Chapter 11: The Therapeutic Relationship

Morrison-Valfre: Foundations of Mental Health Care, 7th Edition

Multiple Choice

1. The nurse is attempting to develop trust with a newly admitted female client for the purpose of establishing a therapeutic relationship. The nurse is currently administering medications to all clients on the unit. The newly admitted client asks the nurse to sit and talk with her for a while. What is the nurse’s best response?

a. “I am busy right now, but I will come back later.” b. “Give me just a few more minutes to finish passing medication to the other clients.” c. “I will return in 20 minutes so we can talk.” d. “I have to finish giving all the clients their medications, but I will then come back so we can talk.”

ANS: D

This is an honest statement that lets the client know exactly what the nurse is doing and helps to build trust in that the nurse is not making up excuses or making false promises. The nurse’s statement that she is busy right now would make the client feel unimportant. The nurse would be making false promises if she were to say that she will be back in only a few minutes or even in 20 minutes, because most likely it will take more than this amount of time to finish giving out medications.

DIF: Cognitive Level: Application REF: p. 118 OBJ: 2

TOP: Trust KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity a. The client will check his calendar each night to plan for commitments scheduled on the following day. b. The nurse will remind the client weekly of his appointment at the clinic for the following week. c. The client will ask the nurse to call him to remind him of his appointment. d. The nurse will complete the client’s calendar of daily commitments scheduled for the week.

2. A nurse is working with a male client in a mental health outpatient clinic. The client voices a desire to become more autonomous. Which goal will assist the client in becoming more autonomous?

ANS: A

Autonomy refers to the ability to direct and control one’s activities and destiny. Working toward this goal is a simple way to begin to develop control over one’s life. Reminding the client and completing the client’s calendar are nursing goals rather than client goals. If the client asks the nurse to call him to remind him, no responsibility is placed on the client.

DIF: Cognitive Level: Application REF: p. 118

TOP: Autonomy KEY: Nursing Process Step: Planning

MSC: Client Needs: Psychosocial Integrity

OBJ: 2

3. An important aspect of developing a therapeutic relationship with a mental health client is for the nurse to show that she cares about the client. The nurse who is working on an inpatient unit can show signs of caring by: a. telling a client several times a day that he or she cares about him or her. b. asking a client what his or her favorite movie is and then showing that movie during a movie night on the unit. c. giving a client a card that has a sentiment that says the nurse cares about him or her. d. telling a client that he or she is the favorite client.

ANS: B

Showing a favorite movie is a safe way of showing the client that you are aware of him or her as an individual, rather than as just another client. If the nurse only tells the client that she cares about him or her, it does not prove to the client that the nurse cares. Giving a client a card or telling the client that he or she is a favorite is too personal and may mislead the client regarding the development of a social relationship.

DIF: Cognitive Level: Application REF: p. 119 OBJ: 2

TOP: Caring KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity a. “You need to take your lithium unless you want to relapse.” b. “You are doing so well that there is nothing you can’t do if you put your mind to it.” c. “You are doing very well since we found that lithium helps. You should do well as long as you continue your therapy and medication.” d. “A lot of people are much worse off than you are, so you should be thankful that you are doing as well as you are.”

4. The nurse is caring for a female client with a diagnosis of severe bipolar disorder. Out of many treatment methods, the one treatment that the client and the team have found to be most effective is the medication lithium. The client voices concern about her future with this diagnosis. Which nurse response best represents the concept of hope?

ANS: C

This option is realistic and provides hope without providing false hope. Stating that the client will relapse if she discontinues medication suggests that the nurse is threatening the client, which provides no hope. Telling the client that “there is nothing that you can’t do” may be providing false hope. Reminding the client that others are worse off is disregarding the client’s feelings.

DIF: Cognitive Level: Application REF: p. 119

TOP: Hope KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity

OBJ: 2 a. Affective b. Contextual c. Temporal d. Affiliative

5. A male client with schizophrenia has lost his job and home and has been living in a homeless shelter. He voluntarily admits himself into a mental health treatment facility. The client’s current living situation and lack of a job at this time likely will contribute to his having difficulty with which dimension of hope?

