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
Explanation
Choice A rationale:
In a democratic leadership style, the leader involves the group in decision-making and encourages open discussion. By asking the group for their input on resolving the bathroom issue, the nurse is demonstrating democratic leadership.
Choice B rationale:
A surrogate leadership style involves a designated individual acting as a substitute for the leader. It's not applicable in this scenario where the nurse is involving the group in decision-making.
Choice C rationale:
Laissez-faire leadership involves minimal interference and decision-making by the leader. In this scenario, the nurse is actively seeking group input, which contradicts the laissez-faire approach.
Choice D rationale:
An autocratic leadership style involves the leader making decisions without group input. Since the nurse is soliciting ideas from the group, this style doesn't apply here.
Correct Answer is C
Explanation
Choice A rationale:
Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.
Choice B rationale:
Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.
Choice C rationale:
This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.
Choice D rationale:
Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.
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