Chapter 9: Communication and the Therapeutic Relationship
The client says to the nurse, "I wonder what's playing at the movies tonight." Which response by the nurse would be most therapeutic? "There's nothing worth watching." "Why don't you look in the newspaper." "We may have some DVDs available." "Are you telling me you would like to go to the movies?"
"Are you telling me you would like to go to the movies?" Explanation: This nurse is restating or verbalizing the implied, which involves voicing what the client has hinted at or suggested. The nurse should apply this technique to confirm the implications of the client's statement before suggesting solutions to the presumed meaning.
Which statement by the nurse demonstrates acceptance to the client who has made a sexually inappropriate comment? "Why do you think making that comment is appropriate?" "That type of talk is inappropriate and won't be tolerated." "Our relationship is one of a professional nature." "How would you feel if someone said that to you?"
"Our relationship is one of a professional nature." Explanation: The nurse who does not become upset or responds negatively to a client's outbursts, anger, or acting out conveys acceptance to the client. Avoiding judgments of the person, no matter what the behavior, is acceptance. This does not mean acceptance of inappropriate behavior but acceptance of the person as worthy. When responding to such a situation, the reaction should be respectful and controlled by the nurse.
A nurse is working with a client whose background is very different from the nurse. Which would be a good question to ask himself or herself to assure the nurse can be effective working with this client? "Do I understand this client's expectations of me?" "What experiences do I have with people with different backgrounds?" "Is this person going to be able to relate to me?" "Can this person understand me?"
"What experiences do I have with people with different backgrounds?" Explanation: To best assess self-awareness, the nurse should ask, "What experiences have I had with people from ethnic groups, socioeconomic religions, age groups, or communities different from my own?" The nurse should not focus on the client when examining self-awareness; rather, the nurse should reflect on how the nurse's experiences have shaped attitudes and beliefs.
The nurse should use clear, concrete messages when working with clients displaying which conditions? Select all that apply. Illness anxiety disorder Anxiety Anorexia Schizophrenia Dementia
Anxiety Dementia Schizophrenia Explanation: Clients who lose cognitive processing, such as those who are anxious, cognitively impaired, or suffering from perceptual disorders like schizophrenia, often function at a concrete level of comprehension and have difficulty answering abstract questions. The nurse must be sure that statements and questions are clear and concrete. Clarity is needed in all communications, but a particular focus on concrete messages is not necessary with clients who have anorexia or illness anxiety disorder because these do not involve a loss of cognitive processing.
A psychiatric-mental health clinical nurse specialist encourages a psychiatric-mental health nurse to conduct a process recording. The nurse understands that the process recording is designed to achieve which result? Determine what effect communication style has on the client. Provide the client with a way to identify abnormalities in their communication style. Identify abnormalities in the client's communication techniques. Allow the client explore alternate communication techniques that can be used.
Determine what effect communication style has on the client. Explanation: The process recording provides a written analysis of each interactional exchange with clients to assist nurses to recognize the effects of their communication style.
Which action by the nurse or client represents the working phase of the therapeutic relationship? Communicating interest in the client Testing the relationship Reviewing work that has been done Identifying past ineffective behaviors
Identifying past ineffective behaviors Explanation: In the working phase of the relationship, the client is involved actively in achieving goals set during the initial phase. The tasks of the working phase of the therapeutic relationship include identifying past behaviors that have been ineffective for coping with the focal problem; developing a plan of action, practicing implementing it, and evaluating its effectiveness; integrating a new self-concept, worldview, or attitude toward one's illness as a result of changes in behavior and circumstances; and increasing hopefulness for the future and ability to function independently. Communicating interest in the client is the role of the nurse, and this takes place in the orientation phase of the relationship. The client tests the relationship during the orientation phase. Reviewing the work that has been done takes place during the resolution phase of the relationship.
Which statement is true of empathy? Select all that apply. It is the ability to place oneself into the experience of another for a moment in time. It is developed by gathering information from the client. It involves interjecting the nurse's personal experiences and interpretations of the situation. The client must learn to develop empathy for the nurse. It results in negative therapeutic outcomes.
It is the ability to place oneself into the experience of another for a moment in time. It is developed by gathering information from the client. Explanation: Empathy is the ability to place oneself into the experience of another for a moment in time. Nurses develop empathy by gathering as much information about an issue as possible directly from the client to avoid interjecting their personal experiences and interpretations of the situation. It results in positive therapeutic outcomes. The nurse must develop empathy with the client but there is no expectation on clients to reciprocate empathy for the nurse.
A psychiatric-mental health nurse is using the Transitional Relationship Model as a strategy for developing therapeutic relationships. When applying this model, the nurse understands that it is based on the works of which theorist?
