Welcome to your reviewer and NCLEX practice quiz guide about therapeutic communication techniques in nursing! In this nursing test bank, test your knowledge and understanding about therapeutic communication. The goal of this quiz is to help student nurses on how to answer therapeutic communication questions in the NCLEX.
Therapeutic Communication Techniques in Nursing Practice Quiz
In this section are the NCLEX practice questions to help you familiarize yourself with therapeutic communication items. Included in this nursing test bank are 50 questions divided into two parts. We hope that this practice quiz will help you gain an understanding of the essential elements and concepts of therapeutic communication.
Quizzes included in this guide are:
- Part 1: Therapeutic Communication in Nursing NCLEX Practice Quiz (25 Questions)
- Part 2: Therapeutic Communication in Nursing NCLEX Practice Quiz (25 Questions)
- Read and understand each question before choosing the best answer.
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Part 1: Therapeutic Communication in Nursing NCLEX Practice Quiz (25 Questions)
This is the first part of your therapeutic communication quiz. Be sure to read the rationales after each question. Good luck and we hope you learn a lot!
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Looking for the rationales? Please click on the “View Questions” button below to review your answers and read through the rationales for each question.
Question 1 of 25
A patient with a diagnosis of major depression who has attempted suicide says to the nurse, “I should have died! I’ve always been a failure. Nothing ever goes right for me.” Which response demonstrates therapeutic communication?CorrectIncorrect
Question 2 of 25
When the community health nurse visits a patient at home, the patient states, “I haven’t slept the last couple of nights.” Which response by the nurse illustrates a therapeutic communication response to this patient?CorrectIncorrect
Question 3 of 25
A patient experiencing disturbed thought processes believes that his food is has been poisoned. Which communication technique should the nurse use to encourage the patient to eat?CorrectIncorrect
Question 4 of 25
A patient admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting. “Let me out. There’s nothing wrong with me. I don’t belong here.” What defense mechanism is the patient implementing?CorrectIncorrect
Question 5 of 25
A patient diagnosed with terminal cancer says to the nurse “I’m going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I’m the one who’s dying.” Which response by the nurse is therapeutic?CorrectIncorrect
Question 6 of 25
On review of the patient’s record, the nurse notes the admission was voluntary. Based on this information, the nurse anticipates which patient’s behavior?CorrectIncorrect
Question 7 of 25
A patient admitted voluntarily for the treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?CorrectIncorrect
Question 8 of 25
When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient?CorrectIncorrect
Question 9 of 25
The nurse is preparing a patient for the termination phase of the nurse-patient relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase?CorrectIncorrect
Question 10 of 25
The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbors ask the nurse, “How is Mary doing? She is my best friend and is seen at your clinic every week.” Which is the most appropriate nursing response?CorrectIncorrect
Question 11 of 25
The nurse calls security and has physical restraints applied when a client who is admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.CorrectIncorrect
Question 12 of 25
The nurse in the mental health unit recognizes which of the following as therapeutic communication techniques? Select all that apply.CorrectIncorrect
Question 13 of 25
A patient being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism?CorrectIncorrect
Question 14 of 25
A patient’s unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-patient relationship?CorrectIncorrect
Question 15 of 25
Which statement demonstrates the best understanding of the nurse’s role regarding ensuring that each client’s rights are respected?CorrectIncorrect
Question 16 of 25
Which therapeutic communication technique is being used in this nurse-client interaction?
Client: “When I get angry, I get into a fistfight with my wife, or I take it out of the kids.”
Nurse: “I notice that you are smiling as you talk about this physical violence.”CorrectIncorrect
Question 17 of 25
Which therapeutic communication technique is being used in this nurse-client interaction?
Client: “My father spanked me often.”
Nurse: “Your father was a harsh disciplinarian.”CorrectIncorrect
Question 18 of 25
Which therapeutic communication technique is being used in this nurse-client interaction?
Client: “When I am anxious, the only thing that calms me down is alcohol.”
Nurse: “Other than drinking, what alternatives have you explored to decrease anxiety?”CorrectIncorrect
Question 19 of 25
Nurse Patrick is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a general lead?CorrectIncorrect
Question 20 of 25
A nurse states to a client, “Things will look better tomorrow after a good night’s sleep.” This is an example of which communication technique?CorrectIncorrect
Question 21 of 25
A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening?CorrectIncorrect
Question 22 of 25
A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations?CorrectIncorrect
Question 23 of 25
A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening?CorrectIncorrect
Question 24 of 25
An instructor is correcting a nursing student’s clinical worksheet. Which instructor statement is the best example of effective feedback?CorrectIncorrect
Question 25 of 25
After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, “I’m so proud of you for being assertive. You are so good!” Which communication technique has the leader employed?CorrectIncorrect
Therapeutic Communication in Nursing
The guide below is your reviewer for the concepts of therapeutic communication in nursing. We’ve made it as condense as possible by including only the key facts to help you refresh your memory!
