Chapter 8

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

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

A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:

"Were you tired and depressed before starting the new medication?" Sequencing is used to place events in a chronologic order or to investigate a possible cause-and-effect relationship between events. Nursing assessment is facilitated when events leading to a problem are placed in sequence. The symptoms the client is complaining of are common adverse effects of this drug. Sequencing can determine the cause and effect in this scenario. Clients taking metoprolol should check their blood pressure and pulse before taking their medication. Asking about the current diet or exercise regimen does not uncover the cause and effect.

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

"What did your health care provider tell you about your need to be admitted?" When obtaining a nursing history, use the open-ended question technique to allow the client a wide range of possible responses. The greatest advantage of this technique is that it prevents the client from giving a simple "yes" or "no" answer, which limits the client's response. The questions related to medication use, allergies, and an advanced directive are examples of closed communication, in which only one or a few words are required for an answer.

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:

an audiologist. A nurse who suspects a speech, language, or hearing problem should refer the client to a speech-language pathologist or audiologist. A speech-language pathologist is a professional educated in the study of human communication, its development, and its disorders. An audiologist is a professional educated in the study of normal and impaired hearing. An ophthalmologist is a medical doctor who specializes in the treatment of eye disorders. An optometrist has a practice doctorate and focuses on vision. A clinical psychologist is a behavioral health expert.

To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?

Therapeutic communication Therapeutic communication facilitates interactions focused on the client and the client's concerns. Therapeutic communication is purposive, but this is not a discrete category of communication. Intrapersonal communication is communication with oneself, or self-talk. Metacommunication is communication about communication.

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

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

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position." The nurse should provide correct knowledge as well as reassurance. Thoracentesis is a painful procedure and it is important for the client to sit still to avoid injuring the pleura. The nurse should reassure the client that the nurse will be present during the procedure and help the client throughout. Likewise, the nurse should avoid giving false reassurance by saying that the procedure will be painless. Additionally, the nurse should abstain from stating reasons that could scare the client.

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages. Conversation skills used in therapeutic communication include controlling the tone of one's voice so that exactly what is intended is conveyed and not any hidden message. Periods of silence have an important role in conversations because they allow for reflection. The nurse should avoid using cliches, and the conversation should be flexible.

During an annual performance review with an employee, the nurse manager does not maintain eye contact and seems concerned about the time and the next appointment. What type of communication is the manager exhibiting?

Nonverbal Use of eye contact as a nonverbal form of communication demonstrates attention, presence, and interest. In addition, listening can be hampered by the listener's lack of interest in the topic, premature interpretation of the message, or preoccupation with practice. The nonverbal cues that accompany the message are essential aspects of effective communication. The nurse manager is not exhibiting consistent or clarifying communication.

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

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

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

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

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation?

"My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital." ISBARR was recently revised by the QSEN institute to include initial identification of the nurse and the client. The nurse should identify oneself and one's role during the initial conversation with the physician, as in the answer in which the nurse states the full name and degree. This allows the physician to understand the role of the nurse should the physician need to provide orders or instructions regarding the client. The other responses fail to identify the nurse in the beginning of the conversation or fail to adequately identify the client.

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

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

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

Empathy The nurse should empathize with the family for their loss. Empathy helps the nurse to provide effective care and support without being emotionally distraught by the family's condition. If the nurse becomes indifferent to the family's condition, the nurse may not be able to assess their needs. The nurse should not pity, or provide sympathy to, the family for their loss, as it would involve the nurse emotionally.

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?

"I think there is a better way to handle this." Assertive behavior is the ability to stand up for oneself and others using open, honest, and direct communication. The focus is on the issue and not the person. Assertive behaviors, which are one hallmark of professional nursing relationships, are very different from aggressive (i.e., harsh, injurious, or destructive) behaviors. They also differ greatly from avoidance or acquiescent behaviors. The key to assertiveness is expressing feelings and beliefs in a non-defensive manner. "I" statements—"I feel . . ." and "I think . . ."—play an important role in assertive statements. They communicate personal feelings and preferences without expressing a judgment or blaming another person.

