Ch. 9: Therapeutic Relationships

Question 1

1. A nurse assesses a confused older adult. The nurse experiences sadness and reflects, The patient is like one of my grandparents . . . so helpless. What feelings does the nurse describe?
   a. Transference
   b. Countertransference
   c. Catastrophic reaction
   d. Defensive coping reaction

Answer 1

ANS: B
Countertransference is the nurses transference or response to a patient that is based on the nurses unconscious needs, conflicts, problems, or view of the world.

Question 2

2. Which statement shows a nurse has empathy for a patient who made a suicide attempt?
   a. You must have been very upset when you tried to hurt yourself.
   b. It makes me sad to see you going through such a difficult experience.
   c. If you tell me what is troubling you, I can help you solve your problems.
   d. Suicide is a drastic solution to a problem that may not be such a serious matter.

Answer 2

ANS: A
Empathy permits the nurse to see an event from the patients perspective, understand the patients feelings, and communicate this to the patient. The incorrect responses are nurse centered (focusing on the nurses feelings rather than the patients), belittling, and sympathetic.

Question 3

3. After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference?
   a. The patients reactions toward the nurse seem realistic and appropriate.
   b. The patient states, Talking to you feels like talking to my parents.
   c. The nurse feels unusually happy when the patients mood begins to lift.
   d. The nurse develops a trusting relationship with the patient.

Answer 3

ANS: C
Strong positive or negative reactions toward a patient or an overidentification with a patient signals possible countertransference. Nurses must carefully monitor their own feelings and reactions to detect countertransference and then seek supervision. Realistic and appropriate reactions from a patient toward a nurse are desirable. One incorrect response suggests transference. A trusting relationship with the patient is desirable.

Question 4

4. A patient says, Please dont share information about me with the other people. How should the nurse respond?
   a. I wont share information with others without your permission, but I will share information about you with other staff members.
   b. A therapeutic relationship is just between the nurse and the patient. Its up to you to tell others what you want them to know.
   c. It really depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others.
   d. I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us.

Answer 4

ANS: A
A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff members need to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse-patient contract is established, and suggest mutual problem solving. The relationship must be patient centered.

Question 5

5. A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, I really need to talk to you right now. The nurse should:
   a. say to the interrupting patient, I am not available to talk with you at the present time.
   b. end the unproductive session with the current patient and spend time with the patient who has just interrupted.
   c. invite the interrupting patient to join in the session with the current patient.
   d. tell the patient who interrupted, This session is 5 more minutes; then, I will talk with you.

Answer 5

ANS: D
When a specific duration for a session has been set, the nurse must adhere to the schedule. Leaving the first patient would be equivalent to abandonment and would destroy any trust the patient had in the nurse. Adhering to the contract demonstrates that the nurse can be trusted and that the patient and the sessions are important. The incorrect responses preserve the nurse-patient relationship with the silent patient but may seem abrupt to the interrupting patient, abandon the silent patient, or fail to observe the contract with the silent patient.

Question 6

6. Termination of a therapeutic nurse-patient relationship with a patient has been successful when the nurse:
   a. avoids upsetting the patient by shifting focus to other patients before the discharge.
   b. gives the patient a personal telephone number and permission to call after discharge.
   c. discusses with the patient changes that have happened during the relationship and evaluates the outcomes.
   d. offers to meet the patient for coffee and conversation three times a week after discharge.

Answer 6

ANS: C
Summarizing and evaluating progress help validate the experience for the patient and the nurse and facilitate closure. Termination must be discussed; avoiding the discussion by spending little time with the patient promotes feelings of abandonment. Successful termination requires that the relationship be brought to closure without the possibility of dependency-producing ongoing contact.

Question 7

7. What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate:
   a. great sense of independence.
   b. rapport and trust with the nurse.
   c. self-responsibility and autonomy.
   d. resolution of feelings of transference.

Answer 7

ANS: B
The development of rapport and trust is necessary before the relationship can progress to the working phase. Behaviors indicating a greater sense of independence, self-responsibility, and resolved transference occur in the working phase.

