chapter_004 therapeutic communication

Fortinash: Psychiatric Mental Health Nursing, 5th Edition

Chapter 04: Therapeutic Communication

Test Bank

MULTIPLE CHOICE

1. An example of an environmental factor that would cause a nurse to modify a planned critical interaction occurs when the:

a. Patient expresses a personal dislike for the nurseb. Patient is in total denial about her conditionc. Nurse lacks the degree of knowledge required for the interactiond. Nurse learns that the patient’s mother has been hospitalized with a stroke

ANS: DEnvironmental factors include timing. Timing of critical interventions is important. It should occur when the individual can give full attention to the topic. It would be inappropriate to continue with the plan in the face of the patient’s distress related to her mother’s illness. The remaining options reflect other types of factors that influence communication such as attitudes, knowledge, and relationships.

DIF: Cognitive Level: Application REF: Page 63TOP: Nursing Process: Planning (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

2. The nurse suspects that the patient’s communication is being negatively influenced by personal attitude when he is heard stating:

a. “They think I’m mentally ill but I’m not; I just get a little depressed at times.”b. “I can’t concentrate on anything besides getting out of here and back to my kids.”c. “Obviously my therapist can’t understand where I’m coming from because our

lives are so different.”d. “There isn’t anyone here in this hospital I can trust enough to talk to about why I

abuse alcohol and drugs.”

ANS: CAttitude determines how one person responds to another. It includes one’s biases, past experiences, and openness. People of different socioeconomic backgrounds may have difficulty surmounting this barrier. The remaining options reflect factors that can negatively influence communication but they are environmental, knowledge, and relationship oriented.

DIF: Cognitive Level: Application REF: Page 64TOP: Nursing Process: Assessment (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Test Bank

3. The nature of the communication characterized in this exchange between a nurse and a chronically depressed patient is:

Nurse: Is it true that you enjoy knitting?Patient: Yes, I’ve done it for years and am pretty good at it.Nurse: I’m just a beginner. Do you think you could give me some tips?Patient: I guess so. What would you like to know?a. Therapeuticb. Collegialc. Sociald. Intrapersonal

ANS: CAlthough the conversation takes place between the nurse and a patient, it is of a social nature. It is superficial and benefits both parties mutually by encouraging a relationship based on mutual interest. No expectation of help exists. Therapeutic communication promotes patient growth and is patient-focused. Collegial conversation occurs for the purpose of professional collaboration. Intrapersonal communication takes place within the individual.

DIF: Cognitive Level: Comprehension REF: Page 66TOP: Nursing Process: Implementation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

4. A patient expresses a sense of genuineness in the nurse providing care when sharing with family members that:

a. “I believe the nurse can feel what I’m feeling.”b. “I always know what the nurse expects of me; the explanations are always clear.”c. “I can tell the nurse is sincere because the face supports what the mouth is saying.”d. “I may not always like what the nurse has to say but I can always depend on what

I’m told.”

ANS: CGenuineness is demonstrated by congruence between verbal and nonverbal behavior. Empathy is seeing things from the patient’s viewpoint. Clearly stating expectations is a characteristic of clarity. Trustworthiness can be described as dependability.

DIF: Cognitive Level: Application REF: Page 69TOP: Nursing Process: Implementation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

5. When providing discharge teaching to a patient for whom English is a second language, what technique will the nurse use to assess the patient’s understanding of the information being shared verbally?

a. Continuously evaluating the patient’s nonverbal cuesb. Periodically asking the patient if they have any questionsc. Asking the patient to repeat the information they are givend. Providing the information in concise, written form


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Test Bank

ANS: AIndividuals from different cultures or even different generations often misunderstand and misinterpret an unfamiliar language. Being aware of and critically examining cues that result from nonverbal responses is an excellent technique to check their interpretations. Asking if they have questions is an ineffective technique in light of the language barrier. Repeating the information is no guarantee that the patient understands the information. Providing the information in written form reinforces the material but does not ensure understanding especially if the patient has deficiencies related to reading the language.


