Chapter 1:  Establishing the Therapeutic Alliance

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____	1.	Which of the following statements is true about interactions with patients?
A.	Our attitudes are expressed at a conscious level as well as an unconscious level.	
B.	Our past experiences have little to do with our present therapeutic relationships.	
C.	Our past experiences shape our attitudes toward our patients, but not our beliefs.	
D.	Unchallenged assumptions about our patients generally are favorable.	

____	2.	Based on common biases in the U.S. health-care community, which of the following patients is likely to be at greatest risk for experiencing negative bias?
A.	A 10-year-old boy with chickenpox	
B.	A 28-year-old obese Mexican woman with chest pain	
C.	A 43-year-old female athlete with a fractured leg	
D.	A 72-year-old Caucasian man with osteoarthritis of the knee	

____	3.	Which of the following has been described as “the last acceptable form of prejudice”?
A.	HIV/AIDS bias	
B.	Mental illness bias	
C.	Obesity bias	
D.	Substance abuse bias	

____	4.	Health-care biases must be recognized to be changed. Which of the following actions would be most helpful in changing our beliefs?
A.	Be aware of behaviors in others that might reflect bias.	
B.	Look for reinforcement of our beliefs within our peer group.	
C.	Reflect annually on our attitudes and beliefs about others.	
D.	Seek out commonalities with those we perceive as different.	

____	5.	When you communicate with your patients, you convey information with your words as well as your body. Which of the following statements about “body language” is true?
A.	It is more difficult to interpret than spoken words.	
B.	It is used as a primary means of communicating information.	
C.	It is used to communicate interpersonal attitudes.	
D.	It makes up about 25% of our communication with patients.	

____	6.	When communicating with your patients in an adult rehabilitation unit, it is important to do which of the following?
A.	Ask each patient with whom you are working whether they understand what you have told them.	
B.	Read the chart before seeing the patient so that you can refer to him or her by first name.	
C.	Refer to the patient by last name (preceded by “Mr.,” “Mrs.,” “Ms.,” or “Miss”) rather than just by diagnosis or room number.	
D.	Use appropriate medical terms with your patients as you explain therapeutic interventions.	

____	7.	You just took a job working in a nursing home that employs a few very experienced therapists. You are surprised by some of the problems encountered by the therapy staff, such as poor productivity and frequent absenteeism. Which of the following factors most likely accounts for these problems?
A.	The patients are very high-maintenance and difficult to work with.	
B.	The productivity requirements are very high, and no one can meet them.	
C.	The therapy staff is experiencing burnout due to a heavy caseload.	
D.	The therapy staff is older and more prone to illness and family issues.	

____	8.	For which of the following patients are patient’s rights most closely regulated?
A.	A 6-month-old boy having surgery for shunt placement	
B.	A 22-year-old woman from Russia having scoliosis surgery	
C.	A 63-year-old man who is terminally ill with lung cancer	
D.	A 75-year-old woman who just had her hip replaced after a fall	

____	9.	Culture is best defined as
A.	a group of people living in a specific area.	
B.	the fact or state of belonging to a social group.	
C.	the geographical characteristics associated with a group.	
D.	the beliefs, customs, and norms of a particular group.	

____	10.	Which of the following examples is indicative of acculturation in the United States?
A.	A Jewish couple from Israel attends an orthodox temple.	
B.	A Swedish couple travels 20 miles to shop at a Danish market.	
C.	A rural Vietnamese youth sings in a local rock group.	
D.	An elderly Latino speaks only Spanish at home.	

____	11.	You are working with a 17-year-old high school football player who was diagnosed with spinal cord injury 5 months ago. Which of the following responses might you expect in this stage of his disease?
A.	Evidence of dissociation with a sense that the accident happened to someone else	
B.	Lack of acknowledgment of the situation	
C.	An interest in doing all he can to get better	
D.	Anxiety, alarm, and a feeling of imminent crisis	

____	12.	You have just received a referral to evaluate a 93-year-old woman who has had a stroke. When you go in to see her, it is clear that she is upset and wants to talk. She mentions her concern about dying and seems to want to talk about spiritual matters. What would be the best response in this situation?
A.	Allow her to express her concerns and offer additional resources.	
B.	Tell her that it is hospital policy that you can only discuss therapy with her.	
C.	Tell her that you will go get the physician to speak with her.	
D.	Tell her what you believe so she can choose the best spiritual path.	

____	13.	Which of the following factors is most likely to motivate patients to engage in ongoing healthful behaviors?
A.	Awareness that significant change is needed	
B.	Freedom from demands of work and home	
C.	Knowing the benefits of healthful behaviors	
D.	A high sense of self-esteem	

____	14.	You are working with a 57-year-old man who just had a transtibial amputation. You have instructed the patient how to do a number of exercises you would like him to engage in when he goes home next week. What is the most effective way to encourage his adherence to the exercise program?
A.	Include exercises that he can do lying down and sitting up in the chair.	
B.	Include exercises that require assistance from his wife.	
C.	Include exercises that will require only 10 min each day.	
D.	Include exercises that will further his goal of walking with a prosthesis.	

____	15.	You are covering for a colleague who is sick today and you have to see a patient of hers who, based on what your colleague has told you, is very difficult. You are anxious about seeing her because you are expecting the treatment interaction to be unpleasant. Which of the following techniques should you use to help avoid a “difficult” encounter with the patient?
A.	Ask the nurse to go into the room first and see whether the patient is in a good mood.	
B.	Use active listening techniques to identify the patient’s underlying needs.	
C.	Ask the physical therapy technician to do bed exercises with her today.	
D.	Have everything planned ahead of time so that she has no opportunity to complain.	

