A nurse on a mental health unit enters the day room and observes a client hit another client. Which of the following statements should the nurse make?

Choice A Reason:
Assessing the client's readiness for therapy is a crucial role of the nurse in CBT. It involves determining whether the client is willing and able to participate in therapy, understands the CBT process, and is motivated to engage in the cognitive and behavioral changes that CBT requires. This assessment helps ensure that the therapy is client-centered and tailored to the individual's specific needs and readiness level.

Choice B Reason:
While involving the client's family can be beneficial in therapy, implementing therapeutic techniques that involve only the client's family does not align with the primary goals of CBT. CBT focuses on the individual's patterns of thinking and behavior, and while family support can be part of the process, the nurse's role is not limited to family involvement alone.

Choice C Reason:
Educating the client to identify and challenge negative thoughts is a fundamental aspect of CBT. The nurse helps the client recognize their automatic negative thoughts, understand the impact these thoughts have on their emotions and behavior, and learn to challenge and reframe these thoughts in a more positive and realistic way.

Choice D Reason:
Evaluating to determine the effectiveness of the actions is part of the nurse's role in CBT. This involves monitoring the client's progress, assessing the outcomes of the interventions, and making necessary adjustments to the treatment plan. Evaluation is an ongoing process that ensures the therapy is effective and meets the client's needs.

Choice E Reason:
Collaborating with the client to set achievable goals is essential in CBT. The nurse works with the client to establish clear, measurable, and attainable goals that guide the therapy process. These goals provide direction and motivation, and they help the client focus on making specific changes that will improve their mental health.

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.