6. When communicating with a psychotic, schizophrenic patient, the nurse avoids the use of slang phrases most importantly because:

a. Such phrases have different meanings for different people.b. Such phrases will likely trigger anxiety and frustration in the patient.c. The use of such phrases is not appropriate when communicating therapeutically

with a patient.d. This patient’s altered thought processes will serve to make understanding such

phrases very unlikely.

ANS: DPrecise verbal communication is important because spoken words often mean different things to different people. Figures of speech, jokes, clichés, colloquialisms, and other terms or special phrases carry a variety of meanings especially to individuals with altered thought processes. A person with schizophrenia interprets concretely and literally whereas psychosis generally brings about loose associations. Although all the options are reasons to avoid the use of slang phrases, the primary reason in this case in to avoid confusing the patient.

DIF: Cognitive Level: Analysis REF: Page 64TOP: Nursing Process: Planning (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

7. The nurse is considering the need for both effective means of communication and safety when caring for a patient with impulse control issues and poor social skills. Which nursing intervention is most appropriate to address these needs?

a. Reminding the patient with each interaction what space boundaries are considered safe and desired

b. Asking the patient to describe and set space boundaries that feel safe and facilitate effective communication

c. Clearly setting space boundaries for the patient so both patient and staff feel safe and can communicate more effectively

d. Discussing the need for space boundaries and how they help both the patient and the staff feel safe and aide in communicating effectively


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Test Bank

ANS: DSpace as a concept of boundaries and safety is important to understand because the nurse and the patient need to respect the distance that each needs. For successful communication to occur, both parties need to feel safe. Some patients have problems with their boundaries and invade other patients’ own safe zones; patients who perceive this as threatening react aggressively to such boundary violations. The nurse may need to help the patient understand the need for appropriate distances in order for everyone to feel safe and to communicate effectively. Reminding the patient of what the boundaries are without first discussing the importance of space boundaries is not an effective technique. Having the patient set the boundaries does not take into consideration the needs of others, whereas staff setting the boundaries without patient involvement ignores the needs of the patient and prevents the patient from understanding of the situation.

DIF: Cognitive Level: Application REF: Page 65TOP: Nursing Process: Planning (Communication and Documentation)MSC: NCLEX: Safe and Effective Care Environment; Psychosocial Integrity

8. During the termination phase of the nurse-patient relationship with a dependent patient, the nurse evaluates the effectiveness of coping techniques learned by:

a. Role playing with the patient in order to practice being assertiveb. Asking the patient to define the difference between being assertive and being

aggressive.c. Discussing how her father effectively used both assertiveness and aggressiveness

to control herd. Asking, “When you used assertiveness to deal with your father during his visit,

how did it work?”

ANS: DEvaluation is a task of the termination phase. Asking such a question encourages patients to evaluate actions and look at the outcomes of behaviors. Role playing to practice the technique, defining the relevant terms, and discussing the effects of the father’s behavior would occur during the working phase of the relationship and does not encourage evaluation of the newly learned skills.

DIF: Cognitive Level: Application REF: Page 75TOP: Nursing Process: Evaluation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

9. The nurse has developed a plan in which nursing interventions are used to reinforce the patient’s healthy behaviors. Which statement by the nurse will positively reinforce the patient’s efforts regarding the plan?

a. “How can a stress reduction plan help you at home?”b. “It sounds like you have the incentive to make healthy choices.”c. “When you tried to follow the plan, how well did it work for you?”d. “It sounds as though making healthy choices is very important to you.”


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Test Bank

ANS: BThis answer offers a positive response to a patient who is trying out new behaviors. This nursing response will serve to encourage the patient’s efforts. The remaining options do not provide positive reinforcement but rather are attempts to gather more information or clarify the patient’s motivation to change.

