Chapter 2: Therapeutic Nurse-Patient Relationship

Question 1

1. A novice nurse states, “Psychiatric nursing can’t be very difficult. After all, I believe in showing care and in mutual exchange with my friends.” The experienced nurse’s understanding of the difference between a social and a therapeutic relationship is primarily based on the:
   a. kind of information given.
   b. amount of emotion invested.
   c. degree of satisfaction obtained.
   d. type of responsibility involved.

Answer 1

ANS: D
Social and therapeutic relationships both involve the giving of information, emotional investment, and personal satisfaction. These aspects all have differences, but they are minor in comparison with the difference in responsibility that exists between social and therapeutic relationships. In the therapeutic relationship the nurse has both ethical and legal responsibilities to the patient; these responsibilities do not exist in the social relationship.

Question 2

3. Which strategy can the nursing student use to foster authenticity in therapeutic relationships with patients?

a. Reading and discussing textbook assignments with a study group
b. Modeling behaviors with patients on the behaviors of a clinically competent staff nurse
c. Attending patient-centered clinical conferences on the assigned psychiatric inpatient unit
d. Analyzing feelings associated with psychiatric clinical experience with the help of instructors and peers

Answer 2

ANS: D
Nursing students have many new experiences that provide opportunities for self-learning. Nurses should focus on and discuss the feelings related to these experiences. Instructors and peers can help students by facilitating self-awareness during these discussions; self-awareness contributes to authenticity.

Question 3

4. A person who has always wished to care for “special children” adopts a biracial child and another child who has spina bifida. What is the highest step of the value clarification process that this person has achieved?
   a. Doing something with the choice in a pattern of life
   b. Choosing freely from alternatives
   c. Being happy with the choice
   d. Affirming the choice publicly

Answer 3

ANS: A
The highest level of value clarification is acting in a pattern. Adopting two “special children” is affirmation of a pattern. Acting follows choosing and prizing in the sequence of value clarification.

Question 4

5. A nurse makes observations that a depressed patient is more energetic and is smiling much more. Still, the nurse shares with the unit manager that when thinking about the patient a sense of hopelessness surfaces. The nurse manager replies:
   a. “Sometimes it’s best to disregard subjective perceptions like that and focus on the objective signs.”
   b. “Pay attention to your feelings. They can provide valuable clues about the patient’s feelings.”
   c. “You should share your perceptions with the patient and seek an explanation.”
   d. “Confrontation can be a useful tool in situations like this.”

Answer 4

ANS: B
The feelings that nurses have serve an important purpose. They are valuable clues about the patient’s problems, and they are barometers for feedback about the nurses themselves and their relationships with others.

Question 5

6. A new nurse has the following thoughts: “How will I handle things if my patient walks away from me? How will I react if the patient is sexually provocative? How will I cope with a patient who cries?” These thoughts indicate that the nurse is engaged in:
   a. role modeling.
   b. self-exploration.
   c. altruistic thinking.
   d. value clarification.

Answer 5

ANS: B
Self-exploration leads to the development of self-awareness, and it is essential that the nurse be self-aware to learn to deal with anxiety, anger, sadness, and joy in helping patients through the health-illness continuum.

Question 6

7. A nurse’s most appropriate initial action during the preinteraction phase of a relationship with a homosexual patient should be to:
   a. examine personal feelings about homosexuality.
   b. review the literature that pertains to the human sexual response.
   c. attempt to identify the underlying reasons for the patient’s values.
   d. focus on a method to assist the patient with changing personal sexual values.

Answer 6

ANS: A
Self-examination is a task of the preinteraction phase of a relationship. This is especially important if the value systems of the nurse and patient are known to be different.

Question 7

8. A nurse engaged in the preinteraction phase of the nurse-patient relationship will:
   a. consider what he or she has to offer the patient.
   b. form a workable but detailed contract.
   c. review the general goals of a therapeutic relationship.
   d. plan for the first interaction with the patient.
   e. identify existing stressors affecting the relationship.

Answer 7

ANS: D
In the preinteraction phase the nurse and the patient have not yet met. The nurse prepares for the initial contact by performing self-assessment, gathering available data about the patient, reviewing the goals of a therapeutic relationship, and considering what he or she has to offer the patient. Contract creation is addressed in the orientation phase while the identification of stress factors occurs in the working phase.

