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”

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

Choice A Reason:

Grooming is correct. Grooming assesses the client's personal care and hygiene, providing insight into their ability to perform self-care activities.

Choice B Reason:

Long-term memory is correct. Evaluating long-term memory helps assess the client's ability to recall past events and information, which can be affected in individuals with dementia.

Choice C Reason:

Support systems is incorrect. While support systems are crucial in the overall care of individuals with dementia, they are not typically assessed in a traditional MSE.

Choice D Reason:

Affecting is correct. Affect refers to the client's emotional expression. Assessing affect helps in understanding the client's emotional state, which can be important in diagnosing and managing dementia.

Choice E Reason:

Presence of pain is incorrect. While assessing pain is essential in clinical care, it may be more pertinent to a physical assessment than a mental status examination specifically focused on cognitive functioning.

A. "It might help you feel better if you talk about it." B. "I'll just sit here with you for a few minutes then." C. “Understand you felt like that before, too." D. “Why are you feeling so down?"

Correct Answer is B

Explanation

Choice A Reason:

"It might help you feel better if you talk about it." While encouraging communication is generally good, the client has clearly expressed a desire not to talk at the moment. Pressuring them to talk may not be beneficial.

Choice B Reason:

"I'll just sit here with you for a few minutes then." This response acknowledges the client's need for solitude while showing a willingness to provide presence and support. It respects the client's autonomy and allows them to lead the interaction.

Choice C Reason:

"I understand; I've felt like that before, too." While expressing empathy can be helpful, it's important not to overshadow the client's experience by sharing personal feelings at this moment.

Choice D Reason:

"Why are you feeling so down?" This question may feel intrusive and may not be well-received by the client, especially when they've indicated a preference not to talk. It's important to approach the conversation with sensitivity and respect for the client's boundaries.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states. "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

Which of the options below would be a priority nursing diagnosis?

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?

Russell enters the clinic for his medication injection. The order states Fluphenazine decanoate 87.5 mg IM every 3 weeks. The vial is labeled Fluphenazine decanoate 25 mg/ml. How many mL(s) will you administer for this dose?

Which statement suggests a struggle with Erikson's phase of Identity vs. role confusion? Select one:

The nurse is educating a patient with depression about the mental health continuum. Which statement made by the patient indicates the need for additional teaching?

Using Maslow's pyramid, which patient comment would the nurse respond to first?

A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?

A nurse is caring for a postpartum client who tells the nurse that she does not want any more children. The client asks which birth control method the nurse would recommend. Which of the following responses should the nurse make?