5 Therapeutic Relationships
During a first meeting a client asks that information shared will not be relayed to immediate family members. Which should the nurse say in response?
"Any information is only shared with other professionals involved in your care." Explanation: The nurse should be clear about any information that is to be shared with anyone else. The nurse shares significant assessment data and client progress with a supervisor, team members, and a physician. Most clients expect the nurse to communicate with other mental health professionals and are comfortable with this arrangement. Restrictions regarding what can be shared and with whom are also covered by state or provincial mental health acts and health information acts. Based upon identified laws, the nurse will unlikely share information with family unless the client provides permission.
A nurse is caring for a client with depression. The client says that the client cannot stop thinking about the client's dead spouse. Which self-disclosure example given by the nurse is most appropriate?
"I can understand your situation; my cousin lost a spouse a few months ago." Explanation: The client is depressed because of a spouse's death. The nurse should provide empathy using self-disclosure examples. The self-disclosure examples should not be related to nurse's concerns or painful experiences of the nurse. Stating that the nurse's father passed away recently could be extremely painful for the nurse. Stating that the nurse recently got divorced would also be painful. Stating that medication could be of great help to relieve the client's depression is not indicative of a self-disclosure example.
The nurse is caring for a client with schizophrenia. The client tells the nurse, "My dead mother is calling me, I will finally be with her tonight. Please do not tell anyone." What is the most appropriate nursing response?
"I cannot keep this a secret. I will ensure that the staff helps keep you safe." Explanation: The nurse is not supposed to keep secrets, especially if the information relates to the client inflicting self-harm. The nurse should inform the client that they will be closely monitored. Asking the client who has influenced the client with these ideas indicates a poor understanding of the nature of the client's illness. For client's with schizophrenia, stimuli are internally generated and can cause emotional dysfunction. The nurse should not exhibit anger, as the nurse is supposed to be accepting of the client in any circumstances. Stating that the client will be restrained may be perceived as threatening.
The nurse is meeting with a client experiencing a mood disorder. Which client statement indicates that the nurse-client relationship has been established?
"I feel worthless and have no real use in life." Explanation: People with psychiatric problems often feel alone and isolated. Establishing rapport helps lessen feelings of being alone. When rapport develops, a client feels comfortable with the nurse and finds self-disclosure easier. The nurse also feels comfortable and recognizes that an interpersonal bond or alliance is developing. All of these factors—comfort, sense of sharing, and decreased anxiety—are important in establishing and building the nurse-client relationship. The client stating feelings of worthlessness and having no real use in life demonstrates comfort with the nurse-client relationship. The other statements indicate that the client is not comfortable with the nurse and does not want to share information or take up much of the nurse's time.
The nurse is conducting a group therapy session when a client yawns loudly when the nurse begins the group session. Which statement given by the nurse indicates acceptance of the client's behavior?
"Perhaps a drink of water will help if you are sleepy." Explanation: The nurse can convey acceptance by responding constructively to the client's behavior, such as the client yawning loudly and possibly causing disruption to the session. Suggesting the client take a drink of water indicates that the nurse is trying to provide a solution to the client's problem without feeling offended or angered. Asking the client to stop the behavior, or conveying unwillingness to teach indicates that the nurse is upset about the client's behavior. A sarcastic comment such as "so sorry we are keeping you awake" may be offensive and limit the ability of the client to have a trusting relationship with the nurse.
Which statement is the most empathic response to a client's disclosure that the client's father abandoned the family when the client was a young child?
"That must have been terribly hurtful experience for you." Explanation: Empathy is important, yet challenging, to communicate. A genuine, open-ended, and nonjudgmental response can often convey empathy to a client. Claiming the same experience, turning the statement into a "lesson," or exploring before acknowledging are communication techniques that can impair communication.
The client presents with signs and symptoms of anxiety. What conversation initiated by the nurse demonstrates an ineffective therapeutic use of self?
"What types of dresses do you like wearing?" Explanation: Asking the client about the client's preferences on fashion and dressing indicate that the nurse is trying to build a social relationship with client, not engaging in a therapeutic use of self. This conversation does not influence the client care in any way. Asking the client about pain indicates that the nurse is gathering information about the client's illness. Asking about the client's food preference indicates that the nurse is finding about the nutrition habits of the client. Asking if the client has informed the spouse about the illness indicates that the nurse is allowing the client to take decisions regarding revealing the condition to other people. These questions indicate that the nurse is engaging in therapeutic communication with the client.