ANS: B

Although all the dimensions of hope listed in these options may be difficult for this client, the dimension that is representative of the living and job situation for this client is contextual, because this refers to inadequate physical, financial, and emotional resources.

DIF: Cognitive Level: Comprehension REF: p. 119

TOP: Hope KEY: Nursing Process Step: Evaluation

MSC: Client Needs: Psychosocial Integrity

OBJ: 2 a. Ignoring the compulsion during the group therapy session and talking with the client privately about the behavior b. Asking the group to remind the client every time she touches her head to help her consciously stop the compulsion c. Pointing out the compulsion to the group each time the client exhibits the behavior d. Asking the client to stop talking during the group session until she has learned to control her compulsion

6. A female client with obsessive-compulsive disorder is undergoing treatment in an outpatient setting and is attending group therapy sessions. She is working on controlling the compulsion of touching her head three times every time she talks. To maintain the therapeutic relationship established with the client, by which action can the nurse show acceptance?

ANS: A

Ignoring the behavior in group therapy shows acceptance of the behavior because the nurse does not embarrass the client in front of the group. Talking with her privately shows compassion for the client. Asking the group to remind the client of the compulsion and pointing out the compulsion to the group could belittle the client. Asking the client to stop talking would defeat the purpose of the support of belonging to a therapeutic group.

DIF: Cognitive Level: Application REF: p. 120

TOP: Acceptance KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity

OBJ: 4 a. “I know exactly how you feel. My husband and I divorced 2 years ago because of his infidelity.” b. “Divorcing my husband was the best thing I ever did.” c. “I have friends who have gone through a divorce. It must be difficult for you.” d. “I am sorry that you have to go through this difficult time.”

7. The characteristic of genuineness helps in establishing a therapeutic relationship with a client. Which nurse response is the best example of a display of genuineness to a client who is going through a difficult divorce?

ANS: C

This response shows the client sincerity and honesty, which are components of being genuine. The nurse should not offer too much personal information, such as providing information about her own divorce. When the nurse says that she is sorry that the client is experiencing the difficult time, it is an example of a sympathetic response.

DIF: Cognitive Level: Application REF: p. 121 OBJ: 4

TOP: Genuineness KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity a. To establish with the client the purpose of the relationship b. To gather and review all possible information regarding the client c. To build trust with the client d. To obtain agreement from the client to work in conjunction with the nurse

8. During the preparation phase of a therapeutic relationship with a client, what is the main task to be completed by the nurse?

ANS: B

The main task during the preparation phase is to gather and review all possible information regarding the client; this can be accomplished by obtaining data from past and current medical records and from the client’s significant others. The other options are tasks that occur during the orientation phase.

DIF: Cognitive Level: Comprehension REF: p. 121 OBJ: 6

TOP: Phases of the Therapeutic Relationship

KEY: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity a. During the orientation phase b. Prior to the last meeting c. During the last meeting d. After all goals have been met

9. When should the nurse begin preparations for the termination phase of a therapeutic relationship?

ANS: B

Preparing for termination of the relationship should begin prior to the last meeting to allow for review of whether goals have been met and to prepare for client independence. The orientation phase is too early in the relationship to prepare for termination, and the last meeting is too late. Unfortunately, not all goals are always met, so preparing for termination of the relationship after goals have been met may not be a possibility.

DIF: Cognitive Level: Comprehension REF: p. 123 OBJ: 6

TOP: Phases of the Therapeutic Relationship

KEY: Nursing Process Step: Evaluation MSC: Client Needs: Psychosocial Integrity

10. The nurse is preparing an adult male client, who has been successfully treated for a social phobia, for the termination phase of the therapeutic relationship. During their last meeting, the client told the nurse that he noticed he has developed a nervous habit that started a few days ago of checking his door at home several times a day to be sure it is locked. This client is exhibiting the client response to termination known as: a. continuation. b. regression. c. withdrawal. d. confabulation.

ANS: A

Continuation sometimes occurs when a client is fearful of ending the therapeutic relationship. This response is characterized by a client’s trying to continue the relationship by bringing up new problems or having the caregiver solve his problems. Regression and withdrawal are also client responses to termination, but they do not fit the description in this situation. Confabulation is not a response to termination. It refers to the making up of answers by a client who is experiencing a memory loss.

