Professional Communication Chapter 5-Therapeutic Relationships (PrepU)
During which phase of the nurse-client relationship does the client identify and explore specific problems? working debriefing orientation resolution
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.
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 will speak with the health care provider about the possible use of physical restraints for you tonight." "I cannot keep this a secret. I will ensure that the staff helps keep you safe." "Don't worry; I will keep this secret to myself." "Who has influenced you with these ideas?"
"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.
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? "I really feel sorry for your child." "What was going on for you when this happened?" "How could you do this to your child?" "Punishing your child would only make your child worse."
"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.
Which clinical situation provides an example of transference? A nurse asks for clarification from a colleague when explaining a coping strategy to a client. A client mirrors the nursing student's nervousness and hesitancy during assessment. A female client with a history of sexual abuse exhibits a profound mistrust of male caregivers. A nurse implements the same interventions with multiple clients despite their personal differences.
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? Teacher Parent surrogate Advocate Caregiver
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 tells the mental health nurse that the client is taking a sewing class to cope with the client's son's move to another state. The use of this adaptive coping skill is an example of which aspect in the therapeutic relationship? Empathy Self-disclosure Respect Client self-exploration
Client self-exploration Explanation: When client self-exploration occurs, the nurse encourages the client to learn positive adaptive or coping skills. Self-disclosure refers to the nurse sharing personal information with the client in order to establish trust and improve rapport. Empathy is the ability of the nurse to perceive the meanings and feelings of the client and to communicate understanding to the client. Respect is also a condition essential for a therapeutic relationship to occur; however, it is not reflective of the client's adaptive coping.
A 68-year-old parent is the sole care provider for a 39-year-old child who has a diagnosis of bipolar disorder. The 39-year-old has been experiencing worsening of the illness over several years. The nurse should recognize that the parent is at risk for what? Compassion fatigue Decompensation Bipolar disorder Failure to thrive
Compassion fatigue Explanation: Compassion fatigue, also referred to by many as burnout, may occur when one provides care for others but loses the ability to take care of oneself. According the neurobiological theories of bipolar disorder, the parent would have already been diagnosed with bipolar disorder if this was a possibility. Although poor self-care could result in a failure to thrive for the client's parent, the parent is more likely to experience compassion fatigue, given the client factors presented in this scenario. Decompensation is a term used to describe worsening symptoms of someone who has maintained recovery of a chronic mental illness. This does not accurately describe the situation for the client's parent.
Which action by the nurse or client represents the working phase of the therapeutic relationship? Reviewing work that has been done Identifying past ineffective behaviors Communicating interest in the client Testing the relationship
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.
The nurse is reviewing the client's history, identifies themes, and considers how the nurse can be most therapeutic to a client who was recently admitted to a psychiatric unit. The nurse is functioning in which phase of the therapeutic relationship? Working Withholding Orientation Resolution
Orientation Explanation: The orientation phase is the phase during which the nurse and client get to know each other. The nurse reads background materials available on the client and considers his or her personal strengths and limitations in working with this client. The working stages involves problem identifcation and exploitation. Resolution, or the termination phase, begins when problems are resolved and signals the end of the therapeutic relationship. Withholding is a phase in a deteriorating relationship in which the nurse is perceived as withholding nursing support.
A nurse is interviewing a client to obtain a health history. Which would be considered a "usual or expected" response during the first session? Rambling due to nervousness Bragging about sexual conquests Showing up late for the first session Being confrontational with nurse and other group members
Rambling due to nervousness Explanation: A client is usually nervous and insecure during the first few sessions and may exhibit behavior reflective of these emotions, such as rambling. Showing up late, being confrontational, and bragging are nontherapeutic ways to not participate in the session.
During the termination phase, a client begins to raise old problems that have already been resolved. Which would be appropriate nursing responses? Select all that apply. Immediately stop the client and inform the client that the nurse is running the session. Reassure the client that they already covered these issues. Review with the client the learned methods to control the problems. Do not acknowledge this issue and continue on with the session as planned. Get angry at the client and ask the client to leave the session.
Reassure the client that they already covered these issues. Review with the client the learned methods to control the problems. Explanation: A typical termination behavior is raising old problems that have already been resolved. The nurse may feel frustrated if clients in the termination phase present resolved problems as if they were new. The clients are attempting to prolong the relationship and avoid its ending. Nurses should avoid addressing these problems. Instead, they should reassure clients that they already covered those issues and learned methods to control them.