A client tells the nurse, "I had to slap my child, I couldn't help that." Which response of the nurse indicates that the nurse is in the state of unknowing?
"What was going on for you when this happened?" Explanation: The state of unknowing is referred to as the nurse's behavior where the nurse is open to seeing and listening to the client's views without imposing any of the nurse's values or viewpoints. Asking the client about what was happening for the client at the time the action took place indicates that the nurse is trying to know more about the client's behavior without making any judgment. The statement about feeling sorry for the child or asking how the client could slap the child indicates that the nurse has a notion that the client has taken a wrong action. In addition, the statement that punishing the child would make it worse indicates that the nurse has a notion that the client has taken a wrong action. Thus, these responses do not indicate that the nurse is in the state of unknowing
A nurse is speaking to a client with a soft smile and eye contact. Which statement said by the nurse would indicate a congruent message?
"Your hard work and determination has helped you recover." Explanation: A congruent message is delivered when the actions and the words spoken match. The nurse has a smiling facial expression which indicates that the nurse is happy. The statement that the client's hard work and determination has warded off the disease indicates that the nurse is happy with the outcomes of the client's hard work. A smiling facial expression while saying this statement would deliver a congruent message. The statement that the client should not disturb the other clients in the ward indicates that the nurse is irritated. A smiling facial expression while saying this statement would not deliver a congruent message. The statement that the client should listen to the instructions before starting the exercises indicates a focused approach. A smiling facial expression while saying this statement would not deliver a congruent message. The statement that the client should wait for the medicines to show the therapeutic effect indicates that the nurse has sympathy for the client. A smiling facial expression while saying this statement would not deliver a congruent message.
Which clinical situation provides an example of transference?
A female client with a history of sexual abuse exhibits a profound mistrust of male caregivers. Explanation: Transference or parataxic distortion occurs when a client exhibits the same attitudes and behaviors with a caregiver as with a significant, seemingly similar person in the client's life.
Which role of the nurse-client relationship is being exhibited when the nurse informs the client and then supports the client in whatever decision the client makes?
Advocate Explanation: In the advocate role, the nurse informs the client and then supports the client in whatever decision the client makes. The primary caregiving role in mental health settings is the implementation of the therapeutic relationship to build trust and explore feelings. In the teacher role, the nurse instructs the client about the client's medication regimen. In the role of the parent surrogate, the nurse may be tempted to assume a parental role.
A client with depression has been admitted to the mental health unit and is attending group therapy sessions as part of the treatment. The client asks the nurse leading the group if the nurse is married or has a girlfriend. The nurse responds, "I am curious what made you ask this question; however, what is important is how you are feeling today." The nurse's response is what?
Appropriate, because the focus of the therapeutic relationship is the client, not the nurse. Explanation: The nurse's response is appropriate because the focus of the therapeutic relationship is the client. The other options do not place the focus of care on the client's needs or reflect a full understanding of the therapeutic relationship.
Which occurs when the nurse responds to the client based on personal unconscious needs and conflicts?
Countertransference Explanation: Countertransference occurs when the nurse responds to the client based on personal, unconscious needs and conflicts. During exploration, the client identifies the issues or concerns causing problems. Self-disclosure means revealing personal information, such as biographical data and personal ideas. Transference occurs when the client unconsciously transfers to the nurse feelings he or she has for significant others.
The nurse has a client who seems like the nurse's sister, with whom the nurse has a close and positive relationship. This phenomenon is best characterized by which term?
Countertransference Explanation: Countertransference refers to an instance when the nurse has preconceived attitudes or feelings toward a patient that stem from prior experience. When feelings, either positive or negative, seem extreme or disproportionate to the circumstances, the nurse should consider whether a transferential reaction has occurred.
The nurse is preparing to interview a newly admitted client. Which action will the nurse make a priority during the first interaction with this client?
Establish rapport. Explanation: Rapport is the development of interpersonal harmony characterized by understanding and respect. Rapport is important in developing a trusting, therapeutic relationship and should be established as soon and quickly as possible with a new client. Demographics can be validated at any time. Orientation to the care area can occur at any time. Identifying the client's main condition would be a part of the interview that would occur after rapport is established.
When comparing social interactions with therapeutic interactions, the nurse understands that therapeutic interactions do what?
