A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Directly tell the client that the delusions are not real.

Use frequent touch to provide client support.

Place the client in seclusion if visual hallucinations are present.

Limit the number of questions asked during assessments.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Directly telling a client that their delusions are not real is not typically recommended. This approach can be confrontational and may lead to increased anxiety or agitation in the client. It's important to maintain a therapeutic relationship by validating the client's feelings and working within their current reality, rather than directly challenging their perceptions.

Choice B Reason:
Using frequent touch to provide support may not be appropriate for all clients, especially those with schizophrenia who may have altered perceptions of reality. Some individuals may find touch comforting, while others may perceive it as threatening or invasive. It's crucial to assess each client's comfort level with physical contact and proceed accordingly.

Choice C Reason:
Placing a client in seclusion can be a traumatic experience and is generally considered a last resort when other interventions have failed and the client is a danger to themselves or others. Seclusion should not be used solely because a client is experiencing visual hallucinations.

Choice D Reason:
Limiting the number of questions during assessments can help reduce the potential for overwhelming the client. Clients with schizophrenia may have difficulty processing too much information at once, and a barrage of questions can be stressful. Simplifying communication and allowing the client to focus on one question at a time can be more effective.

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Correct Answer is D

Explanation

Choice A reason:
Evaluation is the final step in the nursing process, where the nurse determines the effectiveness of the nursing care plan and whether the client's goals and outcomes have been met. In the context of milieu therapy, evaluation would involve assessing the client's progress within the therapeutic environment.

Choice B reason:
Planning involves setting goals and expected outcomes for the client's care and then determining the specific interventions that will be used to achieve those goals. In milieu therapy, planning would include designing the structure and activities of the therapeutic environment to meet the needs of the clients.

Choice C reason:
Assessment is the first step in the nursing process, where the nurse collects comprehensive data pertinent to the client's health and the situation. In milieu therapy, assessment would include understanding the client's mental health status, personal history, and specific needs within the therapeutic environment.

Choice D reason:
Implementation is the step where the nurse puts the care plan into action. In the context of milieu therapy, implementation refers to the nurse's role in actively creating and maintaining the therapeutic environment, facilitating group activities, and ensuring that the daily routine is therapeutic for all clients.

A. A mental health unit, which includes milieu therapy, is focused on stabilizing clients who are in an acute phase of mental illness. B. A mental health unit, which includes milieu therapy, is less intensive, focusing only on one psychiatric illness or substance abuse disorder. C. A mental health unit, which includes milieu therapy, ensures every aspect of care is intentionally focused on creating a safe and therapeutic environment. D. A mental health unit, which includes milieu therapy, is focused on long-term care of clients who have specific mental health disorders.

Correct Answer is C

Explanation

Choice A reason:
While a mental health unit that includes milieu therapy may focus on stabilizing clients, it is not limited to those in an acute phase of mental illness. Milieu therapy is a comprehensive approach that can benefit individuals at various stages of their treatment.

Choice B reason:
Milieu therapy is not necessarily less intensive nor does it focus solely on one psychiatric illness or substance abuse disorder. It is a versatile treatment method that can be applied to a range of conditions and is integrated into the daily life of the unit.

Choice C reason:
This choice accurately reflects the essence of milieu therapy. It is a therapeutic approach where the environment is used as an integral part of treatment. The goal is to create a stable, adaptive reality through routines, boundaries, and open communication, fostering a sense of safety and support for therapeutic change.

Choice D reason:
Milieu therapy is not exclusively focused on long-term care but is adaptable to the needs of clients, whether they require short-term stabilization or long-term treatment. It is designed to help individuals learn healthier ways of thinking and behaving within a supportive community setting.

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A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working in a mental health facility is utilizing milieu therapy to provide a therapeutic environment for their clients. Which of the following steps of the nursing process is the nurse demonstrating?

Correct Answer is D

Explanation

A nurse has described the behavioral health unit being based on milieu therapy to a client. The client asks, "How is a unit that has milieu therapy different from other hospital units?" Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is leading a group family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members?

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures?

The nurse is caring for a client diagnosed with catatonia. Which of the following should be a priority action by the nurse?

A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

While in a therapeutic group, two clients get into a heated debate over politics that turns aggressive. The nurse makes the decision to have both patients removed from the group session. The nurse has demonstrated which leadership style?

A nurse is teaching about physiological responses to stress with a group of clients. The nurse should identify that which of the following changes reflect long-term physiological responses to stress? (Select all that apply)