Learning the techniques of therapeutic communication is an important skill that nurses should possess since communication is an integral part of being a nurse. This is a study guide about the basic principles of therapeutic communication, its purpose, differences of verbal and nonverbal communication, and lastly, the different therapeutic communication techniques.
What is Therapeutic Communication?
Therapeutic communication is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information. Skilled use of therapeutic communication techniques helps the nurse understand and empathize with the client’s experience.
Goals of Therapeutic Communication
Therapeutic communication can help nurses to accomplish many goals:
- Establish a therapeutic nurse-client relationship.
- Identify the most important client concern at that moment (the client-centered goal).
- Assess the client’s perception of the problem as it unfolds; this includes detailed actions (behaviors and messages) of the people involved and the client’s thoughts and feelings about the situation, others, and self.
- Facilitate the client’s expression of emotion.
- Teach the client and the family necessary self-care skills.
- Recognize the client’s needs.
- Implement interventions designed to address the client’s needs.
- Guide the client toward identifying the plan of action to a satisfying and socially acceptable resolution.
Verbal Communication Skills
Verbal communication consists of the words a person uses to speak to one or more listeners.
- Using concrete messages. The nurse should use words that are as clear as possible when speaking to the client so that the client can understand the message; in a concrete message, the words are explicit and need no interpretation, the speaker uses nouns instead of pronouns; concrete questions are clear, direct, and easy to understand.
- Using therapeutic communication techniques. The choice of technique depends on the intent of the interaction and the client’s ability to communicate verbally; overall, the nurse selects techniques that facilitate the interaction and enhance communication between client and nurse.
- Avoiding nontherapeutic communication. In contrast, there are many nontherapeutic techniques that nurses should avoid; these responses cut off communication and make it more difficult for the interaction to continue.
- Interpreting signals or cues. To understand what a client means, the nurse watches and listens carefully for cues; cues are verbal or nonverbal messages that signal keywords or issues for the client; finding cues is a function of active listening often, cue words introduced by the client can help the nurse to know what to ask next or how to respond to the client.
Nonverbal Communication Skills
Therapeutic communication also involves nonverbal communication is behavior that a person exhibits while delivering verbal content.
- Facial expression. The human face produces the most visible, complex, and sometimes confusing nonverbal messages; facial movements connect with words to illustrate meaning; this connection demonstrates the speaker’s internal dialogue.
- Body language. Body language (gestures, postures, movements, and body positions) is a nonverbal form of communication; closed body positions, such as crossed legs or arms folded across the chest, indicate that the interaction might threaten the listener who is defensive or not accepting; a better, more accepting body position is to sit facing the client with both feet on the floor, knees parallel, hands at the side of the body, and legs uncrossed or crossed only at the ankle.
- Vocal cues. Vocal cues are nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the sender’s message; volume, the loudness of the voice, can indicate anger, fear, happiness, or deafness; tone can indicate whether someone is relaxed, agitated, or bored; pitch varies from shrill and high to low and threatening; intensity is the power, severity, and strength behind the words; emphasis refers to accents on words or phrases that highlight the subject, and speed is the number of words spoken per minute.
- Eye contact. The eyes have been called the mirror of the soul because they often reflect our emotions; eye contact, looking into the other person’s eyes during communication, is used to assess the other person and the environment and to indicate whose turn it is to speak; it increases during listening but decreases while speaking.
Therapeutic Communication Techniques
Choosing the appropriate therapeutic communication technique is critical in establishing and maintaining the nurse-patient relationship. These techniques are discussed below:
|Therapeutic Communication Technique||Example||Rationale|
“I understand what you said.”
|An accepting response indicates the nurse has heard and followed the train of thought.|
Allowing the client to take the initiative in introducing the topic.
|“Is there something you’d like to talk about?” |
“Where would you like to begin?”
|Broad openings make explicit that the client has the lead in the interaction.|
Searching for mutual understanding, for accord in the meaning of the words.
|“Tell me whether my understanding of it agrees with yours.”||For verbal communication to be meaningful, it is essential that the words being used have the same meaning for both (all) participants.|
Asking that similarities and differences be noted.
|“Was it something like…?”Have you had similar experiences?||Comparing ideas, experiences, or relationships brings out many recurrent themes.|
|Encouraging description of prescriptions.|
Asking the client to verbalize what he or she perceives.
|“Tell me when you feel anxious.”|
“Do tell me what is happening?”
