Situation: V., age 40, is admitted to the medical unit for treatment of a peptic ulcer.
30. A nursing assistant remarks. "I don't know what's wrong with V. He never looks at me when I talk to him. He just stares at the floor." How should the nurse respond to the nursing assistant?
a) I wouldn't worry about it. That's just how some people are
b) when I give him his medication, I'll ask him if he is aware that he does this
c) you need to develop more patience with V. It takes time for patients to feel at ease in the hospital
d) what seems to bother you most about V.'s not looking at you?
31. The nurse can help the nursing assistant understand patient responses that are different from her own by explaining the importance of:
a) accepting the patient's way of responding and treat all patients alike
b) suppressing any feelings of discomfort or anxiety that the patient's behaviors create
c) evaluating behaviors in the context of the patient's cultural background
d) confronting the patient about his behaviors in order to understand their meaning.
Situation: The nurse has been caring for G., a 58 year old chronic paranoid schizophrenic patient, for several months. She has held several one-on-one sessions with him. During this particular session, he appears more anxious than usual.
32. At the beginning of the session, G. speaks quite rapidly and loudly. This behavior indicates a possible change in which form of nonverbal communication?
a) appearance
b) kinesics
c) paralanguage
d) proxemics
33. Still speaking loudly, G. says, "Speak up! You talk too softly. Who could carry on a conversation with someone who sounds like a squeaky little mouse?" According to Berne's theory of communication, the patient is communicating from which "ego state"?
a) parent
b) adult
c) adolescent
d) child
34. Besides his loud, rapid speech, G. swings his feet and rapidly taps his fingers on the arm of the chair. Yet he says, "I certainly feel calm today, I didn't life could be so tranquil." Which response by the nurse is most appropriate?
a) I'm glad to hear you are feeling calm and settled this morning
b) you tell me that you are calm, but your body seems to be sending a different message
c) I think we should talk about how calm the weather is today
d) I'm glad you are feeling so calm. Things will be better for you now -- you can count on that
35. G.'s anxiety level takes a toll on the nurse, and she feels her body tensing. The nurse momentarily questions the therapeutic quality of her listening skills. Which behavior on the nurse's part indicates her decreased attention to G.'s problems?
a) moving her chair so she directly faces G.
b) leaning forward toward G.
c) maintaining direct eye contact
d) crossing her arms and legs
36. Which statement is most appropriate to end the one-to-one session with G.?
a) your body seems more relaxed now, G.
b) today we talked about how your body can provide clues to your feelings
c) did you think today's session was of value to you?
d) I'm going to lunch now, our time is up
Situation: D., age 21, has just been admitted to the inpatient psychiatric unit. Her facial expression indicates severe panic, and she repeatedly states, "I know the police are going to shoot me. They found out that I'm the daughter of the devil."
37. To initiate a therapeutic nurse-patient relationship with D., the nurse should say:
a) you certainly look stressed, D. Can you tell me about the upsetting events that have occurred in your life recently?
b) hello, my name is A. I'm a nurse, and I will care for you when I am on duty. Would you like me to call you D., or do you prefer something else?
c) you are having very frightening thoughts. I will help you find ways to cope with this scary thinking
d) hello, D. I am going to be caring for you while I am on duty. You look very frightened, but by tomorrow I'm sure you'll feel better
38. After the assessment and intake procedures are completed, the nurse explains that she will try to be available to talk with D. when needed and that she will spend time with her each morning from 10:00 until 10:30 in a specific corner of the dayroom. The main rationale for communicating these planned nursing interventions is to:
a) provide a structured environment for D.
b) instill hope for D.
c) attempt to establish a trusting relationship
d) provide time for completing nursing responsibilities
39. During the first few one-to-one sessions, D. seems eager to talk, discusses her problems readily, and makes great efforts to focus on and describe her experiences. Then she begins to "forget" to come to scheduled sessions. When she does come, she seems suspicious and reluctant to talk. What is he most likely explanation for her behavior?
