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?

Evaluation

Planning

Assessment

Implementation

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is D

Explanation

Choice A Reason:
Passive-aggressive communication involves expressing negative feelings indirectly rather than openly addressing them. It often manifests as sarcasm, backhanded compliments, or subtle digs. In this scenario, the client is directly stating their preference without any indirect negativity, so it is not passive-aggressive.

Choice B Reason:
Aggressive communication is characterized by speaking in a way that violates or disrespects others. It often includes yelling, interrupting, or demeaning language. The client's statement does not display any of these characteristics; instead, it is a straightforward expression of their wish.

Choice C Reason:
Nonassertive communication, also known as passive communication, occurs when individuals fail to express their thoughts or feelings, or they do so without confidence. The client in the garden is clearly stating their desire to plant the sunflower, which is not indicative of a nonassertive pattern.

Choice D Reason:
Assertive communication is the act of expressing one's opinions, feelings, and needs in a clear, direct, and respectful way. It involves standing up for oneself while also considering the rights and feelings of others. The client's statement, "I would really like to plant the sunflower," is a clear, direct expression of their preference, making it an assertive form of communication.

A. Supporting the client's wish to refuse prescribed medications. B. Making sure the client understands expectations for client participation. C. Explaining unit rules and policies regarding unacceptable behaviors. D. Encouraging client feedback about satisfaction with the facility experience. E. Calmly speaking the client's name out of the car window may seem like a non-threatening action, but it involves direct engagement with the client while he is holding a weapon. This could put the nurse at risk if the client reacts unpredictably or feels threatened.

Correct Answer is A

Explanation

Choice A Reason:

Supporting the client's wish to refuse prescribed medications is a direct demonstration of respecting the client's autonomy. Autonomy in nursing is the right to self-determination, where patients are provided with adequate information to make their own decisions based on their beliefs and values. By supporting the client's decision, the nurse acknowledges the client's capacity to make informed choices about their own health care, even if the choice is different from what the medical team suggests.

Choice B Reason:

Ensuring that the client understands expectations for participation is more about informed consent and education rather than autonomy. While it is related to autonomy, it does not directly demonstrate the ethical concept since it does not involve a decision made by the client.

Choice C Reason:

Explaining unit rules and policies about unacceptable behaviors is part of the education process and setting boundaries within the healthcare environment. This action is necessary for all clients but does not specifically address the client's autonomy in making personal health decisions.

Choice D Reason:

Encouraging client feedback about satisfaction with the facility experience is a way to involve clients in the evaluation process of the facility's services. While this can be seen as respecting the client's opinions, it is not a direct action of supporting the client's autonomous decisions regarding their treatment plan

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Two clients are in the garden disagreeing on which plant should go in the corner. One client says to the other, "I would really like to plant the sunflower." The nurse recognizes this as which form of communication response pattern?

Correct Answer is D

Explanation

A nurse is caring for a client diagnosed with a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

Correct Answer is A

Explanation

A nurse is caring for a client diagnosed with severe manifestations of schizophrenia and is prescribed haloperidol (Haldol) PRN for agitation. The nurse should recognize which of the following as adverse effects of haloperidol (Haldol)?

A nurse overhears a client diagnosed with schizophrenia talking to herself. The client keeps stating, "The flakalas are here. The flakalas are here." The nurse should recognize the client's use of the word "flakala" as an example of which of the following alterations in speech?

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 caring for a client who is hospitalized and says to the nurse, "My partner called and told me my boss hired someone to take my place." Which of the following responses should the nurse make?

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. The findings include blood pressure changes, fever, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

A nurse is caring for a client on the Mental Health Unit. The client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. Which of the following responses should the nurse make?

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?