpersonal 3) Group 4) Intrapersonal

ANS:2 The nurse uses interpersonal communication when interviewing the patient about his health history during the admission assessment. Small-group communication occurs when a person engages in an exchange of ideas with two or more people at the same time. Group communication is interaction that occurs among several people. Intrapersonal communication is conscious internal dialogue. PTS:1DIF:ModerateREF:p. 464 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

The nurse manager of the medical intensive care unit formed a group to help her staff cope with stress more effectively. Which of the comments by group members will lead the manager to evaluate the group as successful? 1) "This was a good idea to form a group; I've been wanting to get to know some of the people working the other shifts." 2) "It really helps me to share feelings about how hard it is to see pain and suffering every day." 3) "I now have a group to help me when I need to work through situations in my own life causing me stress." 4) "It feels good to have a chance to get away from the unit and talk on a regular basis."

ANS:2 Work-related social support groups assist members of a profession to cope with the stress associated with their work. The focus of the group is to share feelings about the stress of the work environment. Although this may also be an opportunity to meet other staff members, get away from the unit, or share personal and family problems, these are not the primary focus of the group. PTS:1DIF:ModerateREF:p. 473 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

Which statement by the nurse demonstrates that active listening has occurred? Choose all that apply. 1) "I listened to my patient while I was changing his IV site." 2) "I made eye contact and listened to my patient to find out his concerns." 3) "I took notes when I listened to my patient describe his symptoms." 4) "I sat with my patient and his wife to talk about their fears before the surgery."

ANS:2, 4 The nurse demonstrates active listening by facing the patient, making eye contact, and listening while he expresses concerns. Arranging time to sit with the patient and his wife to discuss fears about an upcoming surgery also indicates active listening. Listening to the patient while performing activities, such as hanging an IV infusion or bathing him, distracts the nurse from active listening. Although taking detailed notes can help the nurse to accurately recall the patient's words, this activity while listening to the patient speak can also be a distraction and could reduce eye contact and nonverbal cues of care and concern. PTS:1DIF:ModerateREF:p. 476 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

A patient tells the nurse, "I'm having a lot of pain in my hip." Which response by the nurse is open-ended and would stimulate the patient to provide the most complete data? Choose all that are correct. 1) "Is your pain severe?" 2) "Tell me about your pain." 3) "When did you first notice this pain?" 4) "How would you describe your pain?"

ANS:2, 4 The responses "Tell me about your pain" and "How would you describe your pain?" are open-ended responses that stimulate conversation. Although it is important information, the question "Is your pain severe?" prompts a "yes" or "no" response. "When did you first notice this pain?"—also important information—is likely to stimulate a brief, factual answer. Such questions allow the nurse to control the patient's response. Limiting the response might lead to an incomplete assessment. PTS:1DIF:ModerateREF:p. 476; includes cross-reference to Chapter 3 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

Which of the following is a nonverbal behavior that enhances communication? 1) Keeping a neutral expression on the face 2) Maintaining a distance of 6 to 12 inches 3) Sitting down to speak with the patient 4) Asking mostly open-ended questions

ANS:3 Sitting down to speak with the patient enhances communication because it communicates a willingness to listen. A concerned expression, not a neutral one, demonstrates interest and attention. Maintaining a distance of 18 inches to 4 feet, not 6 to 12 inches, while speaking allows most patients to feel comfortable, thereby enhancing communication. When the interpersonal distance is too close, patients might feel uncomfortable. Asking open-ended questions is a verbal communication strategy, not a nonverbal behavior. PTS:1DIF:ModerateREF:p. 467 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Comprehension

A patient had surgery 6 hours ago. When the nurse enters the room to turn him, she notes that he is restless and grimacing. Considering the patient's nonverbal communication, what action should the nurse take first? 1) Administer pain medication to the patient. 2) Turn and reposition the patient. 3) Assess to determine the cause of the grimacing. 4) Leave the patient's room so he can rest quietly.

ANS:3 The nurse should assess the patient to determine whether he is having pain. The nurse should not assume by the patient's nonverbal communication that the patient is in pain and administer pain medication; the nurse should validate the message being sent. The nurse should not turn and reposition the patient without assessing him. Leaving the patient without addressing his nonverbal cues is neglectful. PTS:1DIF:ModerateREF:pp. 466-467 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

A patient who speaks only French was admitted to the hospital after a motor vehicle accident. Assuming that the nurse does not speak French, what is the best way to communicate with this patient? 1) Use sign language for communicating. 2) Ask a family member to serve as a translator. 3) Request the services of a hospital translator. 4) Speak in English, but speak very slowly.

ANS:3 The nurse should request the services of a hospital translator to communicate with the patient who does not speak English. A family member should not be used as a translator unless there are no other options because it is often culturally unacceptable to have a family member ask personal questions. Also, considering the patient's right to confidentiality, it is not appropriate to share private information about the patient with family members unless permission is obtained. Using sign language can be an effective strategy for hearing-impaired persons. Speaking slowly in English is not useful if the patient does not understand the language. PTS:1DIF:ModerateREF:p. 475 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows she should use touch cautiously, especially when communicating with which patient? 1) Middle-aged woman just diagnosed with terminal lung cancer 2) Middle-aged man experiencing the acute phase of myocardial infarction 3) Older adult with a history of dementia admitted for dehydration 4) Young adult in the rehabilitative phase after arthroscopic surgery

ANS:3 The nurse should use touch especially cautiously when communicating with a person who suffers from impaired mental health, such as dementia, because the patient may have difficulty interpreting the meaning of touch. In general, touch can be used with most patients, such as patients with cancer, an acute MI, or general orthopedic surgery, and with all age groups. However, the nurse should always be conscious of the situation, environment, and receptivity of the patient. PTS:1DIF:ModerateREF:p. 467 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis

.Which statement by the nurse indicates that the nurse-patient relationship is entering the termination phase? 1) "I'll be admitting you to our nursing unit as soon as I obtain your health history." 2) "You seem upset today. Would you like to talk about whatever is bothering you?" 3) "I'm leaving for the day. Is there anything I can do for you before I leave?" 4) "Hello. My name is Leslie, and I'm going to be your nurse today."

