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:
Coordinating the implementation of the nursing care plan and documents is inappropriate. This choice is more related to general nursing responsibilities and care coordination. Milieu therapy specifically focuses on creating a therapeutic environment rather than coordinating care plans and documents.
Choice B Reason:
Providing and maintaining a safe and therapeutic environment in collaboration with others is appropriate. Milieu therapy involves creating a therapeutic environment that promotes the patient's mental health and well-being. This includes ensuring safety, providing structure, and creating a supportive atmosphere for patients. The nurse, in collaboration with the healthcare team, is responsible for establishing and maintaining this therapeutic milieu.
Choice C Reason:
Applying current knowledge to assess the patient's response to medication is inappropriate.
Assessing the patient's response to medication is an important nursing responsibility, but it is not the primary focus of milieu therapy. Milieu therapy is more concerned with the overall environment and its impact on the patient's mental health.
Choice D Reason:
Giving anticipatory guidance to prevent or reduce mental illness and enhance mental health is inappropriate. While anticipatory guidance is important in nursing care, it may not capture the essence of creating and maintaining a therapeutic environment, which is the core of milieu therapy. This choice is more related to health education and preventive measures rather than the overall therapeutic environment.
Correct Answer is D
Explanation
Choice A Reason:
Formulating a nursing diagnosis is incorrect. This occurs after a comprehensive assessment of the patient's needs, and it helps guide the planning and implementation of nursing care.
Choice B Reason:
Planning for continued care is incorrect. Once the nursing diagnosis is formulated, the nurse can develop a plan of care, including interventions and goals for the patient.
Choice C Reason:
Promoting patient's insight is incorrect. This is a part of the ongoing therapeutic process and involves helping the patient gain self-awareness and understanding of their thoughts, feelings, and behaviors. It typically occurs after the initial assessment and planning.
Choice D Reason:
Examining personal biases is correct. In the nurse-patient relationship, examining personal biases is a foundational and essential step that should happen first. It involves the nurse being self-aware and acknowledging any personal biases or prejudices that might affect the therapeutic relationship. Recognizing and addressing personal biases is crucial for providing unbiased and patient-centered care.
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