Short Answer

	1.	Establishing good rapport enhances patients’ perceptions of being valued and respected. List two benefits of patients’ enhanced perceptions of value and respect.
________________________________

	2.	List three behaviors that might indicate underlying negative beliefs that could hinder your clinical effectiveness.
________________________________

	3.	List three tips for effective listening in a health-care encounter.
________________________________

	4.	Patient education is an integral part of many therapeutic interventions, and not all patients learn information the same way. List three different ways you might give patients information to facilitate learning.
________________________________

Chapter 1:  Establishing the Therapeutic Alliance
Answer Section

MULTIPLE CHOICE

	1.	ANS:	A
When interacting with patients, physical therapists must be aware that their attitudes are expressed at a conscious level as well as an unconscious level. Our experiences have a great deal to do with how we interact with patients and shape our attitudes and beliefs. Unchallenged assumptions can create negative interactions with our patients.

PTS:	1

	2.	ANS:	B
Although the 72-year-old man may experience age bias, the 28-year-old obese Mexican woman with chest pain may be subject to bias based on obesity, nationality, and gender, as well as on symptoms that are not as well recognized in a young person or in a female.

PTS:	1

	3.	ANS:	C
Obesity bias cuts across social groups and is commonly compounded by other prejudices.

PTS:	1

	4.	ANS:	D
When we find commonalities with our patients, they tend to minimize our biases. Being aware of behaviors in others will not help us individually face our biases. It is inappropriate to attempt to reinforce our biases with peer groups, because doing so does not help change our beliefs. An annual reflection is hardly adequate to meaningfully identify and change our biases.

PTS:	1

	5.	ANS:	C
Body language is used to negotiate interpersonal attitudes and is typically easier to interpret than spoken words. Words, not body language, are used primarily to communicate information. Body language makes up the majority of our communication––about 93%, not 25%, of our communication.

PTS:	1

	6.	ANS:	C
It is appropriate to refer to patients by last name preceded by “Mr.,” “Mrs.,” “Ms.,” or “Miss,” because referring to patients by diagnosis or room number depersonalizes them. There are more effective ways to make sure that your patient has understood key concepts, such as asking the person to repeat information back to you. Referring to your patients by first name is not correct, because you do not want to be overly familiar with them. Using medical terms when explaining interventions may be confusing to patients.

PTS:	1

	7.	ANS:	C
Poor productivity and frequent absenteeism are common signs of moderate to severe burnout.

PTS:	1

	8.	ANS:	A
Care would be the most regulated for a 6-year-old boy undergoing shunt placement, because this patient is likely the most vulnerable and least likely to be able to advocate for himself. In general, the greater the perceived vulnerability of the population, the more closely regulated the care is. Older patents can also experience increased vulnerability, but as adults they are assumed to be better able to advocate for themselves and therefore require less oversight and regulation of their care than pediatric patients.

PTS:	1

	9.	ANS:	D
Culture is best defined as the beliefs, customs, and norms of a particular group. A group of people living in a specific area refers to a population or community. A society is defined as the fact or state of belonging to a social group. Race refers to the geographical characteristics associated with a group.

PTS:	1

	10.	ANS:	C
This option is the only example of engaging in a local aspect of  the dominant U.S. culture. The other options are examples of limited acclimation to U.S. customs and attitudes.

PTS:	1

	11.	ANS:	C
Showing an interest in doing what he can to get better is behavior that is more commonly observed after a period of adjustment to the situation. The other options are all typical responses in the acute stage of injury or disability.

PTS:	1

	12.	ANS:	A
Therapists are expected to be open to assuming the role of concern for the spiritual lives of their patients, and patients should be offered the appropriate resources to deal effectively with this aspect of their health. It is not within the therapist’s scope of practice to provide spiritual guidance, however.

PTS:	1

	13.	ANS:	D
Self-esteem plays a large role in motivating patients. Patients with high self-esteem are more likely to feel in control of their lives and more motivated to be engaged in healthful behaviors.

PTS:	1

	14.	ANS:	D
Including exercises that will prepare the patient to walk with a prosthesis is the best choice because studies have shown that patients are more motivated to adhere to treatment programs that are functionally related, as described in this answer.

PTS:	1

	15.	ANS:	B
Listening to the patient can be a surprisingly empowering action and may reveal unmet needs in the rehabilitation process. All of the other choices are not proactive on the part of the therapist, who is responsible for facilitating a positive encounter. It is important not to let another therapist’s bias negatively affect your patient encounters.

PTS:	1

SHORT ANSWER

	1.	ANS:	
Patients who perceive that they are personally valued and respected have better clinical outcomes. Patients who feel valued and respected are much less likely to pursue legal actions against health-care workers.

PTS:	1

	2.	ANS:	
Withdrawing from patient interactions; Relying on protocols and routine treatments without considering the individual’s specific needs; Using humor that makes fun of the patient; Using unauthorized nicknames for the patient; Referring to a patient by diagnosis or treatment group

PTS:	1

	3.	ANS:	
Look at the person who is talking; Make appropriate eye contact; Focus on what the person is saying; Avoid doing other things while the person is talking; Allow time for the person to process and respond to what you have said; Make sure you understand by summarizing or rephrasing what the patient has said.

PTS:	1

	4.	ANS:	
Match the content and instructional method to the patient’s age, developmental stage, knowledge base and health condition. Inquire about the patient’s preferred way of learning. Provide important information in multiple formats. Pace the information provided.  Engage the patient physically and cognitively when possible. Provide feedback. Practice recall of information and performance of activities in settings that are realistic. Encourage patients’ questions and comments.

PTS:	1