Chapter 10: Therapeutic Relationships

Question 1

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents—so helpless.” Which response is the nurse demonstrating?

a. Transference
b. Counter-transference
c. Catastrophic reaction
d. Defensive coping reaction

Answer 1

ANS: B
Counter-transference is the nurse’s transference or response to a patient that is based on the nurse’s unconscious needs, conflicts, problems, or view of the world. See relationship to audience response question.

Question 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 patient’s perspective, understand the patient’s feelings, and communicate this to the patient. The incorrect responses are nurse- centred (focusing on the nurse’s feelings rather than the patient’s), belittling, and sympathetic.

Question 3

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of counter-transference?

a. The patient’s 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 patient’s 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 over-identification with the patient indicate possible counter-transference. Nurses must carefully monitor their own feelings and reactions to detect counter-transference 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

A patient says, “Please don’t share information about me with the other people.” How should the nurse respond?

a. “I will not share information with your family or friends without your permission, but I share information about you with other staff.”
b. “A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know.”
c. “It 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 needs 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 centred.

Question 5

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent 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.” What should the nurse do?

a. Invite the interrupting patient to join in the session with the current patient.
b. Say to the interrupting patient, “I am not available to talk with you at the present time.”
c. End the unproductive session with the current patient and spend time with the interrupting patient.
d. Tell the interrupting patient, “This session is 5 more minutes; then I will talk with you.”

Answer 5

ANS: D
When a specific duration for sessions 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

Termination of a therapeutic nurse–patient relationship has been successful when the nurse does which of the following?

a. Avoids upsetting the patient by shifting focus to other patients before discharge.
b. Gives the patient a personal telephone number and permission to call after discharge.
c. Discusses with the patient changes that happened during the relationship and evaluates 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 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

What is the desirable outcome for the orientation stage of a nurse–patient relationship? The patient will demonstrate behaviours that indicate which of the following?

a. Self-responsibility and autonomy
b. A greater sense of independence
c. Rapport and trust with the nurse
d. Resolved transference

Answer 7

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

Question 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 psychiatric nurse and patient together identify and explore areas that are causing problems in the patient’s life. Often, the patient’s present ways of handling situations stem from earlier means of coping devised to survive in a chaotic and dysfunctional family environment.

Question 9

At what point in the nurse–patient relationship should a nurse plan to first address termination?

a. During the orientation phase
b. At the end of the working phase
c. Near the beginning of 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, the patient should be informed of the number of sessions. If it is open-ended, the termination date will not be known at the outset, and the patient should 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

A nurse introduces the matter of a contract during the first session with a new patient because of which of the following?

a. Contracts specify what the nurse will do for the patient.
b. Contracts spell out the participation and responsibilities of each party.
c. Contracts indicate the feeling tone established between the participants.
d. Contracts 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 outcomes. Contracts do not, however, stipulate roles or feeling tone, and premature termination is forbidden.

Question 11

As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, “Thank you for helping mend my broken heart.” Which is the nurse’s best response?

a. “Accepting gifts violates the policies and procedures of the facility.”
b. “I’m glad you feel so much better now. Thank you for the beautiful necklace.”
c. “I’m glad I could help you, but I can’t accept the gift. My reward is seeing you with a renewed sense of hope.”
d. “Helping people is what nursing is all about. It’s rewarding to me when patients recognize how hard we work.”

Answer 11

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

Question 12

Which remark by a patient indicates passage from orientation to the working phase of a nurse–patient relationship?

a. “I don’t have any problems.”
b. “It is so difficult for me to talk about problems.”
c. “I don’t know how it will help to talk to you about my problems.”
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 behavioural change. Behavioural 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 a reaction that is more typical during the orientation phase.

Question 13

A nurse explains to the family of a mentally ill patient how a 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 shared openly.”
d. “The focus is creation of a partnership in which each member is concerned with growth and satisfaction of the other.”

Answer 13

ANS: A
The focus of the relationship is on the patient’s ideas, experiences, feelings, and personal issues introduced during the clinical interview, with the development of personal insight as a desired outcome. The nurse and the patient identify areas that need exploration and periodically evaluate the degree of change in the patient’s understanding of the stressors and pinpoint strategies to manage them differently. The remaining responses describe events that occur in social or intimate relationships.

Question 14

A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. Which of the following should the nurse do?

a. Restate what the patient says.
b. Use congruent communication strategies.
c. Use self-revelation in patient interactions.
d. Consistently interpret the patient’s behaviours.

Answer 14

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

Question 15

A nurse caring for a withdrawn, suspicious patient recognizes development of feelings of anger toward the patient. Which of the following should the nurse do?

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 counter-transference feelings.

Question 16

A nurse wants to enhance growth of a patient by showing positive regard. The nurse’s action most likely to help achieve this goal is which of the following?

a. Making rounds daily
b. Staying with a tearful patient
c. Administering 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 nurse’s ability to be therapeutic.

Question 17

A patient says, “I’ve done a lot of cheating and manipulating in my relationships.” Select a nonjudgemental response by the nurse.

a. “How do you feel about that?”
b. “I am glad that you realize this.”
c. “That’s not a good way to behave.”
d. “Have you outgrown that type of behaviour?”

