Choice A Reason:

Monitoring nutrition and self-care is correct. Ensuring patients are maintaining proper nutrition and engaging in self-care activities is an essential part of psychiatric nursing care.

Choice B Reason:

Providing round-the-clock supervision is correct. In an inpatient psychiatric unit, especially for patients at risk of harm to themselves or others, providing continuous supervision is often necessary to ensure safety.

Choice C Reason:

Offering structured socialization activities is correct. Structured socialization activities can contribute to patients' well-being and help create a therapeutic and supportive environment.

Choice D Reason:

Establishing a long-term therapeutic relationship is incorrect. While building therapeutic relationships is important, establishing a "long-term" therapeutic relationship might be more applicable in outpatient or community settings. In an inpatient unit, the focus may be on immediate care needs and stabilization.

Choice E Reason:

Assisting patients in self-assessment is correct. Helping patients in self-assessment is a crucial aspect of psychiatric nursing, as it fosters self-awareness and empowers individuals to actively participate in their treatment.

Choice A Reason:

"If it weren't for you and the hours we've spent talking, I don't think I would be on my way to getting my anxiety under control." While this statement acknowledges the importance of the nurse-patient relationship in helping with anxiety, it might imply a somewhat dependent stance. The ideal therapeutic relationship encourages patients to gain skills and tools to manage their issues independently.

Choice B Reason:

"I appreciate the time you spent with me. I have a better understanding of what I can do to manage my problem." This statement reflects the patient's acknowledgment of the nurse's support and guidance, resulting in a positive impact on the patient's understanding and ability to manage their concerns. It emphasizes the constructive nature of the nurse-patient relationship and the effectiveness of the interactions in addressing the patient's needs.

Choice C Reason:

"I really need to talk with you. You always give me good advice about how to address my anger issues." While seeking support and advice from the nurse is positive, the emphasis on always receiving good advice might suggest a more directive approach rather than collaborative exploration and problem-solving, which is often a goal in therapeutic relationships.

Choice D Reason:

"You've been kind to me when I was at a low point. Knowing you've had low points too was such a help. “While mutual understanding and empathy are crucial in the nurse-patient relationship, the statement may focus more on the nurse's experiences rather than the patient's progress or understanding. The primary focus should be on the patient's needs and growth.

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.

Choice A Reason:

To provide support for the patient is not appropriate. While providing support is important in therapeutic communication, the nurse's statement is more focused on bringing attention to an inconsistency rather than offering direct emotional support.

Choice B Reason:

To redirect the patient to an important idea is not appropriate. The nurse's statement is not aimed at redirecting the patient to a specific idea. Instead, it's about highlighting a potential incongruence between the patient's verbal and nonverbal expressions.

Choice C Reason:

To provide a suggestion for coping strategies is not appropriate. The nurse's statement is not directly offering suggestions for coping strategies. It is more focused on helping the patient recognize and explore the discrepancy in their expressed emotions.

Choice D Reasons:

To bring inconsistencies into awareness is appropriate. This therapeutic communication technique is aimed at helping the patient recognize and explore any inconsistencies between their verbal and nonverbal expressions. By pointing out the discrepancy between the patient's statement of feeling sad and the observed behavior of smiling, the nurse encourages the patient to reflect on and explore their emotions more deeply. This can contribute to increased self-awareness and a better understanding of the patient's emotional state.

Choice A Reason:

The coping skills (Choice A) may be observed and assessed as part of the broader clinical picture, but they are not typically specific components of a formal Mental Status Examination.

Choice B Reason:

Ability to perform calculations. This assesses the client's cognitive abilities, specifically related to mathematical reasoning and problem-solving.

Choice C Reason:

Recall ability. Assessing recall ability helps evaluate the client's short-term memory, which can be impaired in individuals with dementia.

Choice D Reason:

Long-term memory. Evaluating long-term memory provides insights into the client's ability to recall information from the distant past, which is another aspect of cognitive function.

Choice E Reason:

Level of orientation. Assessing orientation to time, place, and person is crucial in understanding the client's awareness of their surroundings and current circumstances, which can be affected in dementia.

Choice A Reason:

“I live too far from art and history museums to visit them as often as I would like. “This pertains more to self-actualization and leisure activities, which are higher-level needs.

Choice B Reason:

"Four robberies and three assaults occurred in my neighborhood in the past month. “This statement addresses safety concerns, which fall under the second level of Maslow's hierarchy. Ensuring safety is a fundamental need that takes priority before addressing social or esteem needs.

Choice C Reason:

"I feel so alone. I wish I had someone special in my life." This addresses the need for belonging and social connection, which is a higher-level need compared to safety.

Choice D Reason:

"I did not do a good job on the project my supervisor assigned." This relates to self-esteem and job performance, which are higher-level needs.

Choice A Reason:

Encourages staff to provide frequent negative feedback to patient is incorrect. A therapeutic milieu typically focuses on positive reinforcement and constructive feedback to support patients' growth and development.

Choice B Reason:

Enforces rules and behavioral limits flexibly is incorrect. While establishing rules and limits is important for maintaining safety, flexibility in enforcing them allows for individualized care and consideration of the patient's unique needs.

Choice C Reason:

Permits additional privileges for voluntary admitted patients is incorrect. Additional privileges may be granted based on the patient's progress and participation in their treatment. However, it should be done thoughtfully and as part of a therapeutic plan rather than as a blanket permission for all voluntary admitted patients.

Choice D Reason:

Provides patients a sense of security and comfort is correct. A therapeutic milieu refers to the therapeutic environment or surroundings in a psychiatric setting that promotes the patient's well-being, safety, and recovery. This environment should be supportive, safe, and conducive to healing. Providing patients with a sense of security and comfort is essential for their overall well-being and progress in treatment.

Choice A Reason:

Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. It is not directly related to involving a third person in conflicts.

Choice B Reason:

Scapegoating is incorrect. Scapegoating involves blaming one family member for the family's problems. While this can be a dysfunctional family dynamic, it is not specifically about involving a third person in conflicts.

Choice C Reason:

Double Binding is incorrect. Double binding involves conflicting messages that create a no-win situation for the recipient. It does not specifically involve the inclusion of a third person in conflicts as observed in the given scenario.

Choice D Reason:

Triangulation is correct. Triangulation in family systems therapy occurs when a third person, often a child, is involved in the conflicts between two other family members. In this scenario, Kate is venting her frustrations to her younger son, which creates a triangle or three-person dynamic in the family system. Triangulation can serve as a way for family members to stabilize their relationships by shifting the focus or tension onto a third party.

Choice A Reason:

"Why do you think you might have cancer when your diagnosis is a benign condition?” This response may come across as dismissive and could make the client feel unheard. It does not acknowledge the client's concerns and may discourage open communication.

Choice B Reason:

"I'm hearing that you are concerned that might turn out that you have cancer.” This response demonstrates active listening and acknowledges the client's expressed concern. It encourages the client to share their feelings and provides an opportunity for further discussion. Option B shows empathy and supports the client's emotional needs during a stressful time.

Choice C Reason:

"I'm looking at your chart here and I don't see any reason for you to worry about that.” This response focuses on the medical chart and might minimize the client's emotional concerns. It does not address the client's feelings and may create a sense of invalidation.

Choice D Reason:

"I think that's something you need to discuss with your provider.” While it directs the client to the provider, it doesn't acknowledge the client's emotions or provide immediate support. It may seem like a deflection rather than an empathetic response.

Choice A Reason:

"Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge." This option seems to introduce the topic of termination prematurely, especially if the client's issues and goals haven't been adequately addressed yet.

Choice B Reason:

"You are being discharged today, so I'd like to bring up the subject of termination, which includes discussing your time here and summarizing what coping skills you have attained."This option presents termination at the time of discharge without prior discussion or collaboration with the client.

Choice C Reason:

"Now that we are working on your problem-solving skills and the behaviors you'd like to change, I'd like to bring up the issue of termination." In therapeutic relationships, termination is an essential phase that involves discussing the ending of the relationship and summarizing the progress made. Bringing up the topic of termination when actively working on the client's goals and issues is appropriate. It allows for a collaborative discussion about the achievements, future plans, and coping strategies that the client has developed during the therapeutic process.

Choice D Reason:

"I haven't met my new patient yet, but am working through my feelings of anxiety in dealing with a parent who wanted to kill herself." This statement is not related to the discussion of termination in the ongoing nurse-patient relationship.