Mental Health Chapter 8

A client is talking to a nurse about the recent death of her grandmother. She is sad, and tears roll down her cheeks as she talks. The nurse remembers how she felt when her own grandmother died the previous summer. The nurse puts her hand on the client's shoulder and says, "This must be very difficult for you." The nurse is demonstrating empathy based on which of the following?

A)

The nurse's response reflects an attempt to communicate understanding of the client's feelings.

B)

The nurse's response and use of reassuring touch reinforce the nurse's concern for the client.

C)

The nurse demonstrates understanding of how the client feels because of her own grandmother's death.

D)

The nurse's statement expresses compassion and kindness toward the client.

Ans:

A

Feedback:

Empathy involves the nurse receiving information from the client with open, nonjudgmental acceptance. The nurse should communicate this understanding of the experience and feelings so the client feels understood. It is not necessary for the nurse to have had the same experience, but the nurse needs to imagine how having the experience feels to the client. Sympathy is the expression of compassion and kindness.

A nurse is in the orientation phase of the nurse-client relationship with a client diagnosed with a mental disorder. When interviewing the client during this first encounter, which information about the client would be most important for the nurse to obtain?

A)

Known allergies

B)

Recent hospitalizations

C)

Perception of the problem

D)

Family history

Ans:

C

Feedback:

Although information about allergies, hospitalizations, and family history are important in the orientation phase, it is most important for the nurse to ask a client with a mental disorder about the nature of the problem from the client's perspective. Some clients deny that a problem exists; other clients may have misperceptions about the problem.

Termination takes place during the resolution phase of a nurse-client relationship. During the termination process, a client brings up resolved problems and presents them as new issues to work toward. The nurse interprets the client's action as indicating which of the following? The client:

A)

Is angry that the nurse is abandoning him.

B)

Requires additional therapy.

C)

Is unhappy that the therapy was ineffective

D)

Is attempting to prolong the nurse-client relationship.

Ans:

D

Feedback:

It is not unusual for clients with mental disorders to bring up resolved problems and present them as new issues during the resolution phase. The client is most likely attempting to prolong the nurse-client relationship. The client may be experiencing anxiety about the relationship ending. Anger typically would be demonstrated toward the nurse or displaced onto others rather than through the use of bringing up resolved problems. The client's actions do not indicate that additional therapy is needed, nor that the therapy was ineffective.

When engaged in a nontherapeutic relationship, which of the following would a nurse identify as occurring first?

A)

Failure to recognize the client as a person with a need

B)

The client avoiding the nurse

C)

The nurse being perceived as rude

D)

The client feeling hopeless and frustrated

Ans:

A

Feedback:

In a nontherapeutic relationship, the withholding phase occurs first, in which the nurse fails to recognize that the client is a person with an illness or health needs. The client avoiding the nurse and the nurse being perceived as rude are characteristics of the avoiding and ignoring phase. Feelings of client hopelessness and frustration characterize the end phase of "struggling with and making sense of. . . ."

A nurse is engaged in a therapeutic nurse-client relationship. The relationship is in the working phase. With which of the following would the client be involved? Select all that apply.

A)

Beginning to identify a need

B)

Testing new ways for problem solving

C)

Testing the relationship

D)

Discussing problems related to needs

E)

Examining personal issues

Ans:

B, D, E

Feedback:

During the working phase, the client discusses problems underlying the needs, uses the emotional safety of the relationship to examine personal issues, and tests new ways of solving problems. Identifying a need and testing the relationship typically occur during the orientation phase of the relationship.

A nurse knows rapport has been established when the client:

Select all that apply.

A)

Tries to isolate him- or herself from others in the group.

B)

Acknowledges that they wish to keep many topics off limit and private.

C)

Develops a sense of sharing.

D)

Displays decreased anxiety and feels comfortable in the presence of the nurse.

E)

Begins speaking with a more rapid, repetitive speech.

Ans:

C, D

Feedback:

When rapport develops, a client feels comfortable with the nurse and finds self-disclosure easier. The nurse also feels comfortable and recognizes that an interpersonal bond or alliance is developing. All of these factors—comfort, sense of sharing, and decreased anxiety—are important in establishing and building the nurse-client relationship. The other choices are signs that the client is distrustful of the therapeutic relationship.

Of the following actions, which indicate that the relationship between nurse and client may be moving outside professional boundaries? Select all that apply.

A)

The client brings the nurse a baked item for their lunch.

B)

The nurse is spending more time with the client than the others in the group.

C)

The nurse objectively listens and contributes to the team meeting about behaviors the client is displaying.

D)

The nurse tells a friend that she is the only one who truly understands this client.

E)

The nurse informs her supervisor that the client asked her to "keep a secret from the rest of the staff."

Ans:

A, B, D

Feedback:

Indicators that the relationship may be moving outside professional boundaries are gift giving on either party's part, spending more time than usual with a particular client, strenuously defending or explaining the client's behavior in team meetings, the nurse feeling that he or she is the only one who truly understands the client, keeping secrets, or frequently thinking about the client outside of the work situation.

Of the following items, which should the nurse discuss with the client about what the client's responsibilities are during the first meeting? Select all that apply.

A)

Attendance is expected for each session.

B)

Participation is expected during each session.

C)

How to make up sessions if the client doesn't feel like attending meetings.

