A nurse is caring for an older adult client who had 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?
"Your mother will be fine, you shouldn't work so much."
“So, it seems that you feel responsible for what happened to your mother”
"Why do you blame yourself? You could not have prevented the stroke”
“You are not responsible for your mothers’ stroke but many people in your situation feel this way”
The Correct Answer is B
Choice A Reason:
This response is dismissive and invalidates the son's feelings of guilt. It does not acknowledge or address his emotional distress. Providing false reassurance and shifting focus to work is not therapeutic.
Choice B Reason:
This response reflects therapeutic communication. It validates the son’s feelings by acknowledging his guilt and encourages him to express his emotions. Reflective listening allows the nurse to build trust and support the son in processing his emotions.
Choice C Reason:
Asking "Why" can feel accusatory or judgmental, making the son defensive. While the statement attempts to provide reassurance, it fails to address his emotional state and may shut down further communication.
Choice D Reason:
Although this response provides some reassurance and normalization, it minimizes the son's emotions by focusing on generalizations. It lacks the reflective quality necessary for therapeutic communication in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"Why do you think you might have cancer when your diagnosis is a benign condition?” This response may come across as dismissive and could make the client feel unheard. It does not acknowledge the client's concerns and may discourage open communication.
Choice B Reason:
"I'm hearing that you are concerned that might turn out that you have cancer.” This response demonstrates active listening and acknowledges the client's expressed concern. It encourages the client to share their feelings and provides an opportunity for further discussion. Option B shows empathy and supports the client's emotional needs during a stressful time.
Choice C Reason:
"I'm looking at your chart here and I don't see any reason for you to worry about that.” This response focuses on the medical chart and might minimize the client's emotional concerns. It does not address the client's feelings and may create a sense of invalidation.
Choice D Reason:
"I think that's something you need to discuss with your provider.” While it directs the client to the provider, it doesn't acknowledge the client's emotions or provide immediate support. It may seem like a deflection rather than an empathetic response.
Correct Answer is A
Explanation
Choice A Reason:
Engaging in friendly interactions with the client is correct. Developing a therapeutic relationship involves creating a supportive and empathetic connection with the client. Engaging in friendly interactions helps build trust and rapport. This approach fosters a positive environment for communication and collaboration.
Choice B Reason:
Instructing the client on how he should behave is incorrect. Instructing the client on how to behave can be perceived as directive and may hinder the development of a collaborative and trusting relationship.
Choice C Reason:
Setting limits for the relationship is incorrect. While setting boundaries is important, using the term "limits" can convey a sense of restriction. It's crucial to establish appropriate boundaries, but the term "limits" may not promote the openness needed in a therapeutic relationship.
Choice D Reason:
Promoting the use of transference by the client is incorrect. Promoting transference involves encouraging the client to project feelings from past relationships onto the nurse. This is generally not considered a therapeutic approach and may lead to misunderstandings in the therapeutic relationship.
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