“What does the voice seem to be saying?”
|To understand the client, the nurse must see things from his or her perspective.|
|Encouraging expression. |
Asking the client to appraise the quality of his or her experiences.
|“What are your feelings in regard to...?”|
“Does this contribute to your distress?”
|The nurse asks the client to consider people and events in light of his or her own values.|
Delving further into a subject or idea.
|“Tell me more about that.” |
“Would you describe it more fully?”
|When clients deal with topics superficially, exploring can help them examine the issue more fully.|
Concentrating on a single point.
|“This point seems worth looking at more closely.”||The nurse encourages the client to concentrate his or her energies on a single point, which may prevent a multitude of factors or problems from overwhelming the client.|
|Formulating a plan of action.|
Asking the client to consider kinds of behavior likely to be appropriate in future situations.
|“What could you do to let your anger out harmlessly?”||It may be helpful for the client to plan in advance what he or she might do in future similar situations.|
Giving encouragement to continue.
|“Go on.” |
|General leads indicate that the nurse is listening and following what the client is saying without taking away the initiative for interaction.|
|Giving information. |
Making available the facts that the client needs.
|“My name is…”|
"These are your medications..."
“Visiting hours are…”
|Informing the client of facts increases his or her knowledge about a topic or lets the client know what to expect.|
|Giving recognition. |
Acknowledging, indicating awareness.
|“Good morning Mr…” |
“You’ve finished your list of things to do.”
|Greeting the client by name, indicating awareness of change, or noting efforts the client has made all show that the nurse recognizes the client as a person, as an individual.|
Verbalizing what the nurse perceives.
|“You appear tense.”|
“Are you uncomfortable when..?”
|Sometimes clients cannot verbalize or make themselves understood.|
|Offering self. |
Making oneself available.
|“I’ll sit with you awhile.”||The nurse can offer his or her presence, interest, and desire to understand.|
|Placing event in time or sequence. |
Clarifying the relationship of events in time.
|“What seemed to lead up to…?”||Putting events in proper sequence helps both the nurse and client to see them in perspective.|
|Presenting reality. |
Offering for consideration that which is real.
|“I see no one else in the room.”||When it is obvious that the client is misinterpreting reality, the nurse can indicate what is real.|
Directing client actions, thoughts, and feelings back to client.
|Client: “Do you think I should tell the doctor?”|
Nurse: “Do you think you should?”
|Reflection encourages the client to recognize or accept his or her own feelings.|
Repeating the main idea expressed.
|Client: “I can’t sleep. I stay awake all night.”|
Nurse: “You have difficulty sleeping.”
|The nurse repeats what the client has said in approximately or nearly the same words the client has used.|
|Seeking information. |
Seeking to make clear that which is not meaningful or that which is vague.
|“I’m not sure that I follow. Could you tell me more?”||The nurse should seek clarification through interactions with clients.|
Absence of verbal communication, which provides time for the client to put thoughts or feelings into words, to regain composure, or to continue talking.
|Nurse says nothing but continues to make eye contact and conveys interest.||Silence often encourages the client to verbalize, provided that it is interested and expectant.|
|Suggesting collaboration. |
Offering to share, to strive, to work with the client for his or her benefit.
|“Perhaps you and I can discuss and discover the triggers for your anxiety.”||The nurse seeks to offer a relationship in which the client can identify problems in living with others, grow emotionally, and improve the ability to form satisfactory relationships.|
Organizing and summing up that which has gone before.
|“So in summary..."|
"Have I got this straight?”
|Summarization seeks to bring out the important points of the discussion and to increase the awareness and understanding of both participants.|
|Translating into feelings. |
Seeking to verbalize client’s feelings that he or she expresses only indirectly.
|Client: “I’m dead.”|
Nurse: “Are you suggesting that you feel lifeless?”
|Often what the client says, when taken literally, seems meaningless or far removed from reality.|
|Verbalizing the implied. |
Voicing what the client has hinted or suggested.
|Client: “I can’t talk to you or anyone. It’s a waste of time.”|
Nurse: “Do you feel that no one understands?”
|Putting into words what the client has implied or said indirectly tends to make the discussion less obscure.|
|Voicing doubt. |
Expressing uncertainty about the reality of the client’s perception.