The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment?

"We reviewed your plans for your new diet and medications. Do you have any other questions?" Summarization highlights the important points of a conversation or interaction. Reminding the client that the diet plan and new medications were discussed best summarizes the appointment. The other answers do not review the topics discussed.

The nurse is caring for a client who is a victim of sexual assault. Which action would the nurse take to develop a trusting rapport with the client?

Approach the client with empathy and understanding and allow the client to share feelings without being judged. Rapport is a feeling of mutual trust between nurse and client. Kindness is the quality of being friendly, generous, and considerate. Active listening and the use of silence are communication techniques, but they do not necessarily develop mutual trust between the nurse and client.

A nurse is planning care for an adult client with severe hearing impairment who uses sign language and lip reading for communication and who has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care for this client?

Arrange for a sign language interpreter when discussing treatment. During the planning step of the nursing process the nurse develops and prioritizes an individualized plan of care in partnership with the client, family, and others as appropriate. The client with mental or physical limitations should be included in the plan as much as possible. A sign language interpreter allows the client to participate fully in the plan of care. Consulting with the client's children is not as beneficial because it places them in the difficult position of translating while experiencing the emotional strain of the parent's illness. A TTD line can assist in communication but is not as helpful as a medical interpreter. Consulting the oncology nurse specialist is not as helpful in communicating with this client as an interpreter.

A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?

Be silent and allow the client to continue speaking when ready. When clients are angry or crying, the best nursing response is to remain nonjudgmental, allow them to express their emotions, and return later with a follow-up regarding their legitimate complaints. Therefore, staying silent and allowing the client to continue speaking when ready is the most appropriate response in this scenario. Giving false reassurance, agreeing, giving advice, or avoiding the subject are traps that block or hinder verbal communication.

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

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

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship?

Orientation phase In the psychiatric setting, the orientation phase of the relationship represents the first phase of therapeutic work and involves signing of formal contracts. Formal contracts in this setting are used as a therapeutic tool to help a client develop more insight and control over behavior. The working phase consists of the nurse and client working together to achieve the client goals established in the orientation phase. The termination phase consists of evaluating the client's progress toward meeting the goals and concluding the relationship. There is no intimate phase in the nurse-client relationship.

A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation?

The client stares at the floor and states, "I feel fine." It often helps nurses to understand subtle and hidden meanings in what the client is saying verbally. For example, in the scenario in which the client stares at the floor while claiming to feel fine, the nurse should investigate further because of the incongruence between the client's verbal and nonverbal communication. In the other three scenarios, the nurse-client communication is effective and no further investigation is warranted.

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

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

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

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

A nurse is on lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. One of the physicians, who is in charge of the nurse's clients, points at the nurse and states, "That guy needs to get fired." The best response by the nurse would be to:

ask to speak to the physician in private and address the disrespectful remark. When disruptive physician behavior occurs, it is best to respond assertively and confront the physician directly. If this is not possible, ask to speak to the physician in private and address any disrespectful remarks or behaviors. Nurses should factually document the occurrence of any bullying behaviors and speak to a nurse-manager if the behavior continues.

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

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

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:

have group members confront the dominant member to promote the needed team work. Effective groups have members who are mutually respectful. If a group member dominates or thwarts the group process, then the leader or other group members must confront the member to promote the needed collegial relationship. Planning a secret meeting does not solve the underlying issue. Picking a team leader who is not the dominant member will not address the dominance issue. A written warning would be inappropriate; a verbal communication is what is required among the team.

