A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident.
The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?
"There's nothing you can do here. You should go home to your children."
"You are feeling drawn in two separate directions."
"Perhaps you could call your children to see how they are doing."
"Don't worry.
The Correct Answer is B
Choice A rationale:
Dismissive and unsupportive: This response discounts the client's son's feelings of guilt and obligation toward their parent. It also implies that the client's son's presence is not valuable, which could further increase their distress.
Undermines the client's son's role as a caregiver: It suggests that the client's son has no responsibilities or ability to contribute to their parent's care, which could diminish their sense of agency and potentially lead to resentment or regret.
Fails to address the underlying emotions: It does not acknowledge the client's son's internal conflict and emotional turmoil, which is essential for providing effective support.
Choice C rationale:
Offers a practical solution, but may not address the core issue: While calling the children could provide temporary reassurance, it may not fully alleviate the client's son's feelings of guilt or anxiety about leaving their parent.
May not be feasible or sufficient: The client's son may need more than a phone call to feel comfortable leaving, and they may not be able to reach their children immediately.
Could be perceived as dismissive: It could suggest that the nurse is minimizing the client's son's concerns and not fully understanding their emotional needs.
Choice D rationale:
Reassuring, but may not address the client's son's guilt: While it provides assurance about the client's care, it does not directly acknowledge or validate the client's son's feelings of guilt or obligation.
Focuses on the client's care, but not the client's son's needs: It prioritizes the physical care of the client, but may overlook the emotional needs of the client's son, who is also a primary stakeholder in the situation.
May not be enough to alleviate the client's son's concerns: The client's son may still feel responsible for their parent's well- being, even with reassurance from the nurse.
Choice B rationale:
Empathetic and validates the client's son's feelings: It directly acknowledges the client's son's conflicting emotions and demonstrates understanding of their difficult situation.
Promotes self-reflection and exploration: It encourages the client's son to further express their feelings and explore their options, which can lead to greater clarity and self-awareness.
Facilitates decision-making: It helps the client's son to weigh their priorities and make a decision that aligns with their values and responsibilities, ultimately empowering them to take action.
Strengthens the therapeutic relationship: It demonstrates the nurse's ability to connect with the client's son on an emotional level, building trust and rapport.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
To calculate the amount of fluoxetine to administer, we can use the following steps:
Step 1: Identify the desired dose, which is 40 mg.
Step 2: Identify the available dose, which is 20 mg/5 mL.
Step 3: Set up the equation to solve for the unknown, which is the volume in mL. The equation is (Desired Dose ÷ Available Dose) × Volume = Volume to Administer.
Step 4: Substitute the known values into the equation: (40 mg ÷ 20 mg) × 5 mL = Volume to Administer. Step 5: Solve the equation: 2 × 5 mL = 10 mL.
So, the nurse should administer 10 mL of fluoxetine.
Correct Answer is C
Explanation
Choice A rationale: Having the client join a therapy group immediately upon admission might not be the most therapeutic action. The client is experiencing panic-level anxiety, which is characterized by a heightened state of arousal and fear. Introducing the client to a group setting at this time could potentially increase their anxiety levels due to the unfamiliar environment and people.
Choice B rationale: Suggesting that the client rest in bed might seem like a good idea, as rest can help reduce stress and anxiety. However, this action alone might not be the most therapeutic for a client experiencing panic-level anxiety. The client might continue to experience high levels of anxiety while alone in their room, and without the presence of a healthcare professional, they might not have the necessary support to manage their anxiety.
Choice C rationale: Remaining with the client for a while is the most therapeutic action at this time. The presence of the nurse can provide a sense of safety and security for the client, which can help reduce their anxiety levels. The nurse can also use this time to assess the client’s anxiety levels, provide reassurance, and implement appropriate interventions to help manage the client’s anxiety.
Choice D rationale: Medicating the client with a sedative might help reduce the client’s anxiety levels, but it should not be the first action taken. Medication should be considered as part of a comprehensive treatment plan that includes non-pharmacological interventions, such as providing a safe and supportive environment, using therapeutic communication, and teaching the client coping strategies.
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