|“Isn’t that unusual?”“Really?”||Another means of responding to distortions of reality is to express doubt.|
|Open-ended comments. |
Unfinished sentences that prompt the client to continue. Questions that cannot be answered with a one-word answer.
|“Tell me more about your pain.”|
“Tell me about your family.”
|Allows client to decide what content is relevant.|
Makes the meaning of client’s message clear.
|Client: “Whenever I talk to my doctor, I feel so upset.”|
Nurse: “Tell me what is making you upset?”
|Prevents nurse from making assumptions about client’s message.|
Nurse’s verbal response to incongruence between client’s words and actions.
|Client: “I am so angry at her!” (Stated while smiling).|
Nurse: “You said you are angry, yet you are smiling?”
|Encourages client to recognize potential areas for change.|
|Setting limits. |
Stating expectations for appropriate behavior.
|Nurse: “It seems that you are feeling unsure of how to behave right now.”|
Client: “What do you mean?”
Nurse: “Well, you are asking me a lot of personal questions. The reason you are here is because you have some health issues and problems. Tell me more clearly what brought you here to the clinic so I can help you.?”
|Establishing behavioral parameters.|
Non-Therapeutic communication involves words, phrases, actions, and tones that make a patient feel uncomfortable, increase their stress, and worsen their mental and even physical wellbeing.
|Reassuring||“I would not worry about that.”||Indicating that there is no cause of anxiety.|
|Giving approval||“That’s good!”||Offering unnecessary approval, on the other hand, implies that the behavior being praised is the only acceptable one.|
|Rejecting||“Let’s not discuss about that!”||Refusing to consider or showing contempt for the client’s ideas or behavior.|
|Disapproving||“That’s bad!”||Denouncing the client’s ideas or behavior.|
|Indicating accord with the client.|
|Disagreeing||“I definitely disagree with what you’re saying!”|
“I don’t believe that!”
|Opposing to client’s idea.|
|Advising||“I think you should…”|
“Why don’t you…”
|Telling the client what to do.|
|Probing||“Tell me more about your love story from the day you fell in love!”||Persistent questioning the client. It is invasive, uncomfortable for most clients, and a threat to the client's right to privacy and confidentiality. Probing the client with questions that are not relevant to their health care and health-related concerns is never appropriate.|
|Indicating the existence of an external source.||“Who told you that you were God?!”||Attributing the source of thoughts, feelings, and behavior to others, or to outside influence.|
|Belittling feelings expressed.||Client: “I have nothing to live for. I wish I was dead!”|
Nurse: “Everybody gets down in the dumps!”
|Misjudging the degree of client’s discomfort.|
|Using denial||Client: “I’m nothing!”|
Nurse: “Don’t be silly!”
|Refusing to admit that problem exists.|
|Interpreting||“What you really mean is…”|
“Unconsciously, you’re saying…”
|Seeking to make conscious that which is unconscious, telling the client the meaning of his experiences.|
|Introducing an unrelated topic||Client: “I’d like to die!”|
Nurse: “Did you have visitors this weekend?”
|Changing the subject.|
Tips in Answering Therapeutic Communication Questions
Getting the client’s response or the way you communicate with them is a mainstay of the NCLEX. The psychosocial focus of nursing is a central thread throughout all of the clinical areas. Effective communication is an essential way to establish therapeutic relationships. These type of questions are relatively easy to answer especially if you read these five principles on answering therapeutic communication questions:
1. Responses that focus on the client’s feelings
Most clients at some time find it difficult to express their feelings whether they have a terminal illness, pregnant, or are scheduled for surgery. Any nursing response that elicits these feelings would be therapeutic. Listen and attend to those client cues. For example the question below:
SITUATION: A 20-year-old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Nikki reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is:
a. “I can refer you to a spiritual counselor if you like.”
b. “You shouldn’t allow anyone to pressure you into sex.”
c. “It sounds like this problem is related to your paralysis.”
d. “How do you feel about being pressured into sex by your boyfriend?”
For this question, the correct answer is D. The statement focuses on the expression of feelings and is therapeutic. Option A is not therapeutic because the nurse passes the responsibility to the counselor. Option B. is giving advice is not therapeutic as it virtually terminates the conversation. Option C is not also therapeutic because it confronts the underlying cause.
When it seems as if clients would like to discuss fears, concerns, angry feelings, then encourage their expression.
2. Responses that are honest and direct
It is important that the nurse is honest with her responses to encourage trust and build a therapeutic relationship. Honesty will support a trustful and a firm relationship.
Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is:
a. “Your husband is dead. Let me serve you your breakfast.”
b. “I’ve told you several times that he is dead. It’s time to eat.”
c. “You’re going to have to wait a long time.”
d. “What made you say that your husband is alive?