Peplau Explanation: The Transitional Relationship Model (TRM) is theoretically grounded in the work of Hildegard Peplau; healing occurs in relationships. Freud, Rogers, and Orem are not associated with this model.
A client accused the nurse of "really not caring" and is now consistently 10 minutes late for sessions. To best preserve the nurse-client relationship, how should the nurse respond? The nurse tells the client, "I do care and I am surprised you think I do not." The nurse continues to arrive for the session at the agreed-upon time. The nurse asks the client, "What can I do to prove I really do care about you?" The nurse reschedules the sessions to start 10 minutes later than originally agreed upon.
The nurse continues to arrive for the session at the agreed-upon time. Explanation: The first part of the orientation phase, also called the "honeymoon phase," is usually pleasant but the client usually begins to test the relationship to be convinced that the nurse will really accept him or her. Typical "testing behaviors" include forgetting a scheduled session or being late for appointments. Clients may also express anger at something a nurse says or may accuse the nurse of breaking confidentiality. If the nurse simply accepts the behavior and continues to be available and consistent with the client, these behaviors usually subside. Testing needs to be understood as a normal way that human beings develop trust. Neither rescheduling the time of the sessions nor demonstrating such personal responses to the client's claim will help preserve the nurse-client relationship.
A client expresses worry about the client's child's aggressive behavior. The nurse says "You are in a very challenging situation. Your child's aggressive behavior is very stressful for you, is this correct?" What does this nurse's statement indicate? The nurse is sympathizing with the client. The nurse is comforting the client. The nurse is showing genuine interest in the client. The nurse is empathizing with the client.
The nurse is empathizing with the client. Explanation: Empathizing is the ability of the nurse to perceive the feelings and emotions that the client is trying to communicate. The nurse's statement indicates that the nurse is trying to perceive the problem by relating the problem with the self. This would help the client to feel comfortable and safe while sharing feelings with the nurse. Sympathy is the ability of the nurse to project his or her concern toward the client. The nurse does not perceive the problem of the client. If the nurse is able to empathize with the client then it indicates that the nurse is showing genuine interest and is listening actively to the client.
A psychiatric-mental health is involved in a deteriorating nurse-client relationship. Which phase would the nurse and client experience first? Ignoring Struggling with and making sense of Avoiding Withholding
Withholding Explanation: A deteriorating relationship is also nontherapeutic and has been shown to have predictable phases, starting in the withholding phase during which the nurse is perceived as "withholding" nursing support. The nurse fails to recognize that the client is a person with an illness or health needs. The client feels uncomfortable, anxious, frustrated, and guilty about being ill and does not develop a sense of trust. A barrier exists between the client and nurse. The middle phase of a deteriorating relationship consists of two subphases: avoiding and ignoring. This is followed by the end phase of struggling with and making sense of.
The nurse prepares to assess a client for the first time. Which action should the nurse take to develop a rapport with this client? Select all that apply. listen intently to the client explain problems and issues compliment the client regarding clothing selection explain what confidential information will be shared with others establish professional boundaries suggest that another nurse meet with the client because of arriving late
establish professional boundaries listen intently to the client explain problems and issues explain what confidential information will be shared with others Explanation: When meeting a client for the first time, professional boundaries need to be established in order for the relationship to remain therapeutic. Listening intently demonstrates care and concern. Explaining the need to share information with others helps to establish trust. Reacting to disapproval suggests non-acceptance and will negate efforts to establish rapport. Arriving late is a behavior used to test parameters. The nurse should not react as this behavior works to develop trust.
Which nursing intervention demonstrates congruence in a therapeutic nurse-client relationship? sharing examples of stress management techniques implementing restatement as a therapeutic communication method discussing the client's request for additional privileges with the treatment team getting an appointment with the client at the time previously agreed upon
getting an appointment with the client at the time previously agreed upon Explanation: Congruence occurs when words and actions match. The nurse demonstrates this by fulfilling the promise made to the client. While the remaining options are appropriate behaviors that positively affect the nurse-client relationship, they do not demonstrate congruence.
A student nurse is preparing for a clinical placement in a psychiatric-mental health context. In order to best prepare to engage in therapeutic communication with clients, the student should: diligently study the pathophysiology, epidemiology, and nursing diagnoses related to mental illness. reflect critically on the student's own life experiences, perspectives, and characteristics. decide what aspects of the student's life and experience the student is willing to disclose to clients. seek out a mentor who has extensive experience in the psychiatric-mental health area.
reflect critically on the student's own life experiences, perspectives, and characteristics. Explanation: Self-awareness is a critical prerequisite for therapeutic communication and can only be achieved through critical self-reflection. Knowledge of disease processes is important but does not necessarily facilitate therapeutic communication. Self-disclosure is a comparatively minor variable and is provided cautiously on a case-by-case basis. A mentor is also useful but does not replace self-reflection as a precondition for therapeutic communication.