Encourage personal goal setting Explanation: Therapeutic interactions are designed specifically to encourage the client to engage in personal goal setting. Personal and intimate activities, favors for others, and constructive dependencies are all inappropriate activities for the nurse-client relationship.
What occurs during the working phase of the nurse-client relationship?
Evaluation of mutually identified goals Explanation: Evaluation of mutually identified goals occurs in the working phase of the nurse-client relationship. The nurse discusses expectations during the orientation phase. During the working phase, the nurse assesses client needs. Discussion regarding the termination of the relationship occurs during the orientation phase.
A nursing instructor is teaching a class on empathy. The instructor determines that the class needs additional education when the students identify that empathy involves what?
Feeling the same emotions that the client is feeling at a given time Explanation: Empathy is the ability to experience, in the present, a situation as another did at some time in the past. It is the ability to put oneself in another person's circumstances and to imagine what it would be like to share in those feelings. The nurse does not actually have to have had the experience but has to be able to imagine the feelings associated with it.
Which is not involved in empathy?
Feeling the same emotions that the client is feeling at a given time Explanation: Empathy is trying to understand the experience of the other person. It is not possible for nurses to feel the actual emotions of the other person.
Which theorist was most widely known for the belief that the cornerstone of all nursing care is the therapeutic relationship?
Hildegard Peplau Explanation: Peplau's theory is based on the nurse-client relationship as a therapeutic tool.
Which is an inaccurate statement regarding a preconception?
It enables the nurse to get an accurate picture of the client's problems. Explanation: A preconception does not enable the nurse to get an accurate picture of the client's problems. It is a way that a person expects another to behave and can prevent people from getting to know one another. It may prevent the nurse from developing a therapeutic relationship with the client.
A nurse is in the orientation phase of the nurse-client relationship with a client diagnosed with a mental disorder. When interviewing the client during this first encounter, which information is most important for the nurse to obtain about the client?
Perception of the problem Explanation: Although information about allergies, hospitalizations, and family history are important in the orientation phase, it is most important for the nurse to ask the client with a mental disorder about the nature of the problem from the client's perspective. Some clients deny that a problem exists; other clients may have misperceptions about the problem.
The nurse is having a final session with a client. Which action(s) would the nurse take when the client demonstrates difficulty terminating the relationship? Select all that apply. Remind the client to use the resources provided. Address any problems the client may bring up. Agree to text message with the client going forward. Reassure the client that all issues have been resolved. Redirect the client to new skills to address previous problems.
Remind the client to use the resources provided. Reassure the client that all issues have been resolved. Redirect the client to new skills to address previous problems. Correct response: Incorrect response: Your selection: Explanation: Termination is stressful for the client who may demonstrate behaviors to extend the relationship. The nurse should remind the client to use the resources provided, reassure the client that all issues have been resolved, and redirect the client to use new skills to address previous problems. The nurse should not address any old problems that the client may bring up because this is an attempt to prolong the relationship. The nurse should not provide any personal information nor agree to text message with the client going forward.
A client describes panic attacks during which the client rushes to the emergency department with a feeling that death may be imminent. The nurse discloses having had panic attacks during which the nurse also felt very fearful. Which statement about the nurse's self-disclosure is accurate?
Self-disclosure can help normalize the client's experience. Explanation: Nurses may use self-disclosure in the nurse-client relationship to comfort a client who is feeling frustrated and hopeless, enhance trust, decrease role distancing, facilitate the client's self-disclosure, convey support, or normalize the client's experience.
The nurse is assessing a client diagnosed with myocardial ischemia. Which behaviors indicate to the nurse that the client is in the orientation phase of the nurse-client relationship? Select all that apply. The client identifies with the nurse. The client conveys their needs to the nurse. The client shares their experiences during the previous angioplasty procedure. The client asks questions about the recurrence of the condition and its management to the nurse. The client participates in identifying the behavioral modifications.
The client conveys their needs to the nurse. The client shares their experiences during the previous angioplasty procedure. The client asks questions about the recurrence of the condition and its management to the nurse. Explanation: Conveying the needs, sharing past experiences, asking questions about the illness with the nurse, such behaviors are expected in the orientation phase of the nurse-client relationship. Identifying with the nurse and participating to identify the methods to deal with problems interfering with the management are the behaviors of the client observed in the identification phase of the nurse - client relationship.
