A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

Identify other housing options and sources of transportation.

Notify the facility chaplain to request scheduling an appointment.

Confirm that everything will be all right because belongings can be replaced.

Maintain eye contact with the client and summarize the client's feelings.

Answer and Explanation

The Correct Answer is D

Answer is d. Maintain eye contact with the client and summarize the client’s feelings.

a. Identify other housing options and sources of transportation: While it is essential to address practical needs such as housing and transportation for clients who have experienced a crisis like a house fire, it is not the immediate priority when the client is in acute emotional distress. In this scenario, the client is expressing emotional distress and may not be ready to focus on practical solutions. Therefore, addressing the client's emotional needs should take precedence over addressing practical concerns.

b. Notify the facility chaplain to request scheduling an appointment: While spiritual support can be beneficial for individuals coping with trauma or loss, it should not be the immediate response when a client is in acute emotional distress. While the chaplain's support may be sought later as part of the client's holistic care, it should not precede addressing the client's immediate emotional needs.

c. Confirm that everything will be all right because belongings can be replaced: This option is incorrect because it offers false reassurance and dismisses the client's feelings about their loss. While it is true that belongings can be replaced, the emotional impact of losing possessions, especially in a traumatic event like a house fire, should not be trivialized. The client's feelings of distress and uncertainty are valid and should be acknowledged and addressed by the nurse.

d. Maintain eye contact with the client and summarize the client’s feelings: Correct. This action demonstrates therapeutic communication, which is crucial in providing an atmosphere of support and safety for the client. Maintaining eye contact shows empathy, support, and advocacy, indicating to the client that their feelings are being heard and validated. Summarizing the client's feelings allows the nurse to demonstrate active listening and understanding, fostering trust and rapport between the nurse and client. By prioritizing the client's emotional needs, the nurse can help the client begin to process their feelings and move towards coping and problem-solving.

In summary, the correct answer is d because maintaining eye contact with the client and summarizing their feelings demonstrates therapeutic communication, which is essential in providing support and validation for the client's emotional distress. This approach allows the nurse to establish rapport and trust with the client, facilitating further therapeutic interventions and support.

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Correct Answer is D

Explanation

The correct answer is choice D: "The partner has lost 25 lbs in the past 3 months."

Choice D rationale:

This choice is the correct answer because significant weight loss in a caregiver, such as the partner of a client with Alzheimer's disease, is indicative of caregiver role strain. Caregiver role strain refers to the physical, emotional, and psychological stress experienced by caregivers due to the demands of providing care for a loved one. Weight loss in this context suggests that the partner's own health and well-being are being compromised due to the caregiving responsibilities.

Choice A rationale:

This choice might be related to safety concerns and trying to prevent the client from wandering, but it does not directly indicate caregiver role strain. Placing locks at the top of doors is a common safety measure to prevent clients with Alzheimer's disease from wandering and getting lost.

Choice B rationale:

This choice is actually a positive observation. Redirecting a frustrated client is a helpful and appropriate caregiving strategy. It indicates that the partner is actively engaged in managing the client's behavior and emotions, which is not a sign of caregiver role strain.

Choice C rationale:

Hiring a house cleaner is a practical decision and could be a sign of the partner's effort to manage their caregiving responsibilities more effectively. While it might imply a certain level of stress, it doesn't directly point to caregiver role strain as much as the significant weight loss does.

A. "You are feeling very depressed. I felt the same way when I decided to leave my husband.” B. "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.” C. "You seem depressed. It was a difficult decision to make. Would you like to talk about it?” D. "I know this is a difficult time for you. Would you like medication for anxiety?”

Correct Answer is A

Explanation

Choice A rationale:

The statement "You are feeling very depressed. I felt the same way when I decided to leave my husband." is a non-therapeutic statement that demonstrates sympathy. The nurse is sharing personal experiences, which can shift the focus from the client's feelings to the nurse's own experiences.

Choice B rationale:

The statement "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you." is a therapeutic response that offers support and empathy without diverting the focus to the nurse's experiences. The nurse's willingness to sit with the client is a positive aspect of this response.

Choice C rationale:

The statement "You seem depressed. It was a difficult decision to make. Would you like to talk about it?" is a therapeutic response that acknowledges the client's feelings, offers support, and invites further conversation. This response encourages the client to express themselves.

Choice D rationale:

The statement "I know this is a difficult time for you. Would you like medication for anxiety?" acknowledges the client's difficulties but immediately offers medication as a solution. While medication can be a valid option, it's important to prioritize open communication and emotional support before suggesting medication.

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A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

Correct Answer is D

Explanation

A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?

Correct Answer is A

Explanation

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