DIF: Cognitive Level: Application REF: Page 75TOP: Nursing Process: Implementation; Health Promotion and Maintenance (Communication and Documentation) MSC: NCLEX: Psychosocial Integrity

10. A patient indicates that he is about to share information about his illness that is shocking and embarrassing. Which nursing intervention has priority in this situation in facilitating the communication process?

a. Reassuring the patient that talking will be therapeuticb. Assuring the patient the information will be kept confidentialc. Responding to the patient’s information in an accepting mannerd. Providing the patient with a private place for the discussion to occur

ANS: CResponding to the patient’s information in a nonjudgmental, accepting manner will encourage continued therapeutic communication. The remaining options, although appropriate, will not have the same generalized affect on the communication process as the correct option.


11. A patient whose history includes physically abusing his spouse and children has been admitted to the unit for alcohol and drug dependency. Which nurse will likely experience difficulty establishing a therapeutic relationship with this patient?

a. The nurse who has experienced physical abuseb. The novice nurse who has never cared for an abuserc. The experienced nurse who has ‘seen too many abusers’d. The nurse who has been in treatment for abusing a spouse

ANS: A


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Test Bank

The therapeutic use of the self begins with knowing yourself. Knowing yourself is a complex and lifelong learning process. At the core of self-knowledge is the nurse’s ability to correctly identify his or her own negative or unresolved issues including family backgrounds, dynamic cultural and social issues, values, biases, and prejudices. Having been a victim of physical abuse places this nurse in a situation that can be very harmful to the development of an affective nurse-patient relationship. The novice nurse may lack some of the knowledge and experience necessary to be effective but is not a likely to have intruding biases and prejudices. The experienced nurse is more likely to have worked on the ability to provide effective care in spite of such experience with this type of diagnosis whereas, the nurse having been treated for the diagnosis is most likely to show empathy and caring.

DIF: Cognitive Level: Application REF: 8TOP: Nursing Process: Assessment (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

12. A novice nurse asks, “What is so wrong about being sympathetic with a patient who has also lost a parent like I did?” The psychiatric nurse manager responds:

a. “There is a fine line between empathy and sympathy that when crossed makes you less able to be therapeutic.”

b. “Rather than discussing the loss of your parent with the patient, you can talk to me about it whenever you need to.”

c. “I’ll provide you with some excellent materials that I’m sure will help you to understand why sympathy is less therapeutic.”

d. “Sympathy indicates that you are sharing your personal feelings and that changes the focus of the communication from the patient to you.”

ANS: DEmpathy should not be confused with sympathy. Sympathy is overinvolvement and sharing your own feelings after hearing about another person’s similar experience. It is not objective, and its primary purpose is to decrease one’s own personal distress. Although substituting sympathy for empathy does lessen the ability to be therapeutic, that is not the best explanation for avoiding it. Offering to discuss the nurse’s loss is a kind gesture but does not address the nurse’s question. Providing materials on the subject would be an appropriate reinforcement but does not address the question well.


13. A nurse has for the past 4 weeks been working with a psychotic patient who has been mute and very withdrawn. The patient suddenly encroaches on the nurse’s personal space by touching inappropriately. What is the most therapeutic response by the nurse to address this behavior?

a. Ignore it this time because the patient is, at last, responding.b. Firmly communicate acceptable boundaries to the patient.c. Gently touch the patient’s head and then observe the reaction.d. Smile while telling the patient that people don’t like being touched like that.


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Test Bank

ANS: BThe therapeutic response is to clearly communicate appropriate boundaries. There are times when patients misinterpret the nurse’s nurturing as an invitation to an intimate relationship. In these instances, boundaries must be firmly, but neutrally, explained. The behavior should not be ignored since doing so may well result in the patient repeating the behavior with others, perhaps with disastrous results. Touch is often misinterpreted by psychotic patients and in this case has no therapeutic value. Nonverbal communication should always be congruent so as to avoid confusing the patient.

DIF: Cognitive Level: Application REF: 5TOP: Nursing Process: Implementation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

14. Which statement indicates that a novice nurse understands the purpose of therapeutic communication? “My goal for communication with any patient is to:

a. maintain relationships.”b. mutually share information.”c. promote growth and change.”d. offer advice and make suggestions.”

