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:
Limited the role of the nurse to medication administration and documentation is inappropriate. Peplau's theory goes beyond medication administration and documentation. It emphasizes the interpersonal aspect of nursing, focusing on the therapeutic relationship between the nurse and the patient.
Choice B Reason:
Included both an interpersonal theory and a definition of nursing roles is appropriate. Peplau's Interpersonal Theory of Nursing focuses on the nurse-patient relationship and includes both an interpersonal theory and a definition of nursing roles. Peplau emphasized the importance of the nurse's therapeutic use of self in the relationship with the patient.
Choice C Reason:
Depended on moral theory linked to gender is inappropriate. Peplau's theory is not specifically linked to moral theory or gender. It is more focused on the dynamics of interpersonal relationships in the healthcare context.
Choice D Reason:
Defined the role of the nurse in the mental health setting as an extension of the psychiatrist is inappropriate. While Peplau's theory is applicable to mental health settings, it doesn't define the role of the nurse as merely an extension of the psychiatrist. It highlights the nurse's unique role in building therapeutic relationships and assisting patients in their psychosocial needs.
Correct Answer is D
Explanation
Choice A Reason:
"I’m so sad and I feel I haven't accomplished much in my life." This statement may relate more to feelings of despair and a sense of unfulfilled purpose, which could be associated with Erikson's stage of Integrity vs. Despair (late adulthood).
Choice B Reason:
"I’m so anxious, can't seem to trust anyone. “This statement may indicate difficulties with trust and may be more aligned with Erikson's stage of Trust vs. Mistrust (infancy).
Choice C Reason:
"I'm so tired after work that I just want to watch TV and be alone. “This statement may reflect fatigue or a desire for solitude and may not directly represent the identity development struggles associated with Erikson's Identity vs. Role Confusion stage.
Choice D Reason:
"I'm so confused about what my goals are.” Erikson's phase of Identity vs. Role Confusion occurs during adolescence, and individuals in this stage are exploring and forming their own identity. The statement "I'm so confused about what my goals are" suggests a struggle with establishing a clear sense of identity and future direction, which is characteristic of the challenges faced during this developmental stage.
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