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Chapter 5: Developing Therapeutic Communication Skills
Arnold: Interpersonal Relationships, 7th Edition
MULTIPLE CHOICE
1.When therapeutically communicating with a client who has just found out he is HIV- positive, the nurse should focus on
| a. | professional needs. |
| b. | an unlimited time frame for communication. |
| c. | verbal communication only between the client and the nurse. |
| d. | achieving identified health-related goals. |
ANS: D
Therapeutic communication is defined as a dynamic interactive process consisting of words and actions and entered into by a clinician and client for the purpose of achieving identified health-related goals. Originally conceptualized by Jurgen Ruesch in 1961, communication skills are essential drivers for developing therapeutic relationships and facilitating interdisciplinary collaborative communication with clients and families. Fundamental forms of health communication include verbal and written words and nonverbal communicative behaviors.
DIF:Cognitive Level: ApplicationREF:p. 75
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
2.The nurse demonstrates understanding of the concept of metacommunication through
| a. | recognizing the impact of communication on others. |
| b. | actively listening with good eye contact. |
| c. | implementing barriers to effective communication. |
| d. | ensuring that verbal and nonverbal messages are incongruent. |
ANS: B
Metacommunication refers to how nonverbal cues are used to enhance or negate the meaning of words. In addition to observable nonverbal behavior, client choices about clothing, personal and religious items, hairstyle and hygiene, and voluntary use of gestures inform, add to, and complete verbal messages. Behavioral communication is influenced by life circumstances, culture, and immediate context, so it is susceptible to misinterpretation and requires validation.
DIF:Cognitive Level: ApplicationREF:p. 76
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
3.When communicating with a client, the nurse recognizes that a barrier to effective communication is
| a. | cultural sensitivity. |
| b. | thinking ahead to the next question. |
| c. | completion of physical care in a nonhurried manner. |
| d. | focusing on the current questions asked by the client. |
ANS: B
Barriers to effective communication within the nurse occur when the nurse is not fully engaged with the client because of thinking ahead to the next question; when the nurse has cultural stereotypes and biases; and when the nurse is in a hurry to complete physical care.
DIF:Cognitive Level: ApplicationREF:p. 79
TOP:Step of the Nursing Process: Implementation
MSC:Client Needs: Psychosocial Integrity
4.When communicating with clients, the nurse actively uses listening responses. Which of the following types of listening response should the nurse use?
| a. | Moralizing |
| b. | Giving advice |
| c. | False reassurance |
| d. | Paraphrasing |
ANS: D
Paraphrasing is an example of a listening response that focuses on the client. Moralizing, giving advice, and false reassurances are all examples of negative listening responses.
DIF:Cognitive Level: ComprehensionREF:p. 86| p. 88
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
5.The nurse enters a client’s room with the intent of allowing the client to express feelings in relation to her new cancer diagnosis. The nurse notices that the client is crying and guarding her incision site. After validating physical discomfort, the nurse should
| a. | administer an analgesic and postpone the interaction. |
| b. | sit with the client and hold her hand. |
| c. | explain that pain is expected following surgery but that it is important to increase activity to avoid complications. |
| d. | acknowledge the physical pain but state that it is a priority to immediately address the emotional pain. |
ANS: A
Communication breaks down when the nurse and client do not share the same understanding of messages. Barriers to effective communication occur in clients when they are preoccupied with pain, physical discomfort, worry, or contradictory personal beliefs. The client’s pain must be a priority for the nurse before other needs are addressed.
DIF:Cognitive Level: AnalysisREF:p. 78
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Management of Care
6.A nurse is conducting a medication education group for mentally ill clients. One of the clients states, “I don’t think everyone needs medications. What about psychotherapy? Can you tell me about that?” What is an appropriate response by the nurse?
| a. | Talk to the group about the benefits of psychotherapy. |
| b. | Tell the group that psychotherapy is ineffective and they need medication. |
| c. | Acknowledge the question, but explain the time limitations and focus of that particular group. |
| d. | Explain that it is the physician’s decision what type of treatment modality is for each client |
ANS: C
In the past, nurses had more time with clients. Today nurses must make every second count. Nurses and clients need to select the most pressing health care needs for attention. The nurse should focus on what is essential to know, rather than what might be nice to know. This requires planning and sensitivity to client needs and preferences. Client readiness and capabilities are other factors to take into consideration in selecting content. Unless it is an emergency situation, the nurse can guide but not insist on a particular point of discussion.
DIF:Cognitive Level: ApplicationREF:p. 92
TOP:Step of the Nursing Process: Implementation
MSC:Client Needs: Psychosocial Integrity
7.When teaching a client how to administer insulin, the nurse recognizes that the best method of communicating therapeutically with the client is to
| a. | talk to the client in the visitors’ lounge. |
| b. | talk to the client within his personal space. |
| c. | communicate with the client using touch. |
| d. | face the client while leaning slightly forward. |
ANS: D
Privacy, space, and timing are other aspects to consider. Clients need privacy, to be free from interruption, and to have their space requirements respected to fully engage in meaningful conversations. Therapeutic conversations typically take place within a social distance (3-4 feet is optimal). Touch has contextual and cultural meanings. Women are more likely to welcome and use touch in communication. Touch is a valued form of communication in some cultures. In others, touch is reserved for religious purposes or is seldom used as a form of communication, for example in Asia. Before touching a client, assess the client’s receptiveness to touch. Observing the client will provide some indication, but you may need to ask for validation. If the client is paranoid, out of touch with reality, verbally inappropriate, or mistrustful, touch is contraindicated as a listening response. Minimal physical cues (e.g., leaning towards the client, nodding, smiling) are used to accentuate words and to connect with people nonverbally as well as verbally.
DIF:Cognitive Level: ApplicationREF:p. 76
TOP:Step of the Nursing Process: Implementation
MSC:Client Needs: Psychosocial Integrity
8.When conducting an assessment interview, which of the following is the best communication technique for the nurse to use?
| a. | Ask multiple questions at the same time |
| b. | Offer limited time for the client to respond to each question that is asked |
| c. | Use short, unambiguous listening responses focused on current health issues and client concerns |
| d. | Ensure that all questions are answered immediately in order to avoid the need for related follow-up questions to clarify |
ANS: C
A client-centered interview begins with encouraging clients to tell the story of their illness. This format helps nurses integrate personal with medical perspectives. Using short, unambiguous listening responses focused on current health issues and client concerns is the best means of helping clients tell their story. With relevant queries you will get a better idea of how the client communicates and what clients consider most important about their clinical situation. In addition to using a “here and now” approach, avoid asking more than one question at a time, and allow enough time for the client to fully answer. Related follow-up questions to clarify or help clients expand on what has been introduced can be helpful.
DIF:Cognitive Level: ApplicationREF:p. 82
TOP:Step of the Nursing Process: Assessment
MSC:Client Needs: Psychosocial Integrity
9.The nurse asks a newly admitted client, “Can you tell me what brought you to the hospital today?” The purpose of an open-ended question is to
| a. | influence the direction of an acceptable response. |
| b. | encourage the client to answer the question with a one-word response. |
| c. | allow clients latitude in telling their story. |
| d. | allow the client to engage in a passive relationship with the nurse. |
ANS: C
Open-ended questions permit clients to express health problems and needs in their own words. They are especially helpful at the start of a relationship, when the nurse’s objective is to gather information and to get to know the client as a person. You are more likely to elicit a client’s values, preferences, and ways of thinking about their illness if you allow them latitude in telling their story through open-ended questions. Sharing the personal meanings of an illness rather than identifying a diagnosis or listing discrete symptoms helps the client and nurse link the context of a health disruption with symptoms and provides more complete information. An open-ended question is similar to an essay question on a test. It is open to interpretation and cannot be answered by “yes,” “no,” or a one-word response. Open-ended questions ask clients to think and reflect on their situation. They help connect relevant elements of the client’s experience without influencing the direction of the response. (e.g., relationships, impact of the illness on self or others, environmental barriers, potential resources). Open-ended questions are used to elicit the client’s thoughts and perspectives without influencing the direction of an acceptable response.
DIF:Cognitive Level: ApplicationREF:p. 82
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
10.Which of the following is the best questioning sequence during a client interview in which the client is communicative and not in an emergency situation?
| a. | Begin with focused questions and proceed to open-ended questions. |
| b. | Begin with open-ended questions and proceed to focused questions. |
| c. | Begin with closed questions and proceed to open-ended questions. |
| d. | Begin with open-ended questions and proceed to closed questions. |
ANS: B
Start with open-ended questions to allow the client to tell his or her story in his or her own way to obtain general information. Use focused questions to obtain more specific information Start with open-ended, not focused or closed, questions. Proceed to focused questions, not closed questions.
