A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident.
The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?
"There's nothing you can do here. You should go home to your children."
"You are feeling drawn in two separate directions."
"Perhaps you could call your children to see how they are doing."
"Don't worry.
The Correct Answer is B
Choice A rationale:
Dismissive and unsupportive: This response discounts the client's son's feelings of guilt and obligation toward their parent. It also implies that the client's son's presence is not valuable, which could further increase their distress.
Undermines the client's son's role as a caregiver: It suggests that the client's son has no responsibilities or ability to contribute to their parent's care, which could diminish their sense of agency and potentially lead to resentment or regret.
Fails to address the underlying emotions: It does not acknowledge the client's son's internal conflict and emotional turmoil, which is essential for providing effective support.
Choice C rationale:
Offers a practical solution, but may not address the core issue: While calling the children could provide temporary reassurance, it may not fully alleviate the client's son's feelings of guilt or anxiety about leaving their parent.
May not be feasible or sufficient: The client's son may need more than a phone call to feel comfortable leaving, and they may not be able to reach their children immediately.
Could be perceived as dismissive: It could suggest that the nurse is minimizing the client's son's concerns and not fully understanding their emotional needs.
Choice D rationale:
Reassuring, but may not address the client's son's guilt: While it provides assurance about the client's care, it does not directly acknowledge or validate the client's son's feelings of guilt or obligation.
Focuses on the client's care, but not the client's son's needs: It prioritizes the physical care of the client, but may overlook the emotional needs of the client's son, who is also a primary stakeholder in the situation.
May not be enough to alleviate the client's son's concerns: The client's son may still feel responsible for their parent's well- being, even with reassurance from the nurse.
Choice B rationale:
Empathetic and validates the client's son's feelings: It directly acknowledges the client's son's conflicting emotions and demonstrates understanding of their difficult situation.
Promotes self-reflection and exploration: It encourages the client's son to further express their feelings and explore their options, which can lead to greater clarity and self-awareness.
Facilitates decision-making: It helps the client's son to weigh their priorities and make a decision that aligns with their values and responsibilities, ultimately empowering them to take action.
Strengthens the therapeutic relationship: It demonstrates the nurse's ability to connect with the client's son on an emotional level, building trust and rapport.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Antipsychotic medications are a class of drugs commonly used to treat schizophrenia and other psychotic disorders. They work by blocking dopamine receptors in the brain. However, dopamine is also involved in motor control, and blocking its receptors can lead to extrapyramidal symptoms (EPS).
EPS are a group of movement disorders that can be caused by antipsychotic medications. They include: Akathisia: A feeling of restlessness and an inability to sit still.
Dystonia: Involuntary muscle contractions that can cause twisting or spasms.
Parkinsonism: Symptoms similar to Parkinson's disease, such as tremor, rigidity, and slowness of movement. Tardive dyskinesia: Involuntary, repetitive movements of the face, tongue, or other body parts.
The risk of developing EPS is higher with older antipsychotic medications, such as haloperidol and chlorpromazine. Newer antipsychotic medications, such as risperidone and olanzapine, are less likely to cause EPS, but they can still occur.
Clients who are taking antipsychotic medications should be monitored for EPS. If EPS develop, the medication may need to be changed or the dose reduced.
Choice B rationale:
Enzymes are not known to cause EPS. They are used to treat pancreatitis by helping the body to digest food.
Choice C rationale:
Insulin is not known to cause EPS. It is used to treat type 2 diabetes mellitus by helping the body to control blood sugar levels.
Choice D rationale:
Iron supplements are not known to cause EPS. They are often taken by pregnant women to prevent iron deficiency anemia.
Correct Answer is C
Explanation
Choice A, "Do you think your anxiety is worse than everyone else's?", is invalidating and minimizes the client's experience. Comparing their anxiety to others is unhelpful and could further distress the client.
Choice B, "It doesn't appear as though you are feeling anxious.", is dismissive and ignores the client's self-report. This dismissive response could damage the therapeutic relationship and discourage the client from sharing openly.
Choice D, "I think you should see a therapist and a doctor tomorrow.", is directive and potentially premature. While suggesting mental health resources can be helpful, it's crucial to first understand the client's situation and preferences before making recommendations. Additionally, suggesting both a therapist and a doctor without further assessment might overwhelm the client.
Choice C, "Tell me what has been happening lately.", is an open-ended and validating that encourages the client to share their experiences and concerns. This shows the nurse is actively listening and creates a safe space for the client to explore their anxiety. By understanding the context and potential triggers, the nurse can then provide more tailored support and guidance.
Further rationale for Choice C:
Open-ended s are key tools in therapeutic communication. They promote client engagement, facilitate exploration of thoughts and feelings, and gather valuable information needed for assessment and planning.
Validating the client's experience is crucial in building trust and rapport. Recognizing and acknowledging their anxiety shows the nurse cares and is taking their concerns seriously.
This initial allows the client to guide the conversation, focusing on aspects they feel most comfortable sharing. This empowers the client and promotes autonomy.
Following the client's lead in the conversation also helps the nurse gather specific details about the nature and severity of the anxiety, informing subsequent assessment and intervention strategies.
In conclusion, Choice C, "Tell me what has been happening lately.", is the most appropriate response for a mental health nurse to use when assessing a client who reports an increase in anxiety. It demonstrates active listening, validates the client's experience, encourages engagement, and provides a foundation for further assessment and support.
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