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?

A. Building a trusting relationship:Establishing trust is essential in therapeutic relationships, especially with clients at risk for self-harm. However, ensuring the client’s immediate safety by searching belongings takes precedence to protect the client from further harm.

B. Searching her belongings:This is the first priority to ensure Patty’s immediate safety and prevent access to any objects she could use to harm herself. This action addresses the immediate risk and creates a safer environment for her.

C. Orienting her to the unit. Orientation to the unit helps the client feel more comfortable and understand the rules and layout of the facility, but it is not as urgent as ensuring her safety upon admission.

D. Helping her settle into her room:Assisting Patty in getting comfortable is important for her overall well-being but is secondary to securing her environment by removing any potentially harmful items.

Choice A Reason:

Demonstrate genuineness when communicating is correct. Establishing therapeutic relationships in mental health nursing involves demonstrating genuineness, empathy, and trustworthiness in communication. Genuineness involves being authentic, sincere, and honest in interactions with clients. It fosters a sense of trust and connection, which is essential for the therapeutic relationship.

Choice B Reason:

Focusing on the words of the clients is incorrect. While it's important to listen actively to clients, effective communication goes beyond just focusing on words. Nonverbal cues, emotions, and the overall context of communication are also crucial.

Choice C Reason:

Providing sympathy during interactions is incorrect. Sympathy involves feeling sorry for someone, which may not always be helpful in a therapeutic relationship. Empathy, where the nurse understands and shares the client's feelings, is generally more therapeutic.

Choice D Reason:

Controlling the pace of establishing the nurse-client relationships is incorrect. The establishment of therapeutic relationships is a collaborative process, and attempting to control the pace might hinder the development of trust. It's important to be responsive to the client's needs and preferences.