At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make?
Yes, I have been assigned to lead this group. I will be here for the next 6 weeks.
Yes, I am the leader. You seem angry about not being the leader yourself.
Yes, I am the leader today. Would you like to be the leader tomorrow?
Yes, I will be leading this group. What would you like to accomplish?
The Correct Answer is D
Choice A reason: This response is factual but does not promote engagement or address the client’s passive stance. It emphasizes the nurse’s role without encouraging participation or collaboration from the older adult.
Choice B reason: This statement makes an assumption about the client’s feelings, labeling them as “angry,” which may not be accurate. It risks creating defensiveness and does not foster open communication or trust within the group.
Choice C reason: This response inappropriately offers group leadership to a member without assessing readiness or interest. It minimizes the therapeutic structure of the group and could confuse roles, making the group less effective.
Choice D reason: This option balances the acknowledgment of the nurse’s leadership role with an invitation for the client to share personal goals. It encourages involvement, respects autonomy, and helps build a therapeutic alliance by showing interest in what the older adult wants to accomplish.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The nurse’s role is to advocate for the client by collaborating with the healthcare team and ensuring the guardian respects the client’s best interests and personal preferences. This balances autonomy and protection.
Choice B reason: While explaining changes in decision-making is part of education, focusing only on the loss of control without emphasizing advocacy may increase fear and distress.
Choice C reason: Avoiding communication violates therapeutic principles and disregards the client’s dignity. Even if incapable of informed consent, clients should remain included in discussions.
Choice D reason: Treatment cannot proceed without proper consent unless there is an emergency. Acting before guardianship is finalized would violate legal and ethical standards.
Correct Answer is A
Explanation
Choice A reason: This response acknowledges the client’s experience without reinforcing the hallucination. It demonstrates empathy, maintains reality orientation, and builds trust, which are crucial therapeutic approaches.
Choice B reason: Challenging hallucinations with logic is not effective and can increase client defensiveness or distress. It may also escalate paranoia rather than reduce it.
Choice C reason: Avoiding the client ignores their distress and can increase isolation. Engagement is necessary to provide reassurance and therapeutic support.
Choice D reason: Directly denying the hallucination can invalidate the client’s experience, leading to mistrust and further paranoia. A more supportive acknowledgment is preferred.
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