A nurse in an acute care mental health facility is creating a plan of care for a newly admitted client. Which of the following interventions should the nurse plan to include in the working phase of the nurse-client relationship?

Summarize the objectives the client achieved during the relationship.

Present issues regarding confidentiality.

Promote the client's problem-solving skills.

identify the responsibilities of the client and nurse.

Answer and Explanation

The Correct Answer is C

A. Summarize the objectives the client achieved during the relationship:
This intervention is more appropriate for the termination phase of the nurse-client relationship. During termination, the nurse summarizes the progress made, goals achieved, and skills learned during the therapeutic relationship. This helps both the nurse and the client reflect on the journey and celebrate accomplishments.

B. Present issues regarding confidentiality:
Discussing confidentiality is crucial and typically occurs in the orientation phase of the nurse-client relationship. Establishing trust and clarifying the boundaries of confidentiality early in the relationship helps the client feel secure and promotes open communication. This choice is relevant during the initial stages of the therapeutic relationship.

C. Promote the client's problem-solving skills:
This is the correct choice for the working phase of the nurse-client relationship. In this phase, the focus is on active problem-solving, exploring feelings and thoughts, and encouraging the client to develop coping strategies. The nurse supports the client in identifying problems, generating solutions, and implementing effective strategies. Promoting the client's problem-solving skills is a central aspect of therapeutic work during this phase.

D. Identify the responsibilities of the client and nurse:
Clarifying the responsibilities of both the client and nurse is essential to establish clear roles and expectations. This usually occurs in the orientation phase. During this phase, the nurse explains the purpose of the therapeutic relationship, the roles of both parties and the boundaries of the nurse-client interaction. Establishing clear responsibilities helps create a foundation for a respectful and effective therapeutic alliance.

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Correct Answer is C

Explanation

A. "What have you done to change your situation?"
This response can come off as accusatory and might make the client feel judged. It's not the most therapeutic response in this situation.

B. "You should remove yourself from this situation now."
While removing oneself from a harmful situation is generally good advice, it might not be practical or safe in the heat of the moment. Moreover, this response doesn't address the underlying emotional distress the client is expressing.

C. “Are you thinking about harming yourself?"
This response directly assesses the client's suicidal ideation. It's essential to ask direct questions about self-harm when a person expresses feelings of hopelessness, as it provides an opportunity for the client to talk about their thoughts and feelings and for the nurse to assess the level of risk accurately.

D. “We will help get you through this. You'll be fine."
While offering support and reassurance is essential, it doesn't directly address the immediate concern of potential suicidal thoughts. The nurse should assess the client's safety first before providing reassurance.

A. "This medication is given to help with extrapyramidal side effects." B. "Benztropine helps alleviate your hallucinations." C. "This medication is given to help with your depression." D. "Benztropine is used to counteract your tachycardia."

Correct Answer is A

Explanation

A. "This medication is given to help with extrapyramidal side effects."
Benztropine is an anticholinergic medication used to treat the extrapyramidal side effects (EPS) caused by certain psychiatric drugs, particularly antipsychotics. EPS can include symptoms such as muscle stiffness, restlessness, tremors, and other movement disorders. Benztropine helps to alleviate these symptoms, making it an essential medication for individuals experiencing these side effects from antipsychotic medications.

B. "Benztropine helps alleviate your hallucinations."
This statement is incorrect. Benztropine is not primarily used to treat hallucinations; it is used for movement-related side effects as mentioned above.

C. "This medication is given to help with your depression."
This statement is incorrect. Benztropine is not indicated for the treatment of depression.

D. "Benztropine is used to counteract your tachycardia."
This statement is incorrect. Benztropine is not used to treat tachycardia (fast heart rate). It is specifically used for extrapyramidal side effects related to antipsychotic medications.

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A nurse in an acute care mental health facility is creating a plan of care for a newly admitted client. Which of the following interventions should the nurse plan to include in the working phase of the nurse-client relationship?

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