A nurse is meeting a client for the first time. The nurse observes that the client smiles appropriately but is using rambling speech while answering the nurse's questions. Which would most likely be the reason for this behavior?
The client is nervous and insecure. Explanation: In the beginning, clients may deny problems, employ various forms of defense mechanisms, or prevent the nurse from getting to know them. The client is usually nervous and insecure during the first few sessions and may exhibit behavior reflective of these emotions, such as rambling. Additional assessment would be needed to determine if the client was exhibiting symptoms of a disorder. The behavior would not be considered normal. If a social relationship was the goal, the client would be engaging the nurse to find out more about the nurse.
When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind?
The client is the primary focus of the interaction. Explanation: A fundamental principle of therapeutic communication is that the client must be the focus of the interaction. Self-disclosure should be avoided. Empathy is important and develops over time as the nurse receives information from the client with open, nonjudgmental acceptance. The nurse communicates this understanding of the experience so that the client feels understood. Conversations with clients should be kept confidential.
A nurse is caring for a client in the inpatient psychiatric facility. Which behavior demonstrated by the client indicates the development of a dependancy on the nurse?
The client regresses in the nurse's absence. Explanation: If the client regresses in the nurse's absence this indicates that the client is over dependent on the nurse and is wishes to have the nurse's assistance all the time. Giving too many gifts to the nurse and asking the nurse for their personal home address reflects inappropriate boundaries between the nurse and the client. The client listening intently to the instructions suggests that the nurse and a client have a therapeutic relationship and does not indicate over dependence
Which observation should lead the nurse manager to recognize that countertransference is affecting the therapeutic effectiveness of an individual nurse on the unit?
The nurse frequently refers to an elderly, cognitively impaired client as "my granny" Explanation: Countertransference occurs when a mental health care professional redirects his or her feelings toward a client or becomes emotionally entangled with a client, as is occurring with the nurse's "granny." Being asked to the prom by a client is not an example of countertransference but rather reflects a client's misdirected emotion, referred to as transference. Countertransference does not involve the development of a mental illness or the resulting absenteeism. And countertransference does not involve burnout or the desire to expand one's professional expertise.
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 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 parent expresses concern about a child's aggressive behavior. The nurse responds,"I understand, I might have the same concerns." What does this nurse's statement indicate?
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 self. This may help the client feel comfortable and safe while sharing feelings with the nurse. Sympathy is the ability of the nurse to project his or her concern towards 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.
Which is a nurse's primary tool for treating clients with mental disorders?
The therapeutic use of self Explanation: Through the therapeutic use of self, via therapeutic relationships and communication, nurses help people adapt, change, and grow. Medications and education will influence and enhance growth, but the therapeutic use of self is the nurse's primary tool. Self-help groups do not involve health care professionals.
A client reveals in a therapy session that the client has thought about killing a neighbor. What is the therapist's obligation regarding this revelation?
The therapist must notify authorities and the potential victim. Explanation: As a result of the Tarasoff decision, it is mandatory in most (but not all) states to report any clear threats that psychiatric clients make to harm specific people. Psychiatrists, psychotherapists, and other mental health care providers must warn authorities (if specified by law) and potential victims of possible dangerous actions of their clients, even if the clients protest.
A nursing student is working with a client who has a history of abusing alcohol. Although the nurse has an aversive feeling toward people who abuse alcohol, the nurse feels that the client is worthy of respect and attention regardless of the nurse's own personal feelings. Which correctly describes the nurse's response to the client?
Unconditional positive regard Explanation: The nurse needs to treat each person with respect and dignity, regardless of personal value conflicts.
Termination takes place during the resolution phase of a nurse-client relationship. During the termination process, a client brings up resolved problems and presents them as new issues toward which to work. The nurse interprets the client's action as indicating what feeling in the client?
Wish to prolong the nurse-client relationship. Explanation: It is not unusual for clients with mental disorders to bring up resolved problems and present them as new issues during the resolution phase. The client is most likely attempting to prolong the nurse-client relationship. The client may be experiencing anxiety about the relationship ending. Anger typically would be demonstrated toward the nurse or displaced onto others rather than through the use of bringing up resolved problems. The client's actions do not indicate that additional therapy is needed nor that the therapy was ineffective.