ANS: CTherapeutic communication is intended to assist the patient to grow and change. The other options are characteristics of social communication.


15. The expected outcome of conducting a periodic self-evaluation of one’s own responses to patients is for the nurse to continue:

a. Recognizing the nurse’s need for therapyb. Recognizing personal problems and strengthsc. Maintaining distance from the patients’ problemsd. Maintaining professional boundaries with the patients

ANS: BSelf-evaluation of responses to patients will reveal whether the nurse is responding with objectivity versus subjectivity, acceptance or rejection, calmly or with anger, and with sympathy or anxiety. The goal is not identify the nurse’s need for therapy or to maintain distance for patient problems, but rather to remain objective about them. The purpose of a self-evaluation is to recognize the nurse’s responses, not to maintain boundaries.

DIF: Cognitive Level: Application REF: Pages 68-69TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity


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Test Bank

16. Which nursing response would indicate an empathetic approach to a patient who is depressed over recent losses in her life?

a. “Losing a job isn’t always a bad thing.”b. “I lost my parents last year and still feel sad.”c. “Please tell me more about what you are feeling.”d. “Let’s not focus on what’s sad but rather what is good about life.”

ANS: CEmpathy or empathic understanding is the nurse’s ability to see things from the patient’s viewpoint and to communicate this understanding to the patient. This response focuses on the patient’s feelings and encourages further discussion. Minimizing the loss or suggesting a change in focus sounds judgmental or patronizing and will likely cut off communication. Although self-disclosure can be therapeutic, this focuses on the nurse’s feelings.


17. A nurse is considering the therapeutic value of touch when planning care for an anxious patient. What is the initial question the nurse should answer before initiating this technique?

a. “How comfortable am I with touching this patient?”b. “Will the patient find therapeutic touch supportive?”c. “Does research support the use of therapeutic touch?”d. “Has therapeutic touch proven to be therapeutic with anxious patients?”

ANS: ATouch will only communicate warmth and thus be therapeutic if the nurse is comfortable with it. Although the other options are all appropriate, they do not have priority in this situation.


18. The nurse mentions, “I like to use open-ended questions and statements because they result in fuller, more revealing responses by the patient, and they stimulate discussion.” What statement would the nurse ask to best stimulate conversation with a patient about their family?

a. “Where does your family live?”b. “Tell me about your family.”c. “Do you have a family nearby?”d. “Would you like to talk about your family?”

ANS: B


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Test Bank

This broad opening will encourage discussion as well as allow the patient to decide what to include about his or her family. The remaining options can all be answered with a “yes or no” response and so do not stimulate communication.


19. A patient is struggling to explore and solve a problem. The nurse determines that it would be therapeutic to offer alternatives. Which verbal introduction should the nurse incorporate in order to achieve this objective?

a. “Have you thought of...”b. “You should...”c. “Why don't you...”d. “I think you need to...”

ANS: AThis encourages the patient to consider alternatives without giving advice. The other options are preludes to giving advice, which is not considered therapeutic.


20. A nurse is contemplating the use of self-disclosure. The expected outcome of this strategy is that the patient will:

a. be informed about expected behaviorsb. express previously withheld feelingsc. foster a mutually supportive relationship with the nursed. recognize that the nurse can empathize through shared experiences

ANS: BSelf-disclosure should serve one or more of the following purposes: to model and educate; to build the therapeutic alliance; to provide concrete reflection that encourages reality testing. The nurse does not use self-disclosure foster a interdependent relationship that in any way gives support to the nurse. Empathy does not rely upon shared experiences.


21. The novice nurse is learning about the appropriate use of touch with patients experiencing psychiatric disorders. Which statement about touch will provide the nurse with the best basis for successful practice in psychiatric nursing situations?

a. Touch carries a different meaning for different individuals.b. Touch is rarely misinterpreted by patients because of its universal appeal.


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Test Bank

c. It is seldom inadvisable to touch a patient to convey interest and warmth.d. Paranoid patients accept procedural touch best when combined with humor.