D)

If the client feels anxious, they should take additional antianxiety medications.

E)

The client should be able to focus on the topics and not interrupt others during the session.

Ans:

A, B

Feedback:

The client is responsible for attending agreed-upon sessions, interacting during the sessions, and participating in the nurse-client relationship. The nurse should also explain clearly to the client meeting times, handling of missed sessions, and the estimated length of the relationship.

Which of the following would be considered a "usual or expected" response during the first few sessions?

A)

Showing up late for the first session

B)

Being confrontational with nurse and other group members

C)

Rambling due to nervousness

D)

Bragging about sexual conquests

Ans:

C

Feedback:

A client is usually nervous and insecure during the first few sessions and may exhibit behavior reflective of these emotions, such as rambling. Showing up late, being confrontational, and bragging are nontherapeutic ways to not participate in the session.

Which of the following behaviors would be considered a "testing behavior" that usually happens during the "honeymoon phase" of the relationship?

A)

Talking nonstop and monopolizing the conversation

B)

Sitting away from the group and not participating in the discussion

C)

Accusing the nurse of being too controlling during the session

D)

Expressing anger and accusing the nurse of breaking confidentiality

Ans:

D

Feedback:

The first part of the orientation phase, called the "honeymoon phase," is usually pleasant. However, the therapeutic team typically hits rough spots before completing this phase. The client begins to test the relationship to become convinced that the nurse will really accept him or her. Typical "testing behaviors" include forgetting a scheduled session or being late. Clients may also express anger at something a nurse says or accuse the nurse of breaking confidentiality.

During the termination phase, a client begins to raise old problems that have already been resolved. Which of the following would be the most appropriate nursing response? Select all that apply.

A)

Immediately stop the client and inform them that the nurse is running the session.

B)

Get angry at the client and ask them to leave the session.

C)

Reassure the client that they already covered these issues.

D)

Review with the client the learned methods to control the problems.

E)

Do not acknowledge this issue and continue on with the session as planned.

Ans:

C, D

Feedback:

A typical termination behavior is raising old problems that have already been resolved. The nurse may feel frustrated if clients in the termination phase present resolved problems as if they were new. The clients are attempting to prolong the relationship and avoid its ending. Nurses should avoid addressing these problems. Instead, they should reassure clients that they already covered those issues and learned methods to control them.

In a nontherapeutic relationship, a client may respond by:

A)

Going to the supervisor and ask to be placed in another group.

B)

Getting angry and start attacking the nurse.

C)

Leaving the unit and not be available for the scheduled meeting.

D)

Asking the nurse to talk about her relationships outside of work.

Ans:

C

Feedback:

In a nontherapeutic relationship, the nurse and client both feel very frustrated and keep varying their approach with each other in an attempt to establish a meaningful relationship. Eventually, the frustration becomes so great that the pair gives up on each other and moves to a phase of mutual withdrawal. The client will leave the unit or otherwise be unavailable during scheduled meeting times. If a meeting does occur, the nurse will try to keep it short, thinking, "What's the point—we just cover the same old ground anyway." The client will attempt to keep it superficial and stay on safe topics.

The middle phase of a deteriorating relationship usually consists of which of the following? Select all that apply.

A)

The client trying to avoid the nurse.

B)

The nurse trying to smother the client with attention.

C)

The client beginning to break as many rules as possible.

D)

The nurse ignoring and avoiding the client's requests for help.

E)

The client feeling defeated and hopeless.

Ans:

A, D

Feedback:

The middle phase of a deteriorating relationship consists of two subphases: avoiding and ignoring. The client begins to avoid the nurse and perceives that the nurse is avoiding him or her. The client abides by the rules and because he or she does not want to cause problems. The nurse is perceived as rude and condescending. The nurse ignores and avoids the client's requests for help; in turn, the client becomes more anxious, frustrated, and fearful. The end phase is named struggling with and making sense of. In the final phase of a nontherapeutic the client feels hopeless and frustrated as a result of the lack of support from the nurse.

Which of the following features should appear when motivational interviewing is being utilized? Select all that apply.

A)

Eliciting and strengthening client change talk

B)

Negotiating change plans

C)

Firming up client commitment

D)

Trying to "stick to the plan" without adapting to the moment

E)

Utilizing feedback at the very last session

Ans:

A, B, C

Feedback:

Eight identified features of motivational interviewing (MI) that should appear in every application of this technique include: openness to collaboration with clients' own expertise; proficiency in client-centered counseling, including accurate empathy; recognition of key aspects of client speech that guides the practice of MI; eliciting and strengthening client change talk; rolling with resistance; negotiating change plans; consolidating client commitment; and switching flexibly between MI and other intervention styles.

An advantage to utilizing phone/video conferencing includes:

A)

Ability to rely heavily on nonverbal communication.

B)

All patients have access to reliable technology.

C)

No documentation required since it is recorded on video.

D)

Ability to access clients in remote areas.

Ans:

D

Feedback:

Phone and video conferencing is becoming increasingly popular, especially in remote areas where the land or the isolation of the clinic constitute barriers to the development of a therapeutic relationship. However, three important criteria must be conceded before the use of this technology:

- Nonverbal communication is more difficult to detect and access.

- The client must have reliable access to the technology.

- An appropriate method of documentation must still be used.