DIF: Cognitive Level: Comprehension REF: p. 123 | Table 11.3

OBJ: 6 TOP: Phases of the Therapeutic Relationship

KEY: Nursing Process Step: Evaluation MSC: Client Needs: Psychosocial Integrity

11. When a caregiver becomes a role model for a client during a therapeutic relationship, the caregiver is functioning in the role of a: a. teacher. b. therapist. c. technician. d. change agent.

ANS: D

Serving as a role model is one of the many functions of a change agent. The role of a change agent also includes promoting a climate of anticipation of positive change for the client and serving as a socializing agent. The other options are roles of the caregiver, but role model is not included in those roles.

DIF: Cognitive Level: Comprehension REF: p. 123 OBJ: 7

TOP: Roles of the Care Giver KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity

12. A male client is being discharged from a mental health facility and is worried about what to tell his friends and coworkers regarding his time away. The nurse helps the client plan what to say to others about his disease. The nurse is functioning in the role of: a. change agent. b. teacher. c. therapist. d. technician.

ANS: B

This is an example of a teaching opportunity that the nurse is involved in during a therapeutic relationship. Other teaching opportunities include teaching the client how to cope with stressors, early signs of relapse, and effects of medications and providing public education regarding mental illness. The other options do not incorporate the teaching role as a function.

DIF: Cognitive Level: Comprehension REF: p. 123 OBJ: 7

TOP: Roles of the Care Giver KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity

13. A female client is admitted with suicidal tendencies. The client is placed in suicide precautions for the first 24 hours of her stay. Ensuring client safety is included in the therapeutic role of: a. change agent. b. teacher. c. therapist. d. technician.

ANS: D

In addition to ensuring safety, the role of technician includes medication management, management of medical problems in the mental health environment, and management of environmental factors. These responsibilities are not a function of the other roles.

DIF: Cognitive Level: Comprehension REF: p. 124 OBJ: 7

TOP: Roles of the Care Giver KEY: Nursing Process Step: Intervention

MSC: Client Needs: Safe and Effective Care Environment

14. The nurse who is caring for a client begins to have very protective feelings toward the client that are interfering with the therapeutic relationship between the nurse, the client, and the client’s family. This is an example of a problem that is encountered in some therapeutic relationships and is known as: a. an environmental problem. b. resistance. c. transference. d. countertransference.

ANS: D

Countertransference, the inappropriate emotional response of a caregiver to a client, is occurring in this relationship. Environmental problems refer to items such as privacy and noise levels, resistance is a behavior of the client that demonstrates unwillingness to change or accept the need for change, and transference is the client’s inappropriate feelings or behaviors directed toward the caregiver.

DIF: Cognitive Level: Comprehension REF: p. 125 OBJ: 8

TOP: Problems With Care Providers KEY: Nursing Process Step: Evaluation

MSC: Client Needs: Psychosocial Integrity a. Transference b. Primary resistance c. Secondary resistance d. Tertiary resistance

15. A 19-year-old male client is being treated for a drug addiction. He continually voices his dread of being discharged because he knows he will have to live with his parents and follow their rules until he can earn enough money to live on his own. He is showing increasing resistance to treatment measures, such as attending group sessions, and is refusing to acknowledge that he has an addiction or that he needs treatment. Which behavior is the client demonstrating?

ANS: C

This is an example of secondary resistance in view of the fact that the client is displaying behaviors that will prolong his discharge from the facility, in an attempt to avoid his perception of the unpleasant living situation that awaits him upon discharge. Transference is a client’s emotional response, based on earlier relationships, to the care provider. Primary resistance refers to simple avoidance of change or admitting the need for change. Tertiary resistance is not a used term.

DIF: Cognitive Level: Comprehension REF: p. 125 OBJ: 8

TOP: Problems With Clients KEY: Nursing Process Step: Evaluation

MSC: Client Needs: Psychosocial Integrity

16. A client response to the termination phase of the therapeutic relationship is withdrawal. This response most often is manifested by client behaviors such as: a. bringing up new problems. b. being absent from appointments. c. returning to maladaptive behavior. d. having increased anxiety.