The correct answer is option A. Since the client has signs of dementia, she should be reoriented to reality and be focused on there here and now. Option B is not a helpful approach because of the short term memory of the client. Option C indicates a pompous response. Option D is a cognitive limitation of the client makes the client incapable of giving an explanation.
3. Responses that involve active listening
Encouraging clients to talk through verbal and nonverbal techniques is supportive and serves to further the relationship.
The nurse observes a client pacing in the hall. Which statement by the nurse may help the client recognize his anxiety?
A. “I guess you’re worried about something, aren’t you?
B. “Can I get you some medication to help calm you?”
C. “Have you been pacing for a long time?”
D. “I notice that you’re pacing. How are you feeling?”
The answer here is D. By acknowledging the observed behavior and asking the client to express his feelings the nurse can best assist the client to become aware of his anxiety. In option A, the nurse is offering an interpretation that may or may not be accurate; the nurse is also asking a question that may be answered by a “yes” or “no” response, which is not therapeutic. In option B, the nurse is intervening before accurately assessing the problem. Option C, which also encourages a “yes” or “no” response, avoids focusing on the client’s anxiety, which is the reason for his pacing.
4. Responses that indicate acceptance of the client
Accept the client whatever or how he is regardless of his condition and verbalizations. Additionally, you would not want to reject the client even if you could not condone or accept his behavior.
A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia?
A. “Why didn’t you get someone else to drive you?”
B. “Tell me how you feel about the accident.”
C. “You should know better than to drink and drive.”
D. “I recommend that you attend an Alcoholics Anonymous meeting.”
Choosing option A would make the client feel defensive and intimidated. Option C is judgemental, remember any judgemental approach is not therapeutic. Option D is about giving advice and here, the nurse suggests that the client isn’t capable of making decisions, thus fostering dependency. For this question, option B is the correct answer as it encourages the widest range of client response and makes the client be an active participant in the conversation.
5. Responses that pick up or relate to the client’s cues
Responding to an important cue is an essential therapeutic communication technique if the nurse is to focus on the client and maintain a goal-focused interaction.
A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation?
A. “Everyone diagnosed with OCD needs to control their ritualistic behaviors.”
B. “It is important for you to discontinue these ritualistic behaviors.”
C. “Why are you asking for help if you won’t participate in unit therapy?”
D. “Let’s figure out a way for you to attend unit activities and still wash your hands.”
The most appropriate statement by the nurse is, “Let’s figure out a way for you to attend unit activities and still wash your hands.” This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship or increasing the client’s anxiety.
If you need more information or practice quizzes, please do visit the following links:
- Nursing Test Bank: Free Practice Questions UPDATED!
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- NCLEX Questions Nursing Test Bank and Review UPDATED!
For this nursing test bank, we have included more than 1,000+ NCLEX practice questions covering different nursing topics! We’ve made a significant effort to provide you with the most challenging questions along with insightful rationales for each question to reinforce learning.
Sources and References
The following are the sources and references used for this article. Including some articles and journals we find interesting:
- Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic physician, 9(8), 4968.
- Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., … & Parker, B. (2014). Kozier & Erb’s Fundamentals of Nursing Australian Edition (Vol. 3). Pearson Higher Education AU.
- Keltner, N. L. (2013). Psychiatric nursing. Elsevier Health Sciences.
- Kozier, B. (2008). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, 8/e (With DVD). Pearson Education India.
- Rosenberg, S., & Gallo-Silver, L. (2011). Therapeutic communication skills and student nurses in the clinical setting. Teaching and learning in nursing, 6(1), 2-8.
- Ruesch, J. (1961). Therapeutic communication.
- Sleeper, J. A., & Thompson, C. (2008). The use of hi-fidelity simulation to enhance nursing students’ therapeutic communication skills. International Journal of Nursing Education Scholarship, 5(1), 1-12.
- Stuart, G. W. (2014). Principles and practice of psychiatric nursing-e-book. Elsevier Health Sciences.
- Wachtel, P. L. (1993). Therapeutic communication: Principles and effective practice. Guilford Press.
- Wachtel, P. L. (2011). Therapeutic communication: Knowing what to say when. Guilford Press.
- Webster, D. (2014). Using standardized patients to teach therapeutic communication in psychiatric nursing. Clinical simulation in nursing, 10(2), e81-e86.
- Weber, K., & Farrell, T. (2016). Developing therapeutic communication skills: Integration of standardized client simulation in an associate degree nursing program.
- Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins.