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?

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.

Choice A Reason:

Helping the patient to identify personal strengths and limitations is appropriate. This helps build a positive foundation for the therapeutic relationship by focusing on the patient's strengths and empowering them in the process.

Choice B Reason:

Explore, in depth, the problems faced by the patient is inappropriate. While understanding the patient's concerns is important, diving too deeply into problems at the beginning might be overwhelming. It's often more effective to gradually explore issues as trust is established.

Choice C Reason:

Clarifying how long the relationship will last is inappropriate. Specifying the duration of the therapeutic relationship may create anxiety for the patient. Therapeutic relationships are often open-ended, and discussing termination should occur at an appropriate time in the future.

Choice D Reason:

Reviewing the terms of confidentiality is appropriate. Clarifying the terms of confidentiality is important to establish trust and inform the patient about the boundaries of the therapeutic relationship.

Choice E Reason:

Helping the patient prioritize and revise ineffective coping behaviors is appropriate. Collaboratively working with the patient to identify and address ineffective coping behaviors is a therapeutic intervention that supports the patient in their journey toward improved mental health.