A nurse is caring for an older adult client diagnosed with a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?
"You are not responsible for your mother's stroke, but many people in your situation feel this way.”
"Your mother will be fine. You shouldn't worry so much.”
"Why do you blame yourself? You could not have prevented the stroke.”
"So, it seems that you feel responsible for what happened to your mother.”
The Correct Answer is D
The correct answer is choice d. "So, it seems that you feel responsible for what happened to your mother.”
Choice A rationale: This response attempts to reassure the son but may come off as dismissive of his feelings. It does not encourage further discussion or exploration of his emotions.
Choice B rationale: This response is overly reassuring and dismisses the son’s feelings of guilt. It does not address his emotional state or encourage him to express his concerns.
Choice C rationale: This response questions the son’s feelings directly, which might make him defensive. It does not validate his emotions or encourage him to talk more about his feelings.
Choice D rationale: This response acknowledges the son’s feelings and encourages him to express his emotions. It is a therapeutic communication technique that helps the son feel heard and understood, which is crucial in providing emotional support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
The correct answer is: A, B, C, D.
Choice A reason: Shortening a reading activity when the child appears to become frustrated can help prevent the child from becoming overwhelmed and acting out. This is a common strategy used in managing children with conduct disorders.
Choice B reason: Introducing humor during interactions with the child can help build rapport and make the child feel more comfortable. It can also serve as a positive distraction and reduce tension.
Choice C reason: Redirecting with physical activities when the child’s disruptive behavior begins can serve as a healthy outlet for the child’s energy and frustrations. Physical activities can also help improve the child’s mood and reduce disruptive behaviors.
Choice D reason: Explaining to the child the importance of picking up crayons when thrown on the floor can help teach the child responsibility and respect for their environment. This can also be a part of behavioral therapy where the child learns about consequences of their actions.
Choice E reason: Placing the child in a vest restraint when disruptive behavior occurs is not recommended. Using physical restraints can be traumatizing and should only be used as a last resort when the child’s behavior poses a risk to themselves or others. It’s always better to use de-escalation techniques and positive reinforcement to manage disruptive behavior.
Correct Answer is A
Explanation
The correct answer is choice A: Set limits for the relationship.
Choice A rationale:
Setting limits for the therapeutic relationship (Choice A) is an essential nursing action. Boundaries help create a safe and structured environment, ensuring that both the nurse and client maintain appropriate roles. Limits prevent overstepping boundaries that could compromise the therapeutic alliance.Setting limits for the relationship is an essential part of establishing a therapeutic relationship in a mental health setting. This helps to maintain professional boundaries and ensures that the relationship remains focused on the client’s needs and therapeutic goals.
Choice B rationale:
Engaging in affectionate interactions with the client (Choice B) is not appropriate in a therapeutic relationship. Professionalism and maintaining appropriate boundaries are crucial in psychiatric nursing. Affectionate interactions could blur the lines between the therapeutic relationship and personal relationships, potentially harming the client's progress.
Choice C rationale:
Promoting the use of transference by the client (Choice C) is not a suitable approach. Transference occurs when a client projects feelings and emotions onto the nurse based on past experiences. While it can be valuable to explore transference, actively promoting it could lead to confusion and misunderstandings in the therapeutic relationship.
Choice D rationale:
Instructing the client on how they should behave (Choice D) is contrary to the principles of a therapeutic relationship. The therapeutic relationship is client-centered, where the nurse supports the client's self-discovery and growth. Directing the client's behavior undermines their autonomy and inhibits their progress.
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