A nurse reviews a client's psychiatric and medical history before approaching the client for an assessment. The history reveals the client has a history of sexual abuse from a caregiver in early adolescence. Which zone would be the best place for the nurse to sit the nurse to begin the assessment? intimate social public personal
social Explanation: The client has a known history of sexual abuse. Clients with a history of abuse have had others touch them in harmful, hurtful ways, usually without their consent. This client may be hesitant or even unable to tell the nurse when closeness or touch are uncomfortable. The most appropriate position for the nurse would be to sit in the social zone while conducting the assessment. The nurse would be sitting 4-12 feet away from the client. The intimate zone would only leave 0-18 inches between the client and the nurse. This would not be appropriate, particularly given the client's history of sexual abuse. The personal zone leaves only 18-36 inches between the nurse and client. It would be more appropriately used between two people who know each other well. The public zone leaves 12-25 feet between the nurse and client. This distance is too far to carry out an assessment and may, in fact, compromise confidentiality.
A nurse who is new to the psychiatric-mental health setting is preparing to create a process recording of her first interaction with a newly-admitted client. The nurse should: submit a transcript of the conversation to a more experienced nurse for analysis. analyze and record the themes in the conversation as they are occurring. ask the client if he or she is able to write down feelings and thoughts rather than verbally stating them. write down a verbatim transcript of the dialogue as soon as it is complete.
write down a verbatim transcript of the dialogue as soon as it is complete. Explanation: A process recording begins with a verbatim transcript of the dialogue between nurse and client. Analysis does not occur in real time during the conversation and does not have to be delegating to a more experienced nurse. Clients are not normally asked to write down their thoughts for the sole purpose of facilitating process recording.
The graduate nurse is working in mental health and is learning about the use of touch with clients that have psychiatric disorders. The seasoned mental health care nurse differentiates information about this part of therapeutic communication by stating which information? "Touch is best mixed with compassion when dealing with the anxious client." "Touch is used in situations in which the client is unstable." "Touch is used to express interest and warmth." "Touch carries different meanings for different individuals."
"Touch carries different meanings for different individuals." Explanation: Touch can elicit both positive and negative reactions. Depending on the people involved and the circumstances of an interaction, touch carries different meanings for different individuals. Although the statements, "Touch is best mixed with compassion when dealing with the anxious client," "Touch is used in situations in which the client is unstable," and "Touch is used to express interest and warmth", can be true and demonstrate how touch can be used, these statements do not demonstrate how touch is interpreted.
After teaching a class about the phases of the therapeutic relationship, the instructor determines a need for additional education when the class identifies which as a goal of the working phase? Develop a plan of action with appropriate strategies Develop a sense of trust within the relationship. Promote a supportive healing process Identify previous ineffective behaviors for coping with the problem
Develop a sense of trust within the relationship. Explanation: The goal of the orientation phase is to develop trust and security within the nurse-patient relationship. Problem identification and development of strategies to address the problem (which helps to promote a supportive healing process) occurs during the working phase.
A nurse is reading a journal article about the therapeutic relationship. The nurse demonstrates understanding of the information when the nurse identifies which aspect as the primary difference between social and therapeutic relationships? The focus of the relationship. The kind of information given. The amount of emotion invested. The degree of satisfaction obtained.
The focus of the relationship. Explanation: The nurse has the responsibility for the therapeutic relationship. The therapeutic relationship focuses on the needs, experiences, feelings, and ideas of the client only. A social relationship is fundamentally different because it is primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task. Both types of relationships can be intensely emotional, though in different ways. The information given in each relationship will differ but the most significant difference is in the purpose. Similarly, both relationships can be satisfying, but in very different ways.
A college student decides to go to a party the night before a major exam instead of studying. After receiving a low score on the exam, the student tells a fellow student, "I have to work too much and don't have time to study. It wouldn't matter anyway because the teacher is so unreasonable." The defense mechanisms the student is using are: rationalization and projection. regression and compensation. denial and displacement. reaction formation and resistance.
rationalization and projection. Explanation: When stating that it wouldn't matter if the student had studied, the student is using rationalization, which is excusing individual behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect. When stating that the teacher is unreasonable, the student is using projection, or the unconscious blaming of unacceptable inclinations or thoughts as an external object. Denial is the failure to acknowledge an unbearable condition. Displacement is the ventilation of intense feelings toward persons less threatening than the one who aroused those feelings. Reaction formation is acting the opposite of what one thinks or feels. Resistance is overt or covert antagonism toward remembering or processing anxiety-producing information. Regression is moving back to a previous developmental stage to feel safe or have needs met. Compensation is overachievement in one area to offset real or perceived deficiencies in another area.
