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 B
Explanation
Choice A rationale:
Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.
Choice B rationale:
Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.
Choice C rationale:
Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.
Choice D rationale:
Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.
Correct Answer is C
Explanation
The correct answer is choice C. Suspended from school several times in the past year.
Choice A rationale:
The client's father's recent death (Choice A) is not a typical expected assessment finding of conduct disorder. While emotional disturbances can be associated with conduct disorder, the primary characteristics involve behavioral issues rather than reactions to significant life events.
Choice B rationale:
Adhering strictly to routines (Choice B) is not a common expected assessment finding of conduct disorder. Conduct disorder is characterized by patterns of defiant and disruptive behaviors, not necessarily a rigid adherence to routines.
Choice C rationale:
Suspended from school several times in the past year (Choice C) aligns with the expected assessment findings of conduct disorder. Conduct disorder often involves aggressive behavior towards others, violation of rules, and disregard for the rights of others, which can lead to disciplinary actions such as school suspensions.
Choice D rationale:
Experiencing frequent facial tics (Choice D) is not a typical expected assessment finding of conduct disorder. Facial tics are associated with conditions like Tourette's syndrome or other tic disorders, not conduct disorder.
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