When engaged in a therapeutic relationship, the nurse's focus is on what? The client The self The family The environment
The client Explanation: In a therapeutic relationship, the nurse focuses on the client and client-related issues even when engaging in social activities with that client. This is essential to the most effective nurse-client relationship, one that is client-centered.
Avoiding which outcome is the primary reason for establishing professional boundaries with clients? The possibility of inappropriate sexual tension developing The loss of therapeutic effectiveness The possibility of losing control of the milieu The likelihood of a client becoming too dependent on the nurse
The loss of therapeutic effectiveness Explanation: The priority reason the psychiatric nurse is careful to maintain professional boundaries with clients is to avoid the loss of therapeutic effectiveness. While the other options can result during the course of a relationship, none of them is the priority reason the psychiatric nurse is careful to maintain professional boundaries with clients.
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 meet with an ethics committee to determine the course of action. The therapist must evaluate the threat and notify authorities if it meets credibility criteria. The therapist must notify authorities and the potential victim. The therapist must keep the comment confidential, because the disclosure is protected by therapist-client confidentiality.
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.
The psychiatric nurse recognizes that excessive social communication with a client is to be avoided primarily due to which reason? To avoid giving the client the impression that the nurse is not interested in providing effective care To prevent the client from viewing the nurse as a friend rather than health care provider To prevent disruption of the time that is to be used for therapeutic communication To avoid making the client feel that the client's problems are not viewed as being serious
To prevent the client from viewing the nurse as a friend rather than health care provider Explanation: The psychiatric nurse recognizes that excessive social communication with a client is to be avoided primarily because it is likely to encourage the client to view the nurse as a friend rather than health care provider. Boundaries of the nurse-client relationship can only be set effectively if the nurse primarily engages in therapeutic communication with the client as opposed to social
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? Countertransference Partnership Genuineness Unconditional positive regard
Unconditional positive regard Explanation: The nurse needs to treat each person with respect and dignity, regardless of personal value conflicts.
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: nontherapeutic communication. apathy. empathy. sympathy.
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.
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 about the client would be most important for the nurse to obtain? known allergies perception of the problem family history recent hospitalizations
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 a 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.
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? "My father passed away recently. I can understand your problem." "I just had a divorce; I can understand how it would feel to be without a partner." "I can understand your situation; my cousin lost a spouse a few months ago." "I can understand your situation. Medication could be of great help to relieve your depression."
"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.
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? "I too have been disappointed by important people in my life." "You will find that one of the constants in life is that people will often let you down." "What do you think motivated your father to do that." "That must have been terribly hurtful experience for you."
"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.
A nurse is speaking to a client who attempted suicide. The client says, "It is my dream to become a doctor, and I failed the entrance exam. I am so mad at myself." Which statement indicates genuine interest by the nurse? "It is wrong to commit suicide." "You must have been really upset." "What would you gain by killing yourself?" "You were killing yourself for this?"
"You must have been really upset." Explanation: By stating "you must have been really upset," the nurse avoids communicating value judgments about the client's behavior. Indicating that the client attempted to kill oneself for a trivial goal, asking what the client would gain by killing oneself, or telling the client that the behavior was wrong indicate that the nurse is judgmental and void of genuine interest.
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?" "Do you want me to inform your spouse about your illness?" "Do you take a vegetarian or nonvegetarian diet?" "How did the pain start?"
"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 35-year-old was discharged from care after recovery from depression. The nurse therapist and the client spent many hours working through issues related to the depression. Six months later, the client is admitted again for depression associated with issues similar to those that were previously addressed in the client's therapy. The nurse therapist says to a coworker, "This is unbelievable; we're back at square one again. The client should know better at this point." The nurse's comments reflect what? Countertransference Poor boundaries A judgmental attitude Exploitation
A judgmental attitude Explanation: Judgmental attitudes and preconceptions deter the development of therapeutic relationships. Nurses must examine their own beliefs about mental illness, such as believing that mental illness is as real as any physical illness, suspecting that clients are overdramatizing their symptoms or using them as a crutch to avoid work and social responsibility, viewing mental illness as a sign of a weak character, or asking, "Why doesn't this person just snap out of it, put his or her problems in perspective, or focus on something else?" Countertransference refers to the nurse's response to the client based on personal unconscious needs and conflicts. Exploitation refers to the phase in the therapeutic relationship when the nurse guides the client to examine feelings and responses to develop better coping mechanisms and a more positive self image. Poor boundaries refers to inappropriate levels of personal disclosure to the client or overly social/intimate relationships with the client.
