Self-awareness- process of developing an understanding of one’s own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitations and how these qualities affect others
Therapeutic Use of Self- the nurse beginning to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills and perceptions to establish relationship with clients
JOHARI’S WINDOW UNKNOWN- UNDISCOVERED QUALITIES BY ONESELF AND OTHERS HIDDEN- QUALITIES KNOWN ONLY TO SELF BLIND- QUALITIES KNOWN ONLY TO THERS OPEN - QUALITIES ONE KNOWS ABOUT ONESELF AND OTHERS ALSO KNOW
Rationale: The nurse indicates what is real through not arguing with the client. The intent is to indicate an alternative line of thought for the client to consider and not to ‘convince” the client that he/she is wrong.
Allow client to express feelings more often than possible without being judgmental in order to understand what is going on with the client. This would facilitate better action in dealing with client’s concerns thus helping him arrive at solutions at his own pace.
Rationale: approval indicates the client is “right” rather than “wrong’ which gives him/her the impression that he or she is right because of agreement with the nurse. There is no opportunity for the client to change his or her mind.
Client: “I have nothing to live for..I wish I was dead”
Nurse: “Everybody gets down in the dumps.”
Rationale: When the client tries to equate the intense and overwhelming feelings the client has expressed to “everybody’, the nurse implies that the discomfort is temporary, mild, self-limiting or not very important.
6. During the initial interview, a client with schizophrenia suddenly turns to the next chair and whispers, “Now just leave, I told you to stay home. There‘s not enough work here for both of us.” What is the nurse’s best initial response?
A. “When people are under stress, they may see or hear things that others do not. Is that what just happened?”
B. “I’m having a difficult time hearing you. Please look at me when you talk.”
C. “There is no one else in this room. What are you doing?”
D.“Who are you talking to? Are you hallucinating?”
7. A client with major depression tells the nurse, “Life’s just not worth living. I can’t stand the pain any longer.” What is the nurse’s best response?
“ Sometimes when people feel depressed and helpless, they feel like hurting themselves. Do you feel like hurting yourself?”
“ Perhaps you should discuss this in group therapy today.”
“ I think you may want to use your p.r.n. lorazepam now.”
“ You don’t feel like living?”
. A woman, age 18, highly dependent on her parents and fears leaving home to go away to college. Shortly before the next semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. The client asks the nurse, “Why has this happened to me?” What is the nurse’s best response?
A. “You’ve developed this paralysis so you can stay with your parents. You must deal with this conflict if you want to walk again.”
B. “It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical.”
C. “Your problem is real but there is no physical basis for it. We’ll work on what is going on in your life to find out why it’s happened.”
D. “It isn’t uncommon for someone with your personality to develop a conversion disorder during times of stress.”
9. While pacing in the hall, a client with paranoid schizophrenia runs to the nurse and says, “Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!” How should the nurse respond during the early stage of the therapeutic process?
A. “I’m a nurse. I’m not poisoning you. It’s against the nursing code of ethics.”
B. “I’m a nurse, and you’re a client in the hospital. I’m not going to harm you.”
C. “I’m not poisoning you. And how could I possibly steal your soul?”
10. A client has just begun to discuss important feelings when the time of the interview is up. The next day, when the nurse meets with the client at the agreed-upon time, the initial intervention would be to say:
A. “Good morning! How are you today?”
B. “Yesterday you were talking about some very important feelings. Let’s continue.”
C. “What would you like to talk about today?”
D. Nothing and wait for the client to open a topic.
12. Kristina is a 29 year old woman admitted to the surgical unit after an accident in a small airplane. Her husband the pilot was killed. She had some minor bruises and contusions but she is physically stable. She has a 2-year old son. The day after admission, the nurse enters the client’s room to find the shades drawn and her in bed sobbing quietly. The most therapeutic nursing response is:
A. “It’s a beautiful day outside, let’s get some sunshine here.”
B. “Obviously you are upset, let’s talk about what you’re feeling now.”
C. I”ll be back when you’re feeling better, you seem upset.”
D. “it’s not good for you to sit in here in the dark.”
13. Several days after learning of her pregnancy, a recently widowed client tells the nurse. I’m going to have an abortion. I can’t bear the thought of raising this child alone.” What is the best response?”
A. “Well, it sounds as though you already have made a decision.”
15. Mr. Levy was admitted with a diagnosis of bipolar disorder. On Mr. Levy’s admission, his daughter said to the nursing staff, “He’s been really tough to handle. I hope you can calm them down, because I sure can’t. Which of the following responses would be most helpful at this time?
A. “You must really be fed up. I’ve never seen anyone this maniacal.”
B. “Sounds like this has been very difficult for you. Hospitalization will be very helpful for both of you.”
C. “I can appreciate your embarrassment. He is really high, isn’t he?”
D. “You must wonder why your father is acting aggressively in order to gain attention.”
16. Mrs. Adam a 65 year old woman, admitted herself to the hospital after she began hearing the voices of her dead husband. She says to the nurse, “My husband says I shouldn’t talk to you.” What is the most appropriate response?
