A nurse in an acute care mental health unit is speaking with a client who reports that other clients leave trash in the lounge. Which of the following actions should the nurse take?

Call housekeeping to clean up the lounge.

Promise the client that the issue will be discussed at the next community meeting.

Help the client clean up the dayroom.

Encourage the client to discuss the problem with other clients.

Answer and Explanation

The Correct Answer is D

Answer: (D) Encourage the client to discuss the problem with other clients

Rationale:

A) Call housekeeping to clean up the lounge: While involving housekeeping might address the immediate issue, it does not empower the client or involve them in the community aspect of the unit. The goal in a mental health setting is to encourage clients to take an active role in resolving communal issues, fostering responsibility, and promoting interpersonal communication.

B) Promise the client that the issue will be discussed at the next community meeting: While addressing the issue in a community meeting is appropriate, simply promising to bring it up without involving the client may not address the immediate concern or empower the client to take an active role. The client might feel dismissed if their concerns are not immediately acknowledged or acted upon.

C) Help the client clean up the dayroom: Assisting the client in cleaning the lounge may resolve the mess temporarily but does not address the underlying issue of other clients leaving trash. It is more beneficial for the client to engage in communication with their peers to foster a sense of community and mutual respect.

D) Encourage the client to discuss the problem with other clients: Encouraging the client to communicate directly with their peers is a therapeutic approach that fosters assertiveness and problem-solving skills. It allows the client to express their concerns and take responsibility for addressing issues within the community, which is beneficial in their mental health recovery process.

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Correct Answer is D

Explanation

Respecting and honoring the autonomy of the clients is important in a mental health setting. Allowing clients to determine the boundaries of the nurse-client relationship empowers them to have control over their own treatment and fosters a sense of autonomy. It encourages clients to express their needs, preferences, and comfort levels in the therapeutic relationship, which can contribute to a more collaborative and effective treatment process.

The other options mentioned are not appropriate actions for the nurse to take:

A. Orienting clients to their responsibilities on the unit is an important task, but it is not specific to the context of a community meeting. It is more relevant during individual client orientations or at the beginning of their admission.

B. Focusing on client weaknesses to increase adaptation is not a therapeutic approach. It is important to focus on clients' strengths and support their growth and development rather than emphasizing weaknesses.

C. Planning to discuss any topic presented by clients can be unfeasible or not relevant in a community meeting. It is essential to have structure and purpose in group discussions to facilitate meaningful interactions.

A. Whether the client is unwilling to accept that treatment is needed. B. client is financially incapable of paying for prescribed medications. C. Whether the client is a danger to herself or others. D. Whether the client is unable to make arrangements to stay with someone.

Correct Answer is C

Explanation

When a client is involuntarily admitted to a mental health unit, there is typically a specific time frame, such as 72 hours, during which they can be held involuntarily for evaluation and
treatment. At the end of this initial hold period, further determination is required to determine if continued hospitalization is necessary.
The primary consideration for extending the client's stay is whether they continue to pose a danger to themselves or others. This determination is based on a comprehensive assessment of the client's mental state, behavior, and potential for harm. If the client still exhibits signs of being a threat to themselves or others, the healthcare team may decide to continue their hospitalization to ensure their safety and the safety of others.
The other options listed are not the primary criteria for determining the need for continued hospitalization:
● Whether the client is unwilling to accept that treatment is needed: While the client's willingness to accept treatment is an important factor, it is not the sole determinant for extending their stay. Even if the client recognizes the need for treatment, if they are still a danger to themselves or others, their hospitalization may be prolonged.
● Whether the client is financially incapable of paying for prescribed medications: Financial considerations do not directly impact the decision to extend the client's stay. The focus is on their safety and the need for continued psychiatric assessment and treatment.
● Whether the client is unable to make arrangements to stay with someone: The client's living arrangements or ability to stay with someone outside of the hospital are not the main factors in determining the need for extended hospitalization. The key consideration is whether the client continues to pose a danger to themselves or others.

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A nurse in an acute care mental health unit is speaking with a client who reports that other clients leave trash in the lounge. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is participating in a community meeting with a group of clients. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

Correct Answer is C

Explanation

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