A nurse is caring for a client with hemiplegia who has been depressed. The client tells the nurse, "I don't feel I would ever be independent again. I would be a burden to everybody in my house." The nurse responds by stating, "Your family misses you a lot and wants you home as soon as possible. The rehab team is very confident about your progress." Which phase of nurse-client relationship is occurring?
Working Explanation: The nurse is helping the client to examine the feelings and responses and tries to develop better coping skills and a more positive self-image. The conversation indicates that the client is upset about the client's disability and the nurse is trying to motivate the client. Thus, this conversation is indicative of the working phase. In the orientation phase, the nurse explains the purpose of their meeting and the schedules of the treatment sessions, identifies themes surrounding the client's problems, and clarifies expectations. In the resolution phase, the problems of the client are resolved and the nurse-client relationship comes to an end. Mutual withdrawal is a phase in a nontherapeutic relationship in which the client and nurse give up on each other due to extreme frustration.
The graduate nurse asks the nurse preceptor to observe them during a new client admission assessment to the inpatient mental health unit. "Can you help me evaluate whether my verbal and nonverbal behavior is congruent?" Which nursing responsibility does this activity represent?
developing self-awareness Explanation: Seeking feedback from colleagues and others is an essential component of developing self-awareness. How others perceive one may be different from one's self-perception or intentions. Assessment of the nurse's actions is not useful in determining if the client is experiencing unconscious reactions to unmet needs from the nurse. Clarification of values would involve nurse introspection on what they want from their work or relationships with others. Personal knowing involves reflection on knowledge gained from personal experiences rather than the insight of colleagues.
During an individual therapy session, a nurse is listening to a client describe the client's drug addiction. The client says, "I know I am doing the wrong thing for my kids, but I just can't stop using drugs." The nurse maintains eye contact and nods occasionally. The nurse responds by saying, "You're going through a difficult time." The nurse's actions and words are an example of:
empathy. Explanation: Being empathetic is an active process requiring careful listening and attending to the client. Direct eye contact, a concerned expression, occasional head nods, and a lean forward while listening are nonverbal communication skills that convey empathy. Empathetic responses, such as "You're going through a difficult time," can provide clients with an opportunity to listen to themselves and gain self-awareness.
Which nursing intervention demonstrates congruence in a therapeutic nurse-client relationship?
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.
The manager schedules a staff nurse to attend a motivational interviewing training session. Which nurse behavior caused the manager to make this decision? Select all that apply. interrupting the client minimizing the client's concerns asking the client to clarify a particular issue arguing with a client over agreed upon plans restating the client's perception of a problem
interrupting the client minimizing the client's concerns arguing with a client over agreed upon plans Explanation: The success of motivational interviewing depends upon the quality of interaction between the nurse and client. Strong communication is the cornerstone of this technique and unhelpful defense mechanisms such as interrupting, minimizing, and arguing do not support the motivational interviewing process. Asking for clarification and restating a perception support the motivational interviewing process.
The most important tool of psychiatric nursing is the:
self. Explanation: The most important tool of psychiatric nursing is the self.
What should the nurse avoid when demonstrating genuine interest for a client by making a self-disclosure?
shifting the emphasis to the nurse Explanation: Self-disclosure examples are most helpful to the client when they represent common day-to-day experiences and do not involve value-laden topics. Self-disclosure can be helpful on occasion, but the nurse must not shift emphasis to his or her own problems rather than to the client's. None of the option are inappropriate.
The nurse is playing a game of cards with a client and sharing a story about a recent date. The client and nurse are laughing about how the date went and the nurse asks whether they should pursue a second date. This interaction could be considered what type of relationship?
social Explanation: A social relationship is primarily superficial, usually focuses on sharing ideas, feelings, and experiences and meets the basic need for people to interact. Advice is often given. Roles may shift during social interactions, causing this type of relationship to become nontherapeutic. A therapeutic relationship would focus on client needs rather than the nurse's and would not involve the nurse receiving advice from the client. An intimate or emotional relationship would involve mutually beneficial sharing of emotions and needs and is non-therapeutic.
During which phase of the nurse-client relationship does the client identify and explore specific problems?
working Explanation: During the working phase, the client uses the relationship to examine specific problems and learn new ways of approaching them. Debriefing is not a phase of the nurse-client relationship. During the orientation phase the nurse and client get to know each other. The final phase, resolution, is the termination stage of the relationship and lasts from the time the problems are resolved to the close of the relationship.