Question 8

9. When asked to contrast social superficiality with therapeutic intimacy, an experienced nurse mentor explains to a new nurse that the termination component in therapeutic intimacy is:
   a. unknown.
   b. open-ended.
   c. specified and agreed to.
   d. closed to negotiation or agreement.

Answer 8

ANS: C
Conditions for termination are part of the nurse-patient contract negotiated during the introductory/orientation phase of the relationship. In a social relationship, termination is open-ended.

Question 9

10. Which task would be most appropriate to focus on during the introductory phase of work with a teenage patient with low self-esteem?
    a. Mutual formulation of a contract
    b. Nurse’s self-analysis of strengths
    c. Promotion of patient use of constructive coping mechanisms
    d. Review of progress of therapy and goal attainment with patient

Answer 9

ANS: A
The tasks of the introductory phase of the nurse-patient partnership include establishing a climate of trust, understanding, acceptance, and open communication and formulating a contract with the patient.

Question 10

11. A patient admitted with a diagnosis of schizophrenia, paranoid type, coldly tells a nurse during the admission interview, “I am here because my family brought me here and locked me up.” The nurse’s best response would be:
    a. “How has hospitalization affected your life?”
    b. “Do you feel angry or resentful about being hospitalized?”
    c. “I see you are angry about being here. I hope that after we talk you will feel differently.”
    d. “We are here to protect you and see that you do not harm yourself or others in your anger.”

Answer 10

ANS: C
It is appropriate to acknowledge the angry or otherwise negative feelings of a patient who has not voluntarily sought treatment. Feeling understood by the nurse paves the way for a therapeutic relationship.

Question 11

12. A patient is admitted to the unit and complains of being depressed. The patient says, “I want to feel like my old self again.” Which nursing response will be most therapeutic?
    a. “How long have you felt this way?”
    b. “We’re all here to help you get better.”
    c. “What do you think the hospital can do for you?”
    d. “Tell me more so that I can better understand.”

Answer 11

ANS: D
When a patient initially offers psychiatric symptoms as the reason for admission, the nurse will want to ask for clarification and elaboration to better understand the life experiences of the patient. Understanding fosters empathy, empathic remarks lead the patient to feel understood, and this understanding paves the way for the therapeutic nurse-patient partnership.

Question 12

13. In the initial sessions a patient frequently asks the nurse for money and expresses doubt about the nurse’s ability to help. Which principle provides guidance for the nurse in this situation?
    a. This behavior is typical of transference reactions.
    b. All patients have feelings of insecurity and low self-esteem.
    c. Manipulative behavior is part of this patient’s psychopathology.
    d. Testing behavior is common during the introductory phase of a relationship.

Answer 12

ANS: D

Testing behavior serves the purpose of exploring the nurse’s consistency and intent.

Question 13

14. A young adult has been receiving treatment for an anxiety disorder. Which statement by the patient confirms that the nurse and patient are most likely entering the terminal phase of the therapeutic relationship?
    a. “My anxiety seems to be a result of having so much to get done.”
    b. “I don’t know whether I’ll be able to handle things alone.”
    c. “I can’t seem to be able to manage going to school and working.”
    d. “I need to find a way that can help me manage my anxiety.”

Answer 13

ANS: B
Establishing the reality of separation is difficult for both the nurse and patient. Patients often respond to impending termination with increased anxiety; they may experience negative feelings associated with earlier terminations, and they may regress to previous, less adaptive behaviors in the hope of postponing termination. The expression of the cause of the anxiety is reflective of the working phase while a general statement of the problem is appropriate for the introduction phase. Expressing a need for help is seen in the preinteraction phase.

Question 14

15. A psychiatric nurse will recognize which action as demonstration of resistance behavior?
    a. Regularly referring to himself as a “loser”
    b. Becoming tearful during every therapy session about abuse
    c. Asking to postpone a therapy session until after visiting hours
    d. Consistently describing his drug use as starting “a little while ago”

Answer 14

ANS: D
Resistance is the patient’s reluctance or avoidance of verbalizing or experiencing troubling aspects of himself or herself. This is often caused by the patient’s unwillingness to change when the need for change is recognized. The remaining options lack the needed reluctance to open communication seen with resistant behaviors.

Question 15

16. During the working phase of the relationship, the nurse assesses that the patient may be demonstrating resistance. The most appropriate way to deal with this would be to:
    a. assist the patient in exploring his or her past for uncovered issues and conflicts.
    b. clarify, share observations, and reflect content and feelings with the patient.
    c. confront the patient with the behavior and state, “You will be expected to work harder.”
    d. avoid mentioning the therapeutic barrier and wait until the patient again indicates readiness.

Answer 15

ANS: B
The relationship can become stalled if the nurse is not prepared to deal with the impasse. The nurse may use clarification by saying something such as, “I sense that you’re struggling with yourself and wanting to explore your relationship with your parents, but that you don’t yet want to experience the pain it may bring.”

Question 16

17. A patient reports seeing a “frightening” face on the wall of the dayroom. A nurse attempts to calm her by providing an explanation for the flawed perception of what she saw. The nurse would implement this strategy by stating:
    a. “Let’s see if anyone else has seen those frightening faces on the walls of the dayroom.”
    b. “The shadows of the tree outside the window make strange shapes on the dayroom walls.”
    c. “Have you ever seen frightening faces like that on the dayroom walls before today?”
    d. “Did someone in the dayroom tell you there were frightening faces on the walls?”

Answer 16

ANS: B
Perception is the identification and interpretation of a stimulus based on information received through the senses. In this instance the patient has incorrectly interpreted the shadows as a face on the wall. The remaining options do not relate to a misinterpretation of what the patient actually saw.

Question 17

18. A patient says to a nurse, “My spouse and I get along just fine. We usually agree on everything.” The nurse observes nonverbal communication that disagrees with what the patient has verbally communicated. Which of the patient’s actions is incongruent with her statement?
    a. Getting up from her chair while making the statement
    b. Walking toward the nurse while talking about her spouse
    c. Staring down at her shoes during the conversation
    d. Smiling while talking with the nurse

Answer 17

ANS: C
Incongruent communication occurs when the verbal content and the nonverbal level of communication are not in agreement. Avoiding eye contact during the statement would demonstrate such a disagreement. The remaining options are not in disagreement and so are not incongruent.

Question 18

19. A nurse tells a patient who is feeling guilty about an infidelity to call the spouse and beg for forgiveness. According to the transactional model of communication, the nurse’s response originated from which state?
    a. Adult
    b. Child
    c. Parent
    d. Complementary

Answer 18

ANS: C
The nurse’s statement can be construed as critical. The parent ego state consists of all the nurturing, critical, and prejudicial attitudes, behaviors, and experiences learned from other people, especially from parents and teachers.

Question 19

20. According to transactional analysis theory, when a patient finally recognizes the importance of being medication-compliant, which type of transaction has occurred?
    a. Ulterior
    b. Crossed
    c. Incongruent
    d. Complementary

Answer 19

ANS: D
In this interaction the two parties are communicating from adult ego state to adult ego state. Communication flows smoothly between the sender and the receiver. The remaining options do not demonstrate such effective communication.

Question 20

21. When the nurse suggests the patient communicate to her employer how overwhelmed she is by the workload, the patient responds, “Yes but I’ll get fired if I do that.” According to transactional analysis theory, this is an example of a(n) _____ transaction.
    a. ulterior
    b. crossed
    c. congruous
    d. complementary

Answer 20

ANS: A
This is an example of the “Why don’t you? Yes, but…” game. On the surface the game involves two adults solving problems; in reality, one person is using the child ego state to show what a bad parent the other person is.

Question 21

22. A patient who is currently in an abusive marriage shares, “Some days I think it’s just not worth it. I’d be better off if we separated.” The nurse uses restating as a therapeutic communication technique when responding:
    a. “Are you sure you are ready to be on your own?”
    b. “Can I help you work on a safe, realistic plan to leave?”
    c. “You think you would be better off without your spouse?”
    d. “How much thought have you given to leaving the marriage?”

Answer 21

ANS: C
Clarification involves the nurse attempting to put into words the vague ideas or thoughts that are implicit or explicit in the patient’s conversation.

Question 22

23. When a patient is late for three consecutive therapy sessions, the nurse implements perception sharing as a communication technique when stating:
    a. “You say how important therapy is to you, but you can’t seem to get here on time.”
    b. “Do you think it’s polite being late for therapy sessions like this?”
    c. “Do you have really good reasons for being late so often?”
    d. “I feel that you aren’t ready to work on your problems.”