Question 8

8. During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved?
   a. Preorientation
   b. Orientation
   c. Working
   d. Termination

Answer 8

ANS: C
During the working phase, the nurse strives to assist the patient in making connections among dysfunctional behaviors, thinking, and emotions and offers support while alternative coping behaviors are tried.

Question 9

9. At what point in the nurse-patient relationship should a nurse plan to first address termination?
   a. In the orientation phase
   b. During the working phase
   c. In the termination phase
   d. When the patient initially brings up the topic

Answer 9

ANS: A
The patient has a right to know the conditions of the nurse-patient relationship. If the relationship is to be time limited, then the patient should be informed of the number of sessions. If it is open ended, then the termination date will not be known at the outset and the patient will know that the issue will be negotiated at a later date. The nurse is responsible for bringing up the topic of termination early in the relationship, usually during the orientation phase.

Question 10

10. A nurse should introduce the matter of a contract during the first session with a new patient because contracts:
    a. specify what the nurse will do for the patient.
    b. spell out the participation and responsibilities of each party.
    c. indicate the feeling tone established between the participants.
    d. are binding and prevent either party from prematurely ending the relationship.

Answer 10

ANS: B
A contract emphasizes that the nurse works with the patient rather than doing something for the patient. Working with is a process that suggests each party is expected to participate and share responsibility for the outcomes. Contracts do not, however, stipulate roles or feeling tone, or that premature termination is forbidden.

Question 11

11. As a nurse escorts a patient being discharged after treatment for major depressive disorder, the patient gives the nurse a gold necklace with a heart pendant and says, Thank you for helping mend my broken heart. Which is the nurses best response?
    a. Accepting gifts violates the policies and procedures of the facility.
    b. Im glad you feel so much better now. Thank you for the beautiful necklace.
    c. Im glad I could help you, but I cant accept the gift. My reward is seeing you with a renewed sense of hope.
    d. Helping people is what nursing is all about. Its rewarding to me when patients recognize how hard we work.

Answer 11

ANS: C
Accepting a gift creates a social rather than a therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patients gesture of appreciation, but the gift should not be accepted.

Question 12

12. Which remark by a patient indicates passage from the orientation phase to the working phase of a nurse-patient relationship?
    a. I dont have any problems.
    b. It is so difficult for me to talk about my problems.
    c. I dont know how talking about things twice a week can help.
    d. I want to find a way to deal with my anger without becoming violent.

Answer 12

ANS: D
Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial is often seen in the orientation phase. It is common early in the relationship, before rapport and trust are firmly established, for a patient to express difficulty in talking about problems. Stating skepticism about the effectiveness of the nurse-patient relationship is more typically a reaction during the orientation phase.

Question 13

13. A nurse explains to the family of a patient who is mentally ill how the nurse-patient relationship differs from social relationships. Which is the best explanation?
    a. The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient.
    b. The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented.
    c. The focus of the relationship is socialization. Mutual needs are met, and feelings are openly shared.
    d. The focus is the creation of a partnership in which each member is concerned with the growth and satisfaction of the other.

Answer 13

ANS: A
Only the correct response describes the elements of a therapeutic relationship. The remaining responses describe events that occur in social or intimate relationships.

Question 14

14. A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should:
    a. restate what the patient says.
    b. use congruent communication strategies.
    c. use self-disclosure in patient interactions.
    d. consistently interpret the patients behaviors.

Answer 14

ANS: B
Genuineness is a desirable characteristic involving an awareness of ones own feelings as they arise and the ability to communicate them when appropriate. The incorrect options are undesirable in a therapeutic relationship.

Question 15

15. A nurse caring for a withdrawn, suspicious patient recognizes the development of feelings of anger toward the patient. The nurse should:
    a. suppress the angry feelings.
    b. express the anger openly and directly with the patient.
    c. tell the nurse manager to assign the patient to another nurse.
    d. discuss the anger with a clinician during a supervisory session.

Answer 15

ANS: D
The nurse is accountable for the relationship. Objectivity is threatened by strong positive or negative feelings toward a patient. Supervision is necessary to work through a countertransference of feelings.

