A nurse is caring for a group of clients on a mental health unit. Which of the following actions should the nurse implement to establish therapeutic relationships with the clients?

Choice A Reason:

Grooming is correct. Grooming assesses the client's personal care and hygiene, providing insight into their ability to perform self-care activities.

Choice B Reason:

Long-term memory is correct. Evaluating long-term memory helps assess the client's ability to recall past events and information, which can be affected in individuals with dementia.

Choice C Reason:

Support systems is incorrect. While support systems are crucial in the overall care of individuals with dementia, they are not typically assessed in a traditional MSE.

Choice D Reason:

Affecting is correct. Affect refers to the client's emotional expression. Assessing affect helps in understanding the client's emotional state, which can be important in diagnosing and managing dementia.

Choice E Reason:

Presence of pain is incorrect. While assessing pain is essential in clinical care, it may be more pertinent to a physical assessment than a mental status examination specifically focused on cognitive functioning.

Choice A Reason:

Coordinating the implementation of the nursing care plan and documents is inappropriate. This choice is more related to general nursing responsibilities and care coordination. Milieu therapy specifically focuses on creating a therapeutic environment rather than coordinating care plans and documents.

Choice B Reason:

Providing and maintaining a safe and therapeutic environment in collaboration with others is appropriate. Milieu therapy involves creating a therapeutic environment that promotes the patient's mental health and well-being. This includes ensuring safety, providing structure, and creating a supportive atmosphere for patients. The nurse, in collaboration with the healthcare team, is responsible for establishing and maintaining this therapeutic milieu.

Choice C Reason:

Applying current knowledge to assess the patient's response to medication is inappropriate.

Assessing the patient's response to medication is an important nursing responsibility, but it is not the primary focus of milieu therapy. Milieu therapy is more concerned with the overall environment and its impact on the patient's mental health.

Choice D Reason:

Giving anticipatory guidance to prevent or reduce mental illness and enhance mental health is inappropriate. While anticipatory guidance is important in nursing care, it may not capture the essence of creating and maintaining a therapeutic environment, which is the core of milieu therapy. This choice is more related to health education and preventive measures rather than the overall therapeutic environment.