A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should:

remain honest, open, and frank. One key factor to effective communication is to be open, accepting, frank, respectful, and without prejudice. When a client feels that a nurse is being judgmental, the client might withhold significant information. The nurse needs to develop sensitivity to the unique challenges presented by each client. A urine drug screen may eventually be ordered but is not necessary at this time. There is no evidence the client wants drug rehabilitation at this time. There is no evidence that the skin infection is secondary to the drug use.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:

swaddling the child and gently stroking its head. Touch is the most highly developed sense at birth. Tactile experiences of infants and young children appear essential for the normal development of self and awareness of others. It has also been found that many older people long for touch, especially when isolated from loved ones because of hospitalization or long-term care facility care. Vision, taste, and hearing are not as fully developed as touch in the neonate.

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

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

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

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

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?

"Could you tell me more about how you are feeling right now?" Using an open-ended question is the most effective way to elicit further conversation and information. Asking the client to tell the nurse more about how the client is feeling is an open-ended question, unlike asking whether the client has had chest pain prior to the admission or whether the client took any medication during the pain, which allow for a yes or no response and thus are less likely to elicit much information. When the nurse informs the client about chest pain that the nurse experienced, it takes the focus off of the client and does not facilitate obtaining information that could be helpful.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A nurse and client are in the working phase of the helping relationship. What outcome statement developed by the nurse and client correlates with this phase?

The client will express feelings and concerns to the nurse. The working phase of the nurse-client relationship is when the nurse and the client work together to meet the client's physical and psychosocial needs. The client expressing feelings and concerns demonstrates the work that is going on to meet the specific goals that are set in the orientation phase. Determining when and where they will meet is established in the orientation phase of the relationship. Identifying the goals that have been accomplished during the relationship is established in the termination phase of the relationship.

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse?

"I know this is hard for you. Is there any way I can help?" Empathy is identifying with the way another person feels. An empathic nurse is sensitive to the client's feelings and problems but remains objective enough to help the client work to attain positive outcomes. By retaining this quality, you can establish successful helping relationships without appearing cold or stern. The statement "I am so sorry you are going through this" demonstrates sympathy. Sympathy differs from empathy because it shifts the emphasis from the client to the nurse as the nurse shares feelings and personal concerns and projects them onto the client, limiting the ability to focus objectively on the client's needs. Asking about why the client is crying is part of information gathering but is not empathy. Stating that sitting in the dark will not cure cancer is an abrasive statement that may work against the nurse-client relationship.

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse?

A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's. A proper use of social media by a nurse would be the use of a disclaimer to verify that any views expressed on Facebook are the nurse's and do not represent those of the employer. The nurse should not use social media in any way to describe a client by room number, medical diagnosis, or accomplished medical goal of any type. Serious consequences can result from a nurse not using social media correctly.

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

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

Which nursing actions would most likely help improve communication with clients and achieve a more effective helping relationship? Select all that apply.

The nurse controls the tone of voice so that it conveys exactly what is meant. The nurse makes statements that are as simple as possible, gearing conversation to the client's level. The nurse takes advantage of any available opportunities to communicate information to clients in routine caregiving situations. The following nursing actions would most likely help improve communication with clients and achieve a more effective helping relationship: The nurse controls the tone of voice so that it conveys exactly what is meant; the nurse makes statements that are as simple as possible, gearing conversation to the client's level; the nurse takes advantage of any available opportunities to communicate information to clients in routine caregiving situations. The nurse attempts to remain focused on the topic at hand but must allow the client to diverge to another topic, as appropriate. The nurse must be careful not to use words that might have different interpretations than what the nurse meant. The nurse should admit a lack of knowledge to the client to avoid undermining the client's confidence in the helping relationship.

A nurse is caring for an older adult client hospitalized following a hip fracture. Which action(s) by the nurse will promote the development of a therapeutic relationship? Select all that apply.

asking the client when the client would like to have the bed linens changed encouraging the client to talk about the client's life The nurse can promote the development of a therapeutic relationship by asking the client about personal preferences, such as when the bed linens should be changed, as well as encouraging the client to share personal stories. Both of these actions will help provide the nurse with specific information about the client which will enable a better therapeutic relationship. The other choices do not support or promote the development of a therapeutic relationship because they are not focused on the client.