ANS: AThe meaning of touch is highly individualized and is influenced by the length of the touch, the part of the body touched, the way the patient is touched, and the frequency of touch. Touch is often misinterpreted and not universally accepted. It may be highly inappropriate to use touch with certain patients to convey warmth and interest. Suspicious patients often do not have a sense of humor and regardless would likely find touch unacceptable.


22. A patient who has shown good progress with treatment has shown great resistance to being discharged to an outpatient program. Based on an understanding of the underlying pathology of resistance, the nurse:

a. Recognizes that the behavior will cease when discharge has occurredb. Refers back to the patient’s progress as an indication of the patient’s strengthsc. Assures the patient that outpatient therapy services will continue to be supportived. Shares that although scary, discharge to outpatient therapy is a sign of

improvement

ANS: BResistance to change is part of human nature that both the nurse and the patient need to address and manage so that positive growth will occur. The nurse helps patients to overcome resistance by pointing out their progress and strengths.


23. The nurse manager suspects that a novice nurse is experiencing countertransference regarding a chronically ill, psychotic patient. Which response is most effective at this time?

a. “I realize this is a difficult situation but it will occur again if you don’t manage it now.”

b. “I want you to see our hospital counselor so that you can regain your professional attitudes.”

c. “I believe you are no longer able to be therapeutic so I’m changing your patient assignment.”

d. “I’d like to help you begin to self-reflect on the feelings you seem to have for this patient.”

ANS: D


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Test Bank

Countertransference is an emotional response on the part of the nurse that is a result of certain qualities in a specific patient. The response is dramatic, irrational, and inappropriate. The initial response would be for the nurse to engage in a self-assessment that focuses on why these feelings are occurring. It is true that the nurse needs to manage the situation but will need some guidance regarding how to accomplish that. If self-reflection isn’t successful, then professional counseling would be the appropriate step. Changing the nurse’s assignment is not an effective means of managing the problem because it is a situation that reoccurs in nursing practice.


24. Which of the following nursing responses is an example of the therapeutic technique of empathizing?

a. “I think you may be finding this very difficult.”b. “I see you have been crying since your wife left.”c. “Help me to understand how this is affecting you.”d. “It sounds as if this is important to you.”

ANS: AIn an empathetic response the nurse exhibits warmth and acknowledges the patient’s feelings. Commenting on the patient’s crying is an example of the technique of making observations. Asking for help to understand is an example of seeking clarification. Finding importance is an example of reflection.


MULTIPLE RESPONSE

1. A nurse is discussing unit expectations with a newly admitted patient diagnosed with poor impulse control. The nurse shows an understanding of the use of body language to convey feelings when documenting that the patient is angry and resistant to authority based on which of the following? Select all that apply.

a. Patient’s reluctance to make eye contactb. Crossed-arm posture the patient assumesc. Quizzical expression on the patient’s faced. Sharp rapping of the patient’s fingers against the tablee. Patient’s tendency to lean forward when seated in the chair

ANS: B, D


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Test Bank

Body language includes facial expressions, reflexes, body posture, hand gestures, eye movement, mannerisms, touch, and other body motions. Body posture and facial expressions, including eye movements, are two of the most important cues to determine how a person is responding to the message. This patient’s crossed-arm posture and sharp finger rapping are indicators of anger. Poor eye contract is recognized as poor self-esteem or guilt cues, whereas a quizzical expression is likely an indication of confusion. Leaning forward in the chair is generally viewed as a positive sign of interest and/or cooperation.

DIF: Cognitive Level: Application REF: Page 65TOP: Nursing Process: Assessment (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

2. The nurse is planning approaches to use to begin the establishment of the nurse-patient relationship. Which therapeutic communication techniques will be most useful to achieve this goal? Select all that apply.

a. Attentively listening as the patient describes their obsessive compulsive ritualsb. Asking the anxious patient if they have a plan for controlling their current anxietyc. Encouraging the depressed patient to “come and talk with me whenever you want”d. Sitting quietly in the room while the non-communicating patient unpacks their

belongingse. Responding to the patient’s feelings of loss by stating, “I know that must have

made you very sad.”