ANS:3 When the nurse states, "I'm leaving for the day. Is there anything I can do for you before I leave?" the nurse-patient relationship is entering the termination phase. The termination phase is the conclusion of the relationship, which can occur at the end of a nurse's shift. The pre-interaction phase occurs before the nurse meets the patient. The statement "I'll be admitting you to our floor as soon as I obtain your history" demonstrates the pre-interaction phase of the nurse-patient relationship. The nurse introduces herself to the patient during the orientation phase. During the working phase of the nurse-patient relationship, feelings are explored. This phase is demonstrated by the statement, "You seem upset today. Would you like to talk about whatever is bothering you?" PTS:1DIF:ModerateREF:p. 472 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

During admission to the unit, a patient states, "I'm not worried about the results of my tests. I'm sure I'll be all right." As he observes the patient, the nurse notes that the patient is shaky and tearful and does not make eye contact. Unfortunately, the nurse is called away to an emergency before he has time to complete this discussion. Which of the following actions is most appropriate for the nurse to establish when returning to the patient? Patient will 1) Explain the reason for his incongruent statements 2) Engage in diversional activities to cope with stress 3) Express his concerns to his primary care provider 4) Discuss his concerns and fears with the nurse

ANS:4 The nurse has observed a mismatch between verbal and nonverbal communication. Unfortunately, an emergency has required the nurse to leave the patient. To resolve this mismatch, the nurse will set a goal to have the patient discuss his concerns and fears at their next interaction. It is inappropriate to ask the patient to explain why his verbal message did not match the nonverbal message because this will inhibit further conversation. It may be appropriate to have the patient discuss his concerns with his primary care provider; however, we do not have enough information to suggest this course of action. For example, if the patient is upset about some other matter, this action would not be appropriate. Similarly, it is not appropriate to suggest diversional activities until the reason for the mismatch between his words and behavior is identified. PTS: 1 DIF: Moderate REF: p. 476 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application

After a physician discusses cancer treatment options with a patient, the patient asks the nurse which treatment he should choose. Which response by the nurse is best? 1) "If I were you, I'd go with chemotherapy." 2) "What do you think about radiation therapy?" 3) "Why don't you see what your wife thinks." 4) "I'll give you some information about each option."

ANS:4 The nurse should avoid giving a personal opinion; instead offer the patient more information so he can make an informed decision. Responses such as, "If I were you, I'd go with chemotherapy" and "Why don't you see what your wife thinks" do not respect the patient's right to make his own decisions. "What do you think about radiation therapy," is leading the patient without exploring the other options. PTS:1DIF:EasyREF:pp. 478-479 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

.A nurse has sound, scientific evidence to support changing a procedure that would reduce catheter-related infections on the unit. The unit manager states, nevertheless, that she is unwilling to make the change because it would be too costly. Which response by the nurse represents assertive communication? 1) "This is a widely used practice. If you read more research, you'd probably wonder why we aren't already doing it." 2) "There is extensive evidence to support the new method, but I don't want to create an issue." 3) "Is the budget more important to the hospital than reducing infections and patient suffering?" 4) "I'd like to help gather information regarding the cost of new materials versus the savings in treating infections."

ANS:4 The statement pertaining to helping to gather information about of the cost of materials is an assertive response. It does not threaten the authority of the nurse manager and introduce another element preventing change that is unrelated to the procedure itself. It states the nurse's position and wishes clearly with an "I" statement, and it does not invite negative responses. The statement beginning with "This is a widely used practice" is aggressive and implies criticism and a judgment that the nurse manager does not read as much as she should. The statement ending with "I wouldn't want to create chaos" is passive and submissive. The statement beginning with "Is the budget more important . . ." is aggressive and judgmental. PTS:1DIF:ModerateREF:pp. 470-471 KEY: Nursing process: Implementation | Client need: PSI | Cognitive level: Application

A physician tells a patient that she has cancer and that she should have surgery as soon as possible. The patient is not certain she wants to pursue this treatment approach but responds by saying, "I'll do whatever you think I should do." Which communication style is this patient using? 1) Assertive 2) Aggressive 3) Passive aggressive 2 4) Passive

ANS:4 This patient is using a passive communication style to avoid conflict with others while allowing the other person to be in control. An aggressive approach forces others to relinquish control. The goal of the aggressive approach is to win and be in control. With assertive communication, the person expresses beliefs or feelings without infringing on another's rights. The passive aggressive approach uses a submissive style of communication but is aggressive in the sense that it manipulates the receiver to help the sender win. This allows the sender to be in control without conflict. PTS:1DIF:ModerateREF:p. 470 KEY: Nursing process: Analysis | Client need: PSI | Cognitive level: Application