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 A
Explanation
Choice A Reason:
Technical expert is correct. In Peplau's Interpersonal Relations in Nursing theory, the emphasis is on the interpersonal and psychosocial aspects of nursing. While technical expertise is crucial in nursing practice, it is not specifically identified as a distinct role according to Peplau. The theory focuses more on the nurse's role in facilitating the patient's growth and development through the therapeutic relationship.
Choice B Reason:
Resource is incorrect. Peplau identified the nurse as a resource, emphasizing the nurse's role in providing information, support, and guidance to the patient. This aligns with the concept of the nurse as a source of knowledge and assistance for the patient.
Choice C Reason:
Surrogate is incorrect. The surrogate role in Peplau's theory reflects the nurse's ability to act on behalf of the patient, representing their best interests, especially in situations where the patient may be unable to advocate for themselves. The nurse serves as a substitute or stand-in for the patient in certain circumstances.
Choice D Reason:
Guardian is incorrect. The guardian role in Peplau's theory emphasizes the nurse's responsibility to protect the patient's rights and advocate for their well-being. The nurse acts as a guardian of the patient's interests, ensuring they receive appropriate care and support.
Correct Answer is D
Explanation
Choice A Reason:
Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. It is not directly related to involving a third person in conflicts.
Choice B Reason:
Scapegoating is incorrect. Scapegoating involves blaming one family member for the family's problems. While this can be a dysfunctional family dynamic, it is not specifically about involving a third person in conflicts.
Choice C Reason:
Double Binding is incorrect. Double binding involves conflicting messages that create a no-win situation for the recipient. It does not specifically involve the inclusion of a third person in conflicts as observed in the given scenario.
Choice D Reason:
Triangulation is correct. Triangulation in family systems therapy occurs when a third person, often a child, is involved in the conflicts between two other family members. In this scenario, Kate is venting her frustrations to her younger son, which creates a triangle or three-person dynamic in the family system. Triangulation can serve as a way for family members to stabilize their relationships by shifting the focus or tension onto a third party.
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