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? Free association Reaction formation Transference Countertransference
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.
In what phase of the therapeutic relationship does the assessment process begin? During the working phase After the initiating or orienting phase has been completed During the initiating or orienting phase After the working phase has been completed
During the initiating or orienting phase Explanation: The first step of the therapeutic relationship is called the initiating or orienting phase. During this phase, the nurse sets the stage for a one-to-one relationship by becoming acquainted with the client. At the same time, the nurse also begins the assessment process.
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? Having insight into the meaning of clients' thoughts, feelings, and behaviors Careful listening Feeling the same emotions that the client is feeling at a given time Being in touch with what the client is saying
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.
A nurse is caring for a client on an inpatient mental health unit of a hospital. The nurse tells the client, "You are scheduled to attend therapy sessions every morning at 9:00 a.m. Please make sure that you complete your morning routine, such as using the restroom, bathing, and eating breakfast, before you come for the sessions." Which phase of the nurse-client relationship does this communication indicate, according to the Peplau's model? Orientation phase Identification phase Exploitation phase Termination phase
Orientation phase Explanation: According to the conversation, the nurse is informing the client about the daily schedule of the therapy. This conversation is indicative of the orientation phase of the nurse-client relationship. During this phase, the nurse explains the schedules of meeting, identifies the client's problems, and clarifies the expectations of the client. In the identification phase, the client tries to find the problems that would affect treatment. In the exploitation phase, the client examines the feelings and responses and tries to develop better coping skills and a more positive self-image. The client starts becoming independent in this stage. In the termination phase, the problems of the client are resolved and the nurse-client relationship comes to an end.
A psychiatric-mental health nurse has developed a therapeutic relationship with a client. Which action would alert the nurse to the possibilty that the relationship may be moving outside professional boundaries? Select all that apply. The nurse tells a friend that the nurse is the only one who truly understands this client. The nurse is spending more time with the client than the others in the group. The client brings the nurse a baked item for their lunch. The nurse objectively contributes to the team meeting about behaviors the client is displaying. The nurse informs the supervisor that the client asked the nurse to "keep a secret from the rest of the staff."
The client brings the nurse a baked item for their lunch. The nurse is spending more time with the client than the others in the group. The nurse tells a friend that the nurse is the only one who truly understands this client. Explanation: Indicators that the relationship may be moving outside professional boundaries are gift giving on either party's part, spending more time than usual with a particular client, strenuously defending or explaining the client's behavior in team meetings, the nurse feeling that he or she is the only one who truly understands the client, keeping secrets, or frequently thinking about the client outside of the work situation.
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. The client is demonstrating a normal reaction. The client is experiencing symptoms of a disorder. The client is attempting to engage in a social relationship.
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.
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 is referred to as being in a relationship with a client by that client, and the client wants the nurse to accompany the client to the prom The nurse frequently refers to an elderly, cognitively impaired client as "my granny" The nurse begins to experience the symptoms of depression and calls out sick The nurse asks to be transferred to another unit to avoid burnout and to work with different disorders
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.
Which is a nurse's primary tool for treating clients with mental disorders? The therapeutic use of self Family education and therapy Self-help groups Psychotropic medications
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 nurse notices that a neighbor has been admitted to an inpatient psychiatric unit. The nurse understands that the nurse may not discuss this with any of the nurse's family or neighbors, because doing so would breach the client's confidentiality. Confidentiality is a component of which element of the therapeutic relationship? Caring Genuine interest Positive regard Trust
Trust Explanation: An important component of trust is confidentiality. Mental health providers must reassure clients that they will not share the details of clients' lives outside the professional environment.
During which phase of the nurse-client relationship does the client identify and explore specific problems? Resolution Debriefing Orientation Working
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.
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? Mutual withdrawal Working Orientation Resolution
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.
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 to work toward. The nurse interprets the client's action as indicating what? The client: is unhappy that the therapy was ineffective. requires additional therapy. is angry that the nurse is abandoning the client. is attempting to prolong the nurse-client relationship.
is attempting 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.
The most important tool of psychiatric nursing is the: physician. nurse. environment. self.
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 using situations that have occurred on the unit providing advice on how to manage a problem being too general with the details of the story
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.