Answer 17

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

Question 18

A patient says, “People should be allowed to commit suicide without interference from others.” A nurse replies, “You’re 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. Congruent attitudes are implied.
d. Differing values are reflected.

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. When working with patients, it is important for nurses to understand that their values and beliefs are not necessarily “right” and certainly are not right for everyone.

Question 19

Which issues should a nurse address during the first interview with a patient 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, counter-transference, 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 discussed later in the relationship.

Question 20

An advanced-practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing counter-transference. Which comment by the new nurse confirms this suspicion?

a. “This patient continues to deny problems resulting from drinking.”
b. “My parents were alcoholics and often neglected our family.”
c. “The patient cannot identify any goals for improvement.”
d. “The patient said I have many traits like her mother.”

Answer 20

ANS: B
Counter-transference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviours related to significant figures in the nurse’s past. In this instance, the new nurse’s irritability stems from relationships with the nurse’s parents. The distracters indicate transference or accurate analysis of the patient’s behaviour.

Question 21

Which of the following behaviours shows that a nurse values autonomy?

a. The nurse suggests one-on-one supervision for a patient who has suicidal thoughts.
b. The nurse informs a patient that the spouse will not be in during visiting hours.
c. The nurse discusses options and helps the patient weigh the consequences.
d. The nurse sets limits on a patient’s romantic overtures toward the nurse.

Answer 21

ANS: C
Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. A goal of the nurse–patient relationship is to help patients examine self-defeating behaviours and test alternatives. Autonomy or self-determination is not the issue in any of the other behaviours.

Question 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 nurse’s best action?

a. Recognize the effectiveness of the relationship and patient’s thoughtfulness. Accept the card.
b. Inform the patient that accepting gifts violates policies of the facility. Decline the card.
c. Acknowledge the patient’s 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 patient’s expression of gratitude. See relationship to audience response question.

Question 23

A patient says, “I’m still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?” What is the nurse’s best response?

a. “Why are you asking me when you’re able to speak for yourself?”
b. “I will be glad to address it when I see your doctor later today.”
c. “That’s a good topic for you to discuss with your doctor.”
d. “Do you think you can’t 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

A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. When a novice nurse begins work with this patient, what is the starting point for the relationship?

a. Begin at the orientation phase.
b. Resume the working relationship.
c. Initially establish a social relationship.
d. Return to the emotional catharsis phase.

Answer 24

ANS: A
After 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, the orientation phase sometimes progresses quickly to the working phase. Other times, even after successful termination, the orientation phase may be prolonged.

Question 25

As a patient diagnosed with a 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 nurse’s action blurs the boundaries of the therapeutic relationship.
c. The invitation is therapeutic for the patient’s diversional activity deficit.
d. The nurse’s action assists the patient’s integration into community living.

Answer 25

ANS: B

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

Question 26

A nurse says, “I am the only one who truly understands this patient. Other staff members are too critical.” The nurse’s statement indicates which of the following?

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 over-involved with the patient as a probable result of unrecognized counter-transference. 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

Which descriptors exemplify consistency regarding nurse–patient relationships? Select all that apply.

a. Encouraging a patient to share initial impressions of staff
b. Having the same nurse care for a patient on a daily basis
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 patient’s problems

Answer 27

ANS: B, C, D
Consistency implies predictability. Having the same nurse see the patient daily, provide a daily schedule of patient activities, and set a time for regular sessions will help a patient predict what will happen during each day and 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 therapeutic interventions.

Question 28

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 dialogues 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 behaviours.
d. Reinforce expectations regarding the parameters of the relationship.
e. Help the patient to identify strengths, limitations, and problems.

Answer 28

ANS: A, B
Helping the patient express feelings about the relationship and prioritize and modify socially unacceptable behaviours are part of the termination phase. The other actions would be used in the working and orientation phases.

Question 29

A novice psychiatric nurse has a parent with bipolar disorder. This nurse angrily recalls feelings of embarrassment about the parent’s behaviour 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. The nurse should try to suppress them when working with patients.
c. Recognize that psychiatric nursing is not an appropriate career choice. Explore other nursing specialties.
d. The nurse should 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 nurse’s practice, but supervision is important.

Answer 29

ANS: A, E
The nurse needs support to explore these feelings. An experienced psychiatric nurse may be a helpful resource. The knowledge and experience gained from the nurse’s relationship with a mentally ill parent may contribute sensitivity to compassionate practice. It is important to explore the root of the anger. 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

A novice 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 behaviours will be helpful in meeting the nurse’s goal? Select all that apply.

a. Sitting behind a desk, facing the patient
b. Introducing self to a patient and identifying own role
c. Maintaining control of discussions by asking direct questions
d. Using facial expressions to convey interest and encouragement
e. Demonstrating attending behaviours

Answer 30

ANS: B, D, E
Trust is fostered when the nurse gives an introduction and identifies his or her role. Facial expressions that convey interest and encouragement support the nurse’s verbal statements to that effect and strengthen the message. Attending is a special kind of listening that refers to an intensity of presence, or of being with the patient. At times, simply being with another person during a painful time can make a difference. 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 used to permit either party to look away without discomfort.