Question 16

16. A nurse wants to enhance the growth of a patient by showing positive regard. The action consistent with this wish is:
    a. making rounds daily.
    b. staying with a tearful patient.
    c. administering daily medication as prescribed.
    d. examining personal feelings about a patient.

Answer 16

ANS: B
Staying with a crying patient offers support and shows positive regard. Administering daily medication and making rounds are tasks that could be part of an assignment and do not necessarily reflect positive regard. Examining feelings regarding a patient addresses the nurses ability to be therapeutic.

Question 17

17. A patient says, Ive done a lot of cheating and manipulating in my relationships. Select a nonjudgmental response by the nurse.
    a. How do you feel about that?
    b. Its good that you realize this.
    c. Thats not a good way to behave.
    d. Have you outgrown that type of behavior?

Answer 17

ANS: A
Asking a patient to reflect on feelings about his or her actions does not imply any judgment about those actions, and it encourages the patient to explore feelings and values. The remaining options offer negative judgments.

Question 18

18. A patient says, People should be allowed to commit suicide without interference from others. A nurse replies, Youre wrong. Nothing is bad enough to justify death. What is the best analysis of this interchange?
    a. The patient is correct.
    b. The nurse is correct.
    c. Neither person is totally correct.
    d. Differing values are reflected in the two statements.

Answer 18

ANS: D
Values guide beliefs and actions. The individuals stating their positions place different values on life and autonomy. Nurses must be aware of their own values and be sensitive to the values of others.

Question 19

19. Which issues should a nurse address during the first interview with a patient diagnosed with a psychiatric disorder?
    a. Trust, congruence, attitudes, and boundaries
    b. Goals, resistance, unconscious motivations, and diversion
    c. Relationship parameters, the contract, confidentiality, and termination
    d. Transference, countertransference, intimacy, and developing resources

Answer 19

ANS: C
Relationship parameters, the contract, confidentiality, and termination are issues that should be considered during the orientation phase of the relationship. The remaining options are issues that are dealt with later.

Question 20

20. During the first interview, a nurse notices that the patient does not make eye contact. The nurse can correctly analyze that:
    a. the patient is not truthful.
    b. the patient is feeling sad.
    c. the patient has a poor self-concept.
    d. more information is needed to draw a conclusion.

Answer 20

ANS: D

The data are insufficient to draw a conclusion. The nurse must continue to assess.

Question 21

21. Which behavior shows that a nurse values autonomy? The nurse:
    a. sets limits on a patients romantic overtures toward the nurse.
    b. suggests one-on-one supervision for a patient who is suicidal.
    c. informs a patient that the spouse will not be in during visiting hours.
    d. discusses available alternatives and helps the patient weigh the consequences.

Answer 21

ANS: D
A high level of valuing is acting on ones belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. Autonomy or self-determination is not the issue in any of the other behaviors.

Question 22

22. As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurses best action?
    a. Recognize the effectiveness of the relationship and patients thoughtfulness. Accept the card.
    b. Inform the patient that accepting gifts violates the policies of the facility. Decline the card.
    c. Acknowledge the patients transition through the termination phase but decline the card.
    d. Accept the card and invite the patient to return to participate in other arts and crafts groups.

Answer 22

ANS: A
The nurse must consider the meaning, timing, and value of the gift. In this instance, the nurse should accept the patients expression of gratitude.

Question 23

23. A patient says, Im still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges? What is the nurses best response?
    a. Why are you asking me when youre able to speak for yourself?
    b. I will be glad to address it when I see your doctor later today.
    c. Thats a good topic for you to take up with your doctor.
    d. Do you think you cant speak to a doctor?

Answer 23

ANS: C
Nurses should encourage patients to work at their optimal level of functioning. A nurse does not act for the patient unless it is necessary. Acting for a patient increases feelings of helplessness and dependency.

Question 24

24. A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. A new nurse who begins work with this patient will:
    a. begin at the orientation phase.
    b. resume the working relationship.
    c. enter into a social relationship.
    d. return to the emotional catharsis phase.

Answer 24

ANS: A
After the termination of a long-term relationship, the patient and new nurse usually have to begin at ground zero, the orientation phase, to build a new relationship. If termination is successfully completed, then the orientation phase sometimes progresses quickly to the working phase. Other times, even after successful termination, the orientation phase may be prolonged.

