The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse?

Question

Quizplus · Accepted Answer

The client exhibits anger, which is likely a sign of grief due to loss of control from illness. However, the source of the client's anger is not clear. Therefore, further assessment is now indicated to understand more about the client's feelings and perceptions. Verbalizing feelings may also help the client to move past anger toward acceptance of the loss. The nurse's statement, "It sounds like you are angry" reflects the nurse's perception of the client's emotion and will allow the client to clarify feelings. The open-ended probing statement, "Tell me what's bothering you," facilitates assessment of the client's concerns without making any assumptions about them. This approach will promote accurate assessment of the client's needs and concerns. It will also prevent premature closure, incorrect assumptions, and escalation of the client's anger. (Option A) This client's angry response likely indicates an unmet need. Further assessment is indicated if the client is willing to talk. This response shuts the door on further assessment. (Option B) The nurse is making an assumption that the source of the client's frustration is loss of control. This assumption may cause the nurse to draw inaccurate conclusions about the client's concerns, contributing to further escalation of anger. (Option D) This response will probably diffuse the situation, but further assessment of the client's concern is more important. If the client remains angry and the nurse attempts to take blood pressure after being told to leave, the client may become angrier, putting the nurse's safety at risk. Educational objective: The client with serious illness who exhibits anger may be experiencing anxiety, grief, or fear. The nurse should remain at a safe distance while attempting to diffuse the situation; assess the client's concerns using a calm, non-threatening approach; reflect the client's statements; and try to understand the client's feelings, perceptions, and beliefs to address the priority problem.

The Nurse Is Conducting a Home Visit to Assess an Elderly