A nurse is caring for a client who states, "I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, "Don't worry, no one will harm your family." Which of the following types of communication breakdown does the nurse's response represent?

Choice A Reason:
Assessing the client's readiness for therapy is a crucial role of the nurse in CBT. It involves determining whether the client is willing and able to participate in therapy, understands the CBT process, and is motivated to engage in the cognitive and behavioral changes that CBT requires. This assessment helps ensure that the therapy is client-centered and tailored to the individual's specific needs and readiness level.

Choice B Reason:
While involving the client's family can be beneficial in therapy, implementing therapeutic techniques that involve only the client's family does not align with the primary goals of CBT. CBT focuses on the individual's patterns of thinking and behavior, and while family support can be part of the process, the nurse's role is not limited to family involvement alone.

Choice C Reason:
Educating the client to identify and challenge negative thoughts is a fundamental aspect of CBT. The nurse helps the client recognize their automatic negative thoughts, understand the impact these thoughts have on their emotions and behavior, and learn to challenge and reframe these thoughts in a more positive and realistic way.

Choice D Reason:
Evaluating to determine the effectiveness of the actions is part of the nurse's role in CBT. This involves monitoring the client's progress, assessing the outcomes of the interventions, and making necessary adjustments to the treatment plan. Evaluation is an ongoing process that ensures the therapy is effective and meets the client's needs.

Choice E Reason:
Collaborating with the client to set achievable goals is essential in CBT. The nurse works with the client to establish clear, measurable, and attainable goals that guide the therapy process. These goals provide direction and motivation, and they help the client focus on making specific changes that will improve their mental health.

Choice A Reason:
This response may invalidate the client's experience and can be perceived as dismissive of the client's delusional thoughts. It does not acknowledge the client's current reality or provide any therapeutic communication. An intervention is required to guide the nurse in offering a more empathetic and validating response.

Choice B Reason:
Asking the client to clarify what they mean encourages communication and shows a willingness to understand the client's perspective. It is a therapeutic approach that can help the nurse gain insight into the client's thoughts and provide appropriate support.

Choice C Reason:
This response could potentially validate the client's delusional thinking by engaging in the content of the delusion. It might lead to further discussion about the delusion rather than redirecting the client to reality, which could be counterproductive.

Choice D Reason:
Expressing empathy by acknowledging that the client's feelings must be frightening is a therapeutic response. It validates the client's emotions without confirming the delusional content and can help the client feel understood and supported.