A. “you’re husband has been dead for over 10 years.”
B. ‘When did he say that.”
C. “The more you talk like this the more confused you will become.”
D. “I know that this is real to you. It would be helpful; if we talk about it.”
19. Pong a 25 year old man admitted in an acute psychotic state caused by ingestion of lysergic acid di-ethylamide (LSD), sees red spiders crawling on his bed. Which of the following is the appropriate nursing response?
A. “Come on Pong, you’re putting me on.”
B. Swat the red spiders as if to kill them in the client’s presence.
C. “I understand you believe you see spiders, Pong, I am not seeing any.”
D. Discuss details of the hallucinations with him.
Possible reactions by the nurse: Nurse may feel uncomfortable and experience increased anxiety or feel somehow responsible for making the person cry
Useful responses by the Nurse: Nurse should stay with the client and reinforce that its all right to cry often. It is at this time that feelings are closest to the surface and can be best identified
“ You seem ready to cry.”, “You still are upset about your brother’s death?”, “What are you thinking right now?”
Nurse offers tissues when appropriate
What to do if the client asks the nurse to keep a secret
Possible reactions by the nurse: Nurse may feel conflict because the nurse wants the client to share important information but is unsure about making such a promise
Useful responses by the nurse: Nurse cannot make such a promise. The information maybe important to the health or safety of the client and others.
“ I can not make that promise. It might be important for me to share it with other staff.”
The client then decides whether to share the information or not.
What to do if the client leaves before the session is over
Possible reactions by the nurse: Nurse may feel rejected, thinking it was something that he or she did. The nurse may experience increased anxiety or feel abandoned by the client.
Useful responses: Some clients are not able to relate for long periods of time without experiencing an increased in anxiety, On the other hand, the client maybe testing the nurse.
“ I will wait for you here for 15 minutes until our time is up.”,
During this time, the nurse does not engage in conversation with any other client or other staff.
When the time is up, the nurse approaches the client, tells him/her that the time is up and restates the day and time the nurse will see the client again.
What to do if another client interrupts during time with your selected client
Possible reactions by nurse: nurse may feel a conflict. The nurse does not want to appear rude. Sometimes the nurse tries to engage both clients in conversation
Useful responses: The time the nurse had contracted with a selected client is that client’s time.
By keeping their part of the contract, nurses demonstrate that they mean what they say and that they view the sessions are important.
“ I am with Mr. Rob for the next 20 minutes. At 10AM, after our time is up, I can talk to you for 5 minutes.”
What to do if the client says he wants to kill himself
Possible reactions by the nurse: Nurse may feel overwhelmed or responsible to “talk the client out of it”. The nurse may pick up some of the client’s feelings of hopelessness
Useful responses: Nurse tells the client that this is serious, that the nurse does not want harm to come to the client and that this information needs to be reported to other staff.
“ this is very serious Mrs. Lamb. I do not want any harm to come to you. I will have to report this to the other staff.”
The nurse can then discuss with the client the feelings and circumstances that led up to this.
What to do if the client says she does not want to talk
Possible reactions: the nurse new to this situation may feel rejected or ineffectual
Useful responses: At first, the nurse might say something to this effect: “ Its all right. I would like to spend time with you. We don’t have to talk.”
The nurse might spend short, frequent periods of time (e.g. 5 minutes) with the client throughout the day.
“ Our 5 minutes is up. I”ll be back at 10AM and stay with you for 5 more minutes.”
This gives the client the opportunity to understand that the nurse means what he/she says and is back on time consistently. This also gives the client time between visits to assess the nurse and perhaps feel less threatened.
What to do if the client seeks to prolong the interview
Possible reactions: sometimes clients will open up dynamic or ‘juicy” topics right before the interview time is up. This is often done to test or manipulate the nurse. The nurse might feel tempted to extend the scheduled time or might not want to hurt the client’s feelings.
Useful responses: The nurse sets limits and restates and reinforces the original contract.
The nurse states that they will use the issues for the next session.
“ Our time is up now, Mr. Jones. This would be a good place to start at our next sessions which is Wednesday at 10AM”
What to do if the client gives the nurse a present
Possible reactions: The nurse may feel uncomfortable when offered a gift-the meaning needs to be examined. Is the gift:
Client Behavior: Makes sexual advances toward the nurse (e.g. touching the nurse’s arm, wanting to hold hands or kiss the nurse.)
Client example: “Would you go out with me…Why not?” or “Can I kiss you?…Why not?”
Nurse’s response: “I am not comfortable having you touch me.”, the nurse briefly reiterates the nurse’s role, “This time is for you to focus on your problems and concerns.” (rationale: frequently restating the nurse’s role throughout the relationship can help maintain boundaries)