Question 25

25. As a patient diagnosed with mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario?
    a. The invitation facilitates dependency on the nurse.
    b. The nurses action blurs the boundaries of the therapeutic relationship.
    c. The invitation is therapeutic for the patients diversional activity deficit.
    d. The nurses action assists the patients integration into community living.

Answer 25

ANS: B

The invitation creates a social relationship rather than a therapeutic relationship.

Question 26

26. A nurse says, I am the only one who truly understands this patient. Other staff members are too critical. The nurses statement indicates:
    a. boundary blurring.
    b. sexual harassment.
    c. positive regard.
    d. advocacy.

Answer 26

ANS: A
When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation, the nurse is becoming overinvolved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest positive regard or advocacy.

Question 27

1. Which descriptors exemplify consistency regarding therapeutic nurse-patient relationships? Select all that apply.
   a. Having the same nurse care for a patient on a daily basis
   b. Encouraging a patient to share initial impressions of staff
   c. Providing a schedule of daily activities to a patient
   d. Setting a time for regular sessions with a patient
   e. Offering solutions to a patients problems

Answer 27

ANS: A, C, D
Consistency implies predictability. Having the same nurse see the patient daily, providing a daily schedule of patient activities, and setting a regular time for sessions help a patient to predict what will happen during each day and to develop a greater degree of security and comfort. Encouraging a patient to share initial impressions of staff and giving advice are not related to consistency and would not be considered a therapeutic intervention.

Question 28

2. A nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase? Select all that apply.
   a. Focus dialog with the patient on problems that may occur in the future.
   b. Help the patient express feelings about the relationship with the nurse.
   c. Help the patient prioritize and modify socially unacceptable behaviors.
   d. Reinforce expectations regarding the parameters of the relationship.
   e. Help the patient identify strengths, limitations, and problems.

Answer 28

ANS: A, B

The correct actions are part of the termination phase. The other actions are used in the working and orientation phases.

Question 29

3. A new psychiatric nurse has a parent diagnosed with bipolar disorder. This nurse angrily recalls embarrassing events concerning the parents behavior in the community. Select the best ways for this nurse to cope with these feelings. Select all that apply.
   a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses.
   b. Recognize that these feelings are unhealthy, and try to suppress them when working with patients.
   c. Recognize that psychiatric nursing is not an appropriate career choice, and explore other nursing specialties.
   d. Begin new patient relationships by saying, My own parent had mental illness, so I accept it without stigma.
   e. Recognize that the feelings may add sensitivity to the nurses practice, but supervision is important.

Answer 29

ANS: A, E
The nurse needs to explore these feelings. An experienced psychiatric nurse is a resource who may be helpful. The knowledge and experience gained from the nurses relationship with a parent who is mentally ill may contribute sensitivity to a compassionate practice. Self-disclosure and suppression are not adaptive coping strategies. The nurse should not give up on this area of practice without first seeking ways to cope with the memories.

Question 30

4. A new nurse tells a mentor, I want to convey to my patients that I am interested in them and that I want to listen to what they have to say. Which behaviors are helpful in meeting the nurses goal? Select all that apply.
   a. Sitting behind a desk, facing the patient.
   b. Introducing self to a patient and identifying own role.
   c. Using facial expressions that convey interest and encouragement.
   d. Assuming an open body posture and sometimes mirror imaging.
   e. Maintaining control of the topic under discussion by asking direct questions.

Answer 30

ANS: B, C, D
Trust is fostered when the nurse gives an introduction and identifies his or her role. Facial expressions that convey interest and encouragement support the nurses verbal statements to that effect and strengthen the message. An open body posture conveys openness to listening to what the patient has to say. Mirror imaging enhances patient comfort. A desk would place a physical barrier between the nurse and patient. A face-to-face stance should be avoided when possible, and a less intense, 90- or 120-degree angle is used to permit either party to look away without discomfort. Once introductions have been made, the nurse focuses the interview on the patient by using open-ended questions, such as, Where should we start?