An elderly patient with multi-infarct dementia is striking out ...

[nautica902]

An elderly patient with multi-infarct dementia is striking out with her arms and kicking at people who walk past in the hall. The nurse determines that the patient believes she is at home and that the other patients have broken into her home.
 
  The clinical nurse specialist suggests that staff use validation. Which of the following responses reflect this intervention? a. I'm a nurse who has come to check on you. Tell me about your home..
  b. You are in a nursing home. The others here are patients, just like you are..
  c. I wish you could be home, but you have been sick and are in a nursing home..
  d. You are not at home. This is a nursing home. It is September 10th, 2010..

Question 2

The barrier in the therapeutic relationship that occurs when the client attempts to avoid anxiety-provoking material is called
 
  1. anxiety.
  2. compliance.
  3. resistance.
  4. transference.

[shewald78]

Answer to Question 1

A
Validation involves reducing distress by validating the essence of the patient's experience. By explaining her purpose for being with the patient, the nurse reduces the patient's tendency to see her as one of the home invaders. Asking the patient to talk about her home is the beginning of the validation process; subsequently the nurse will acknowledge the patient's desire to be home, gently guide the patient to reconsider whether her present location is her home, and whether the others might in fact belong there. The other choices are all variations on reorienting the patient to reality and are less likely to be effective (or may even be counterproductive in some patients).

Answer to Question 2

3
Resistance is a client's attempt to avoid recognizing or exploring anxiety-provoking material.