DIF:Cognitive Level: ApplicationREF:pp. 82-83
TOP:Step of the Nursing Process: Assessment
MSC:Client Needs: Psychosocial Integrity
11.A client is admitted to the hospital for unsteady gait resulting in frequent falls. Which of the following is a circular question that the nurse could ask this client?
| a. | “Tell me more about your falls at home.” |
| b. | “How will this hospitalization affect your family?” |
| c. | “Have you experienced dizziness and imbalance before?” |
| d. | “Can you tell me what brought you here?” |
ANS: B
Circular questions are a form of focused questions, which give attention to the interpersonal context in which an illness occurs. These are used to explore the impact of a health disruption on family functioning and relationships with significant others. “Tell me more about your falls at home” is a focused question. “Have you experienced dizziness and imbalance before?” is a closed-ended question. “Can you tell me what brought you here?” is an open-ended question.
DIF:Cognitive Level: ApplicationREF:p. 83
TOP:Step of the Nursing Process: Assessment
MSC:Client Needs: Psychosocial Integrity
12.A client states, “I can’t sleep all night because the nurses are noisy.” Which of the following responses by the nurse best represents the nurse’s recognition of the client’s theme?
| a. | “I will speak to the supervisor about your complaint.” |
| b. | “You cannot sleep because of the noise level at night?” |
| c. | “You need to understand that nurses communicate with other clients during the night.” |
| d. | “I will tell the night nurses that you complained.” |
ANS: B
Listening for themes requires observing and understanding what the client is not saying, as well as what the person actually reveals. Identifying the underlying themes presented in a therapeutic conversation can relieve anxiety and provide direction for individualized nursing interventions. Speaking to a supervisor, explaining that nurses communicate with other clients during the night, and telling the night nurse of the complaint are actions by the nurse, not identification of themes.
DIF:Cognitive Level: ApplicationREF:pp. 83-84
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
13.A client states, “I don’t know about taking this medicine the doctor is putting me on. I’ve never had to take medication before, and now I have to take it twice a day.” The nurse’s response is, “It sounds like you don’t know what to expect from taking the medication.” The nurse’s response is an example of which of the following?
| a. | Clarification |
| b. | Paraphrasing |
| c. | Restatement |
| d. | Validation |
ANS: B
Paraphrasing is a listening response, which focuses on the cognitive component of a message. It is used to check whether the nurse’s translation of the client’s words represents an accurate interpretation of the message. The strategy takes the essential information expressed in the client’s original message and presents it in a shorter, more specific form, without losing its meaning. The focus is on the core elements of the original statement: “In other words, what I think I hear you saying is,” or “let me understand, are you saying that….?” Clarification is a listening response, used to ask clients for more information or for elaboration on a point. The strategy is useful when parts of a client’s communication are ambiguous or not easily understood. Failure to ask for clarification when part of the communication is poorly understood means that the nurse will act on incomplete or inaccurate information. For example, you could say, “May I tell you what I have understood so far, and see if you think I understand your situation? Restatement is an active listening strategy used to broaden a client’s perspective or provide a sharper focus on a specific part of the communication. Restating a self-critical or irrational part of the message in a questioning manner focuses the client’s attention on the possibility of an inaccurate or global assertion. Restatement is particularly effective when the client overgeneralizes or seems stuck in a repetitive line of thinking. To challenge the validity of the client’s statement directly could be counterproductive, whereas repeating parts of the message in the form of a query serves a similar purpose without raising defenses; for example, “Let me see if I have this right…”
Validation is a special form of feedback, used to ensure that both participants have the same basic understanding of messages. Simply asking clients whether they understand what was said is not an adequate method of validating message content. Validation can provide new information that helps the nurse frame comments that match the client’s need.
DIF:Cognitive Level: ApplicationREF:pp. 87-88
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
14.The student nurse is working on an assignment in which she has to interview a fellow student nurse for 30 minutes. The fellow student nurse talks about career plans, possible jobs after graduation, and her part-time work. After 10 minutes, she has stopped talking and both student nurses sit in silence. Which of the following is the best response by the interviewing student nurse?
| a. | “Tell me more about how you selected your career goals.” |
| b. | “Who is the most significant person in your life?” |
| c. | “What impact will these plans have on your life?” |
| d. | Remain silent until the fellow student nurse breaks the silence. |
ANS: C
An open-ended question is usually just the introduction, requiring further dialogue about relevant topics. Ending the dialogue with a general open-ended question such as, “Is there anything else that is concerning you right now?” can provide relevant information that might otherwise be overlooked. Asking a focused question allows the interviewer to obtain more specific information. “Who is the most significant person in your life” is a closed-ended question that is limiting. A silent pause can be helpful, but long silences can become uncomfortable.
DIF:Cognitive Level: ApplicationREF:pp. 82-83
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
15.As the nurse communicates with a client, the feedback provided by the nurse should be
| a. | descriptive, general, and content focused. |
| b. | client focused and evaluative. |
| c. | well-timed and general. |
| d. | specific and focused on observed behavior. |
ANS: D
Feedback is a response message related to specific client behaviors and words. Nurses give and ask for client feedback to ensure mutual understanding. Feedback can focus on the content, the relationship between people and events, the feelings generated by the message, or parts of the communication that are not clear. Feedback should be specific and focused on observed behavior. Analyzing a client’s motivations make clients defensive. Feedback should be a two-way process. Feedback responses reassure the client that the nurse is fully attentive to what the client is communicating. When it offers a neutral mirror, clients are able to view a problem or behavior from a different perspective. Feedback is most relevant when it only addresses the topics under discussion and doesn’t go beyond the data presented by the client. Feedback provided to nurses about their health teaching helps them to individualize teaching content and methodology to better facilitate the learning process.
DIF:Cognitive Level: KnowledgeREF:p. 92
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
16.A client tells the nurse, “I am having a tough time and I am scared about the future.” Which of the following responses by the nurse is the best feedback?
| a. | “I know what you mean.” |
| b. | “You should do something about it.” |
| c. | “I really don’t think you are having a tough time.” |
| d. | “You are having a tough time and you are scared.” |
ANS: D
Feedback is a response message related to specific client behaviors and words. Nurses give and ask for client feedback to ensure mutual understanding. Feedback can focus on the content, the relationship between people and events, the feelings generated by the message, or parts of the communication that are not clear. Feedback should be specific and focused on observed behavior. Analyzing a client’s motivations make clients defensive. Feedback should be a two-way process. Feedback responses reassure the client that the nurse is fully attentive to what the client is communicating. When it offers a neutral mirror, clients are able to view a problem or behavior from a different perspective. Feedback is most relevant when it only addresses the topics under discussion, and doesn’t go beyond the data presented by the client. Feedback provided to nurses about their health teaching helps them to individualize teaching content and methodology to better facilitate the learning process. “I know what you mean” is disconfirming. “You should do something about it” and “I really don’t think you are having a tough time” are examples of responses that are judging or evaluating.
DIF:Cognitive Level: ApplicationREF:p. 92
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
17.When caring for a hospitalized client, the nurse demonstrates effective communication when
| a. | presenting several ideas at a time. |
| b. | using vocabulary that is unfamiliar to the client. |
| c. | stating key ideas only once. |
| d. | putting ideas in a logical sequence of related material. |
ANS: D
Guidelines to effective verbal communication in the nurse-client relationship include putting ideas in a logical sequence of related material, focusing only on essential elements and presenting one idea at a time, keeping language as simple as possible through using vocabulary familiar to the client, and repeating key ideas.
DIF:Cognitive Level: ApplicationREF:p. 92
TOP:Step of the Nursing Process: All phases
MSC:Client Needs: Psychosocial Integrity
18.Which of the following is true in relation to the use of humor?
| a. | Humor is most effective when building rapport. |
| b. | Humor should focus on the client’s personal characteristics. |
| c. | Humor and laughter have healing purposes. |
| d. | Humor should dominate the situation. |
ANS: C
Humor and laughter have healing purposes. Laughter generates energy, and activates b-endorphins, a neurotransmitter that creates natural highs and reduces stress hormones. Humor is most effective when rapport is well established and a level of trust exists between the nurse and client. When humor is used, it should focus on the idea, event, or situation, or something other than the client’s personal characteristics. Humor should fit the situation, not dominate it.
DIF:Cognitive Level: KnowledgeREF:pp. 94-95
TOP:Step of the Nursing Process: Implementation
MSC:Client Needs: Psychosocial Integrity
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