a) D. is fearful that she has revealed too much and that the nurse will now reject her; she is temporarily retreating to a safe distance
b) D. has found one-to-one sessions to be too personally intrusive and is attempting to protect her privacy
c) D.'s suspiciousness indicates that her symptoms have not responded to treatment and that her medication should be reevaluated
d) D. and the nurse are in a personality conflict, and the nurse should consider transferring the patient to another primary nurse
ANSWERS AND RATIONALE
30) D
- effective communication is based on self-understanding. Exploring the nursing assistant's feelings and responses to the patient's behavior facilitates the development of self-awareness, a prerequisite to planning a therapeutic response. Denying the assistant's feelings of frustration without exploring their cause or intervening with the patient on behalf of the assistant at this point would not be helpful to the assistant. Asking the assistant to have more patience may stop her from exploring her feelings about the situation. By exploring the assistant's feelings, the nurse can help her understand the mental health needs of the patient.
31) C
- to assess the patient's needs, the nursing assistant must take into account the patient's cultural influences, values, beliefs, attitudes, and verbal and nonverbal behavior. In some cultures, looking down is a sign of respect. All patients are different and should be treated as individuals. The nurse should encourage the assistant to discuss her discomfort or anxiety rather than suppress it. She should not recommend confronting the patient because this will cause him to feel alienated.
32) C
-
paralanguage is the use of vocal effects, such as tone and tempo, to convey a message.
Appearance is to the way people look.
Kinetics involves body language or movement.
Proxemics is the use of spatial relationships (distance between people) during interaction to communicate learning.
33) A
- the transactional analysis model consists of three ego states -- parent, adult, and child. Each ego state is unique, yet all three combine to form one personality. Berne's
parent ego state includes the aspects of critical parent and nurturing parent. G. sounds like a "critical parent" and therefore is communicating from the parent ego state. A patient communicating from
child ego state would exhibit feelings formulated during childhood, such as fear of authority figures. A patient communicating from the
adult ego state would appear rational and capable of coping with feelings and situations in a logical manner. Berne's theory does not include an adolescent ego state.
34) B
- using confrontation to call attention to the discrepancy between what the patient says (verbal communication) and how he behaves (nonverbal communication) can help the patient become aware of his true feelings. Nonverbal behavior usually is a more precise indicator of feelings. Responses that ignore the incongruent behavior are not therapeutic.
35) D
- crossing the arms and legs can be a sign of defensiveness and decreased involvement with others. Signs of attentiveness and interest include facing another person squarely, leaning forward, and maintaining direct eye contact.
36) B
- summarizing at the end of a one-to-one session helps reinforce the most significant information discussed. Observations about how relaxed the patient appears are more appropriate during the session. Questions that elicit a "Yes" or "No" response are generally nontherapeutic to the patient. The nurse's telling the patient that she is now going to lunch does not focus on the patient and is therefore inappropriate.
37) B
- the first task during the introductory, or orientation phase of the nurse-patient relationship is
to formulate contract, which begins with the exchange of names and an explanation of the roles and limits of the relationship. These tasks should precede the exploration of relevant stressors and new coping mechanisms. Offering false reassurance is never therapeutic.
38) C
- availability, reliability, and consistency are critical factors in establishing trust with patients. Being specific about the time and place of meetings helps establish trust, which is the initial main objective. Although important, structuring the environment and instilling hope are not the primary tasks at this time. Arranging a regular meeting with the patient allows the nurse to plan her work load, but it is not a major reason for such scheduling.
39) A
- patients often are fearful that if they reveal themselves initially, the nurse will reject them, as others have done in the past. D. may or may not be aware that she is pulling back from the nurse. Her behavior actually is an indication of her potential to trust and should be considered a normal response at this point in the nurse-patient relationship. No evidence exists to support the other explanations.
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