ANS: A, C, D, EAttentive listening, offering self, silence and empathy are all therapeutic communication techniques that are appropriate for use in the orientation stage of the nurse-patient relationship. Encouraging plan formulation is reserved for the working phase of the relationship.

DIF: Cognitive Level: Analysis REF: Page 73TOP: Nursing Process: Implementation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

3. The nurse has been working for several weeks with a single mom who has been both verbally and physically abused by her children’s father. Which nursing actions are appropriate for this stage of treatment? Select all that apply.

a. Asking, “How does it make you feel when he hits you?”b. Providing information regarding women’s shelters in the local areac. Assuring the patient that her children can visit when she wants to see themd. Sharing that, “I know leaving him is difficult but you need a plan if he abuses you

again.”e. Responding, “You’ve certainly become more assertive; don’t be afraid to stand up

for yourself.”

ANS: A, B, D


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Test Bank

The working phase of the nurse-patient relationship involves evaluating the affects of the abuse, providing information that will help formulate a plan to end or manage the effects of the abuse, and encouraging the patient to confront the problem even when it is stressful. Assuring the patient that her children may visit is something that would happen in the orientation phase of the relationship when making the patient comfortable and responsive to treatment occurs. Positively reinforcing behaviors occurs in the termination phase as preparations are being made for discharge.

DIF: Cognitive Level: Analysis REF: Pages 74-75TOP: Nursing Process: Implementation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

4. The nurse shows an understanding of an essential purpose of therapeutic communication when (select all that apply):

a. Asking the patient, “How did it make you feel when your son died?”b. Encouraging the patient to assume responsibility for the problems he or she hasc. Attentively listening as the patient describes the reasons he or she is seeking helpd. Providing the patient with feedback regarding how he or she is implementing

stress relief techniquese. Sharing with the patient the details of several extremely stressful personal events

and how they were managed

ANS: A, C, DTherapeutic communication has three essential purposes: (1) to allow the patient to express thoughts, feelings, behaviors, and life experiences in a meaningful way to promote healthy growth; (2) to understand the significance of the patient’s problems and the roles that the patient and the significant people in his or her life play in perpetuating those problems; and (3) to assist with the identification and resolution processes of the patient’s health-related behaviors. Encouraging the patient to assume responsibility for his or her problems may not be appropriate in all cases and it is not appropriate for the nurse to share personal information even if it relates to a problem similar to the patient’s.

DIF: Cognitive Level: Analysis REF: Page 68TOP: Nursing Process: Implementation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

5. What statements indicate that the patient has an understanding of assertive behavior? Select all that apply.

a. “Always stand up for your own rights.”b. “I say what it takes to make my wishes known.”c. “Talking really loud seems to get the focus on me.”d. “I’m not uncomfortable telling someone ‘No’ when I need to.”e. “You don’t have to ignore the rights of others to stand up for yourself.”

ANS: A, D, E


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Test Bank

The assertive person defends their personal rights while respecting the rights of others and is not uncomfortable saying no when they are feeling oppressed. The remaining options are more characteristic of aggressive behavior.

DIF: Cognitive Level: Application REF: Page 71TOP: Nursing Process: Evaluation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity

6. The nurse is working on the inclusion of therapeutic humor in interactions with a chronically ill schizophrenic patient who was hospitalized after an attempted suicide. Which outcomes are realistic expectations for this patient? Select all that apply.

a. Improved cognitionb. Decreased interest in self-harmc. Increased ability to experience pleasured. Decrease in the expression of fear and anxietye. Appropriate expression of emotions through affect

ANS: B, C, D, EIn two studies, researchers found that humor-based group activities provided to patients with chronic schizophrenia showed that they had a significant reduction in negative symptoms, self-injury, self-reported anger, anxiety, and depression. Although the results may be preliminary, they suggest that humor-based interventions may be beneficial for patients with chronic mental illness. There is no supporting evidence that cognitive abilities improve with the introduction of therapeutic humor.



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chapter_004 therapeutic communication

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