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.”

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.

Choice B rationale:

Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.

Choice C rationale:

Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.

Choice D rationale:

Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.

A. Instruct the client to sit down and stop pacing. B. Have a staff member escort the client to her room. C. Walk with the client at a gradually slower pace. D. Allow the client to pace alone until physically tired.

Correct Answer is C

Explanation

The correct answer is choice C. Walk with the client at a gradually slower pace.

Choice A rationale:

Instructing the client to sit down and stop pacing (Choice A) might come across as authoritarian and dismissive of the client's anxiety. It's important to provide a more supportive and empathetic approach.

Choice B rationale:

Having a staff member escort the client to her room (Choice B) might further escalate the client's anxiety. The client may interpret this action as a form of containment or punishment.

Choice C rationale:

Walk with the client at a gradually slower pace (Choice C) is the most appropriate action. This approach acknowledges the client's anxiety and provides a calming presence. Gradually slowing down can help the client naturally transition from pacing to a calmer state.

Choice D rationale:

Allowing the client to pace alone until physically tired (Choice D) might prolong the episode of anxiety. Providing support and engagement is essential in managing the client's distress effectively.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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