A nurse is caring for an older adult client admitted to the hospital following a cerebrovascular accident. The client's daughter tells the nurse, "I wish I could stay with my father, but I need to go home to my family." Which of the following responses should the nurse make?
"Don't worry. We'll take good care of your father while you are gone."
"Perhaps you could stay here and just call your family to see how they are doing."
"There's nothing you can do here. You should go home to your family."
"You are feeling drawn in two different directions."
The Correct Answer is D
The response "You are feeling drawn in two different directions" acknowledges the daughter's conflicting feelings and validates her emotions. It demonstrates empathy and understanding of her situation. It can help the daughter feel heard and supported and opens up an opportunity for further conversation about her concerns and possible solutions.
The other options are less appropriate:
A- "Don't worry. We'll take good care of your father while you are gone." While this response reassures the daughter about her father's care, it does not address her emotional conflict or provide support for her own needs and concerns.
B- "Perhaps you could stay here and just call your family to see how they are doing." This response minimizes the daughter's situation and does not fully acknowledge her need to be with her own family. It may overlook the emotional strain and responsibilities she may have outside of the hospital.
C-"There's nothing you can do here. You should go home to your family." This response dismisses the daughter's feelings and implies that her presence is not necessary or valuable. It does not consider her desire to support her father or the importance of maintaining a connection with him during his hospitalization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A situational crisis is a type of crisis that occurs in response to a specific event or situation that disrupts a person's usual coping mechanisms. In this case, the sudden death of the client's partner has caused significant distress and an inability to cope with work and family responsibilities. The client's feelings of paralysis and inability to function indicate a response to the specific situation they are facing.
Incorrect:
B- Developmental crisis refers to crises that arise during normal stages of growth and development, such as adolescence or midlife crisis.
C- A maturational crisis involves a crisis that occurs as a result of the normal process of aging and the associated challenges and changes that come with it.
D- Adventitious crisis refers to crises that arise from unpredictable, uncommon events that are out of the ordinary, such as natural disasters or accidents.
Correct Answer is B
Explanation
Determining if the client has thoughts of self-harm: This is the priority action for the nurse in this situation. Assessing the client's risk of self-harm or suicide is crucial to determine the level of immediate intervention required. It helps identify the severity of the crisis and enables the nurse to implement appropriate measures to ensure the client's safety.
In the context of a client with generalized anxiety disorder who is exhibiting signs of distress and seeking to be taken care of, it is essential to assess for suicidal ideation or intent. Clients with mental health disorders, especially when experiencing high levels of stress, may be at an increased risk of self-harm or suicide. Therefore, it is vital for the nurse to prioritize the assessment of the client's safety and risk of self-harm in order to provide appropriate care and interventions.
Incorrect:
A- Asking the client to identify the cause of the crisis: While it is important to gather information about the cause of the crisis to understand the client's situation, it is not the nurse's priority at this moment. Assessing the client's safety and immediate risk of self-harm takes precedence.
C- Identifying if friends or family are available to help: While social support from friends and family can be valuable in managing a crisis, it is not the nurse's priority in this situation. The immediate concern is to assess the client's safety and risk of self-harm.
D-Identifying the client's coping skills: Assessing the client's coping skills is an important aspect of the overall assessment process, but it is not the priority at this moment. The nurse needs to first ensure the client's safety and address any immediate risks.
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