A home care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse's job description. Which of the following is an appropriate nursing response?

"I won't be able to shop for you today because I have to get home to my family."

"What I think you should do is wait for the days when you feel better and do your grocery shopping then."

"Let's look at some other resources to solve this problem."

"I would be happy to do whatever I can to help you."

Answer and Explanation

The Correct Answer is C

This response acknowledges the client's need for assistance while redirecting the focus towards exploring alternative solutions. It demonstrates the nurse's willingness to help and initiates a collaborative problem-solving approach. By engaging in a discussion about available resources, the nurse can help the client explore options such as home delivery services, community support programs, or involving family and friends in assisting with grocery shopping.

Let's review the other options and explain why they are not the most appropriate responses:

A. "I won't be able to shop for you today because I have to get home to my family." This response lacks empathy and doesn't address the client's needs. It is important for the nurse to prioritize the client's well-being and explore appropriate solutions rather than providing personal reasons for not being able to assist.

B. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This response overlooks the client's current limitations and implies that the client should solely rely on their own abilities, which may not be feasible or practical for the client.

D. "I would be happy to do whatever I can to help you." While this response conveys the nurse's willingness to assist, it is important to remember that shopping and performing personal errands are typically outside the scope of a home care nurse's responsibilities. It is more appropriate to explore other resources and options to address the client's needs effectively.

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Correct Answer is C

Explanation

Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else. In this case, the client is projecting their own desire to go out and have a drink onto the nurse and others involved in their care. They are attributing their own feelings to others in an attempt to avoid acknowledging or taking responsibility for their own desires.

A- Reaction-formation is a defense mechanism where an individual expresses the opposite of their true feelings or impulses.

B- Compensation is a defense mechanism where an individual tries to make up for their perceived deficiencies by excelling in another area.

D- Identification is a defense mechanism where an individual models their behavior after someone they admire.

A. Wait for the client to initiate interactions with the nurse. B. Set aside short, frequent times each day to spend with the client. C. Disclose some personal information to the client. D. Tell the client he reminds the nurse of her father.

Correct Answer is B

Explanation

Building trust and rapport with a suspicious client takes time and consistency. By setting aside short, frequent times each day to spend with the client, the nurse demonstrates reliability, availability, and a commitment to the client's well-being. This approach allows the client to gradually develop trust and feel more comfortable interacting with the nurse.

The other options are not appropriate actions:

A. Waiting for the client to initiate interactions with the nurse may result in limited or no engagement, as the client's suspicion may hinder their willingness to reach out. It is important for the nurse to take an active role in building the therapeutic relationship.

C. Disclosing personal information to the client is not recommended. The nurse should maintain professional boundaries and focus on the client's needs and concerns rather than sharing personal details that may compromise the therapeutic relationship or create an imbalance of power.

D. Telling the client that he reminds the nurse of her father may inadvertently trigger the client's suspicious thoughts and reinforce their mistrust. Making such personal comparisons is not appropriate and can hinder the establishment of a therapeutic relationship. It is important to focus on the client's individual experiences and needs rather than making personal connections.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

Correct Answer is C

Explanation

A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?

Correct Answer is B

Explanation

A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

A nurse is observing a newly licensed nurse as she assists in providing family therapy for a client regarding relationship concerns with his spouse. Which of the following statements to the client by the newly licensed nurse requires intervention by the nurse?

A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?

A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

A nurse is caring for a client who is scheduled for electroconvulsive therapy In 1 hr. The client asks the nurse, "Can I refuse today's treatment?" Which of the following responses should the nurse make?

A nurse is planning an Interview for a newly admitted client and plans to Include the client's family members. Which of the following methods should the nurse use to determine who to include in the interview?

A nurse on a mental health unit is assisting with several group therapy sessions. The nurse should include which of the following Information about using group therapy as a treatment method?