ANS: B

Being absent from appointments is a behavior that is commonly seen when clients are withdrawing from the termination phase of the relationship. It actually is a response that occurs because the client does not want the therapeutic relationship to end. Bringing up new problems refers to the continuation response, and returning to maladaptive behavior and having increased anxiety refer to the regression response.

DIF: Cognitive Level: Comprehension REF: p. 125 OBJ: 6

TOP: Phases of the Therapeutic Relationship

KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity a. Termination b. Orientation c. Working d. Preparation

17. A 22-year-old woman with depression misses her scheduled meeting with the nurse. Although they have established a contract to meet on an agreed upon schedule, the nurse understands that the client is still testing the relationship and working on trusting her care provider. This behavior usually manifests itself during which phase of the therapeutic relationship?

ANS: B

Testing is an important step during the orientation phase in establishing trust in the therapeutic relationship. Although clients may not appear for scheduled appointments, may use profane language, or may resist sharing their feelings, the caregiver must demonstrate a willingness to continue the therapeutic relationship.

DIF: Cognitive Level: Comprehension REF: p. 122 OBJ: 6

TOP: Phases of the Therapeutic Relationship

KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity a. “You are still in the preparation phase and need to check the medical record for information.” b. “The orientation phase is a time where the client is building trust and testing you.” c. “During the working phase, the client may have growth and resistance.” d. “The termination phase is a difficult one for both nurse and client.”

18. The new nurse confides to his supervisor, “I am feeling frustrated. Mr. J has been doing so well in dealing with his issues over the last month, and today he refused to discuss anything productive in our session.” What is the most appropriate response?

ANS: C

The working phase of the therapeutic relationship has periods of growth accompanied by episodes of resistance. Changing one’s behavior is very hard work. It requires energy and self-disclosure. Clients often feel self-conscious, shameful, and vulnerable during this time.

DIF: Cognitive Level: Comprehension REF: p. 122 OBJ: 6

TOP: Phases of the Therapeutic Relationship

KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

19. As the nurse begins to discuss discharge plans for a 45-year-old female client hospitalized for anxiety, the client states, “You never really cared whether I get better! Why not stop this charade?” The nurse recognizes this to be: a. transference. b. secondary gain. c. countertransference. d. insecurity.

ANS: A

Transference is a client’s emotional response based on earlier relationships. The most outstanding characteristic of transference is the inappropriateness of the client’s responses. Secondary gain occurs when clients profit or avoid unpleasant situations by remaining ill. Countertransference is based on a caregiver’s inappropriate response.

DIF: Cognitive Level: Comprehension REF: p. 125 OBJ: 8

TOP: Problems With Clients KEY: Nursing Process Step: Assessment

MSC: Client Needs: Psychosocial Integrity

Multiple Response

1. For which roles are the caregiver responsible in a therapeutic relationship? (Select all that apply.)

a. Teacher b. Therapist c. Technician d. Friend e. Change agent f. Confidante

ANS: A, B, C, E

These are the typical roles of the caregiver in mental health services. The caregiver should avoid becoming friends with clients because this can cause strain on the professional relationship. The caregiver also should avoid becoming a confidante of the client because this term usually describes someone whom a person trusts with secret or private matters. This is not a role that the caregiver can play, given that caregivers have a responsibility to share with other team members information pertinent to the client’s care.

DIF: Cognitive Level: Knowledge REF: p. 123 | p. 124

OBJ: 7 TOP: Roles of the Care Providers

KEY: Nursing Process Step: Intervention MSC: Client Needs: Psychosocial Integrity a. Acceptance b. Rapport c. Problem-solving d. Genuineness e. Therapeutic use of self f. Mutual support

2. Which of the following are characteristics of a therapeutic relationship? (Select all that apply.)

ANS: A, B, D, E

The focus of the therapeutic relationship is on the client. It is consciously directed as the care provider establishes a connection with the client to help him or her cope with life demands. Acceptance, rapport, genuineness, and therapeutic use of self are the characteristics used to accomplish this. Problem-solving on the part of the care provider does not help the client to cope. Support is provided for the client; it is not mutual.

DIF: Cognitive Level: Knowledge REF: p. 120 OBJ: 4

TOP: Roles of the Care Providers KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity