Countertransference: My Patient’s Alcohol Abuse Reminds Me of My Own Past Struggles
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Bethany, a nurse on the psychiatric unit, has a past history of alcoholism. She has weekly clinical supervision meetings with her mentor, the director of the unit. Which statement by Bethany to her mentor would indicate the presence of countertransference? "My patient, Laney, has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!"
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B This statement indicates countertransference; Bethany may be overidentifying with the patient because of her own past history of alcoholism. She is providing adamant advice to the patient that, besides being nontherapeutic, may be more relevant to her own past than to the patient's. The discharge teaching for a patient being discharged and focusing on the treatment plan for the alcoholic patient are appropriate and show no signs of countertransference. The patient calling the nurse by her daughter's name is transference rather than countertransference
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You are working with Allison on the inpatient psychiatric unit. Which of the following statements reflect an accurate understanding during which phase of the nurse-patient relationship the issue of termination should first be discussed? D"Allison, now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge."
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D The issue of termination is brought up first in the orientation phase. All the other options describe other phases of the nurse-patient relationshipâthe termination phase, the preorientation phase, and the working phase.
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Your patient, Emma, is crying in your one-to-one session while telling you of her father's recent death from a car accident. Which of the following responses illustrates empathy? "Emma, that must have been such a hard situation to deal with."
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C This response reflects understanding of the patient's feelings, which is empathy. Feeling sorry for the client represents sympathy, whereas not addressing the patient's concern belittles the patient's feelings of grief she is expressing by changing the subject. Telling the patient she will get over it does not reflect empathy and is closed-ended.
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Willis has been admitted to your inpatient psychiatric unit with suicidal ideation. He resides in a halfway house after being released from prison, where he was sent for sexually abusing his teenage stepdaughter. In your one-to-one session he tells you of his terrible guilt over the situation and wanting to die because of it. Which of the following responses you could make reflects a helpful trait in a therapeutic relationship? "You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living."
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D This response demonstrates suspending value judgment, a helpful trait in establishing and maintaining a therapeutic relationship. Although it is difficult, nurses are more effective when they don't use their own value systems to judge patients' thoughts, feelings, or behaviors. The other options are all judgmental responses. Judgment on the part of the nurse will most likely interfere with further explorations of feelings and hinder the therapeutic relationship.
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Which of the following statements are true regarding the differences between a social relationship and a therapeutic relationship? (select all that apply): A In a social relationship, both parties' needs are met; in a therapeutic relationship only the patient's needs are to be considered. C Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. D In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship solutions are discussed but are only implemented by the patient.
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A, C, D The other options describe the opposite meanings of social and therapeutic relationships.
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The nurse would NOT address which of the following goals in attempting to establish a therapeutic nurse-client relationship? Providing the client with opportunities to socialize.
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C Addressing the client's need to socialize is not one of the goals of establishing a therapeutic relationship. The other options are goals addressed in a therapeutic relationship.
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An action that is acceptable in a social relationship but not in a therapeutic relationship is giving advice.
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giving advice Giving and receiving advice is acceptable in a social relationship. In a therapeutic relationship, it is appropriate for the nurse to assist the client in exploring alternative solutions to problems and in making his or her own decisions.
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According to Rogers, a synonym for genuineness is congruence.
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congruence. Genuineness refers to self-awareness of one's feelings as they arise within the relationship and the ability to communicate them when appropriate. It is the ability to meet others person-to-person without hiding behind roles. Rogers uses the word congruence to signify genuineness
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The phase of the nurse-client relationship that may cause anxieties to reappear and past losses to be reviewed is the termination phase.
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termination phase Termination, a stage in which the client must face the loss or ending of the therapeutic relationship, often reawakens the pain of earlier losses.
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When a nurse is biased against a client, those feelings will likely make it difficult to view the client with positive regard.
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view the client with positive regard. Whenever a nurse harbors negative feelings about a client, these feelings stand in the way of objectivity and reduce his or her ability to give the client positive regard.
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To help a client develop his or her resources, the nurse must first be aware of the client's strengths.
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the client's strengths. Nurses work to bolster a client's strengths, to identify areas of dysfunction, and to assist in the development of new coping strategies.
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One of the possible sources of boundary violations is placing the focus on meeting the nurse's needs.
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meeting the nurse's needs. Boundary violations have two sources: (1) allowing the therapeutic relationship to slip into a social relationship, and (2) meeting the nurse's personal needs at the expense of the client's needs.
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In the process of trying new values, which step shows the highest commitment to the value? Consistently acting in ways that repeatedly affirm the value
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Consistently acting in ways that repeatedly affirm the value Values clarification theory puts acting consistently on one's belief as the highest level of the process, following prizing and choosing.
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When a nurse and client meet informally or have an otherwise limited but helpful relationship, the relationship is referred to as a(n) therapeutic encounter.
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therapeutic encounter. Correct A therapeutic encounter is a short but helpful interaction between the nurse and client.
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during what stage of the therapeutic nurse-client relationship is a formal or informal contract between the nurse and client established? Orientation
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Orientation Correct Contracting is part of the orientation phase of the relationship. Establishing the operational "rules" provides a foundation for the relationship.
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The primary difference between a social and a therapeutic relationship is the type of responsibility involved.
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type of responsibility involved. Correct n a therapeutic relationship the nurse assumes responsibility for focusing the relationship on the client's needs, facilitating communication, assisting the client with problem- solving, and helping the client identify and test alternative coping strategies.
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A client states "That nurse nevers seems comfortable being with me." The nurse can be described as not seeming genuine to the client.
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not seeming genuine to the client. Correct Hiding behind a role, using stiff or formal interactions, and creating distance between self and client suggest a nurse is lacking in genuineness, or the ability to interact in a person-to-person fashion.
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The pre-orientation phase of the nurse-client relationship is characterized by the nurse's focus on self-analysis of strengths, limitations, and feelings. .
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self-analysis of strengths, limitations, and feelings. During the preorientation phase the nurse prepares for a relationship with a client by engaging in self-examination.
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The orientation phase of the nurse-client relationship focuses on the nurse and client identifying client needs.
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the nurse and client identifying client needs. Correct The orientation phase is the first stage of the nurse-client relationship and focuses on, among other things, the identification of client needs.
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Client reactions of intense hostility or feelings of strong affection toward the nurse are common forms of transference.
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transference. Correct The stirring up of feelings in the client by the nurse is referred to as transference
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The outcome of the nurse's expressions of sympathy instead of empathy toward the client often leads to decreased client communication.
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decreased client communication. Correct Sympathy and the resulting projection of the nurse's feelings limits the client's opportunity to further discuss the problem. REF: Page 143-144
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The use of empathy and support begins in the stage of the nurse-client relationship termed the orientation stage.
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orientation stage. The use of empathy and support should begin in the orientation stage. These tools are helpful in building trust and furthering the relationship. REF: Page 139-140
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A client reports that her mother-in-law is very intrusive. The nurse responds, "I know how you feel. My mother-in-law is nosy, too." The nurse is demonstrating countertransference.
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countertransference. Correct Countertransference refers to the stirring up of feelings in the nurse by the client. REF: Page 134
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A client tells the nurse "I really feel close to you. You are like the friend I never had." The nurse can assess this statement as indicating the client may be experiencing positive transference.
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positive transference. CorrecT Transference involves the client experiencing feelings toward a nurse that belong to a significant person in the client's past. REF: Page 134
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The nurse is finding it difficult to provide structure and set limits for a client. The nurse should self-evaluate for boundary blurring.
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boundary blurring. Correct Boundary blurring is often signaled by the nurse being either too helpful or not helpful enough. REF: Page 133-134
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1. A client says to a nurse, "Why should I talk to you? Everybody knows talking doesn't help!" Which of the following is an appropriate response by the nurse? "I'm here to talk with you about your concerns."
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D. "I'm here to talk with you about your concerns." An appropriate response is a broad opening that focuses on the client's feelings and needs. Option A minimizes the client's ability to make decisions and is obstructive to open expression of feelings. Option B changes the focus of the interview to the primary care provider's orders. Option C implies criticism of the client's response, which could possibly make the client defensive. It is important to avoid minimizing the client's feelings, focusing attention away from the client, or implying criticism of the client's response.
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2. A nurse is caring for a client who follows her around the unit and tries to engage her in conversation, after the nurse has set up a specific time for interaction. The client's behavior is an example of which of the following? Inability to accept limits
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C. Inability to accept limits Limits must be set so that one client will not monopolize a nurse's time. This may be a boundary issue for the client and nurse. There is no evidence that this is a stalking behavior, a sign of close rapport with the nurse, or that the client is lonely.
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3. Which of the following are characteristics of the nurse-client relationship? (Select all that apply.) It is goal-directed. Behavioral change is encouraged.
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X It is goal-directed. X Behavioral change is encouraged. In order for a nurse-client relationship to be therapeutic and beneficial for the client, there must be clear boundaries; there must be clearly identified goals toward which the client is working; and the nurse must encourage behavioral change to improve the client's mental health. The needs of both participants may be met in a social relationship, and an emotional commitment exists between participants in an intimate relationship.
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4. The termination phase of the nurse-client relationship focuses on which of the following? A. Discussing ways to use new behaviors
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A. Discussing ways to use new behaviors During the termination phase, the nurse and the client discuss ways that the client can use newly learned behaviors. Practicing new problem-solving skills and experiencing intense feelings usually takes place during the working phase. Developing goals should take place in the orientation phase.
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5. A nurse is orienting a new client to an inpatient mental health unit. When explaining the unit's community meetings, the nurse should state which of the following to the client? C. "You and the other clients will meet with staff to discuss activities, problems, and other things of interest to all."
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C. "You and the other clients will meet with staff to discuss activities, problems, and other things of interest to all." Community meetings include both staff and clients on a unit. Any topic of interest to the entire group may be discussed, including problems, future activities, and meeting new clients
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6. A client who is newly admitted to the acute care mental health unit has a DSM-IV-TR Axis I diagnosis of paranoid schizophrenia. The client is very frightened and delusional. During the client's first few days of treatment, which of the following aspects of the therapeutic milieu is most important? A. Socialization with other clients B. Structured activities with staff C. Recreational therapy in the community D. Communication in group therapy
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B. Structured activities with staff The greatest risk to this client is injury to self and others. Structured activities are the most effective ways to provide a safe environment for the client, staff, and other clients. Socialization, recreational therapy, and attendance at group therapy are all important aspects of the therapeutic milieu, but they are not the most important for this client.