Answer 22

ANS: D
Sharing perceptions involves asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling. The nurse can provide information and then ask for feedback. The other options do not focus on clarification.

Question 23

24. The therapeutic communication technique of suggesting is appropriate to use when it:
    a. meets the patient’s unmet dependency needs.
    b. shifts responsibility from the patient to the health care professional.
    c. is used during the working stage to present alternative coping strategies.
    d. is used early in the nurse-patient relationship to provide sound, everyday advice.

Answer 23

ANS: C
Suggesting is the presentation of alternative ideas. It is useful in the working phase of the relationship, when the patient has analyzed the problem and is exploring alternative coping mechanisms. At that time, nurse suggestions will increase the patient’s perceived options.

Question 24

25. A teenager being treated for oppositional defiance behavior states: “I wish my parents would stop treating me like an irresponsible child.” The nurse implements confrontation as a therapeutic technique when responding:
    a. “How can they treat you like an adult when you are only a teenager?”
    b. “You want to be treated like an adult, but is it adult-like when you skip school?”
    c. “Your parents have a legal responsibility to care for you until you are eighteen.”
    d. “Your parents are worried about giving you more freedom than you can handle.”

Answer 24

ANS: B
Confrontation is an expression by the nurse of discrepancies in the patient’s behavior such as being irresponsible and untrustworthy while wanting to be treated like an adult. The remaining options are not confrontational since they are not identifying such discrepancies.

Question 25

26. Which statement is true of planning the timing for the use of confrontation?
    a. Confrontation should never be used during the orientation phase of the relationship.
    b. Confrontation is useful during the working phase to focus on specific patient discrepancies.
    c. Confront patients with their limitations early in the relationship and with their assets later in therapy.
    d. Confront patients when other therapeutic action dimensions have proven ineffective.

Answer 25

ANS: B
Confrontation, when posed as an observation of incongruent behavior, can be used infrequently during the orientation phase of the relationship, but it is more useful during the working stage to expand the patient’s awareness and to help him or her move to a higher level of functioning. The remaining options are not true statements.

Question 26

27. The nurse suspects that a client has a problem with the action dimension of immediacy when she states, “You can’t tell people very much about yourself; it gives them too much power over you.” The nurse responds:
    a. “It sounds as though people have tried to control you inappropriately in the past.”
    b. “It’s reasonable for you to be suspicious of me until I’ve earned your trust.”
    c. “Allowing yourself to trust people will be a step toward getting well.”
    d. “It appears that you aren’t ready to discuss your problems yet.”

Answer 26

ANS: B
Immediacy involves focusing on the current interaction of the nurse and the patient in the relationship. In this situation the client is focusing on past issues of trust and the nurse correctly identifies a reasonable reaction to the client’s need to trust the nurse. The remaining options do not deal with the immediate need for trust on the part of the client.

Question 27

28. A chronically depressed patient has been diagnosed with having a dependent personality. The nurse suspects that the situation has resulted in dependence transference when the patient shares that:
    a. “Leaving the hospital and helpful, caring people like you will be really hard.”
    b. “Over the weeks we’ve been meeting I’ve come to feel as though you are a very special person.”
    c. “I think of you as being sent from heaven to guide me out of this darkness of the soul.”
    d. “I know I can count on you to chart my course back to health. I will do whatever you say.”

Answer 27

ANS: D
Dependent reaction transference is characterized by submissive, ingratiating behavior, regarding the nurse as a godlike figure, and overvaluing the nurse’s characteristics and qualities. The remaining options demonstrate gratitude but lack that submissive element.

Question 28

29. A nurse tells the unit supervisor, “I’m having a difficult time empathizing with my patient especially since he is so unwilling to change. Talking with him makes me feel both frustrated and depressed.” The supervisor may suspect that the cause of the barrier in this nurse-client relation is the:
    a. existence of countertransference on the part of the nurse.
    b. patient’s demonstration of resistance to the prescribed plan of care.
    c. violation of a therapeutic boundary by either the nurse or the patient.
    d. nurse’s ineffective use of therapeutic verbal communication techniques.

Answer 28

ANS: A
Countertransference is a therapeutic impasse created by the nurse’s specific emotional response to the qualities of the patient. This response is inappropriate to the content and context of the therapeutic relationship or inappropriate in the degree of intensity of emotion. The remaining options do not relate to inappropriate emotional responses especially by the nurse.