A nurse is caring for an older adult client diagnosed with 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 rationale:

Approaching the client frequently throughout the day for brief interactions might exacerbate the client's suspiciousness and discomfort. Individuals who are extremely suspicious may interpret frequent approaches as intrusive or manipulative, leading to increased agitation or withdrawal.

Choice B rationale:

Disclosing personal information to the client in an attempt to demonstrate approachability is not recommended. Sharing personal information can blur professional boundaries and may not necessarily address the client's suspicion. It's important to build trust gradually through consistent, respectful, and professional interactions.

Choice C rationale:

Adopting a neutral attitude when providing care is appropriate because it helps create a non-threatening environment. Individuals who are suspicious may interpret overly friendly or emotionally charged behavior as insincere or manipulative. A neutral and respectful approach allows the client to feel more comfortable and safe in the nurse's presence.

Choice D rationale:

Waiting for the client to initiate interaction may not be effective in establishing a therapeutic relationship. Extremely suspicious clients might be hesitant to initiate interactions due to their mistrust. Nurses should take the initiative to approach clients with suspicion in a respectful and neutral manner to gradually build rapport and trust.

The correct answer is choice A: "You may experience dizziness upon standing while taking this medication."

Choice A rationale:

This choice is the correct answer because haloperidol, an antipsychotic medication, can cause orthostatic hypotension, which leads to dizziness upon standing. Antipsychotic medications often affect blood pressure regulation and can result in a sudden drop in blood pressure when transitioning from sitting or lying down to standing. This explanation provides essential information to the client to help them understand potential side effects and take necessary precautions.

Choice B rationale:

This choice is incorrect. Haloperidol is not indicated for treating symptoms of obsessive-compulsive disorder (OCD). It is primarily used to manage symptoms of schizophrenia and other psychotic disorders. Providing false information about its indications is not appropriate and may lead to confusion.

Choice C rationale:

This choice is incorrect. Clients should never stop taking antipsychotic medications abruptly without consulting their healthcare provider. Discontinuing such medications can lead to withdrawal effects and a worsening of symptoms. Encouraging the client to stop the medication if side effects are bothersome is not appropriate and could potentially jeopardize their well-being.

Choice D rationale:

This choice is partially correct but not the best answer. While haloperidol can cause excessive salivation (sialorrhea) as a side effect, the primary concern in this situation should be related to orthostatic hypotension and dizziness upon standing. Mentioning excessive salivation would be helpful, but it's secondary to the risk of falls associated with orthostatic hypotension.