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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Scheduling the client for a therapeutic group session may not be appropriate as a priority action. Clients with catatonia often experience significant psychomotor disturbances, which can include immobility or stupor, making participation in group activities challenging and potentially distressing.
Choice B Reason:
Encouraging the client to walk in the hallway is not the most immediate concern. While mobility is important, the safety and medical stability of the client take precedence, especially considering the potential for immobility and resistance to movement in catatonic states.
Choice C Reason:
Encouraging the client to verbalize feelings at all times is not practical as a priority action. Catatonia can involve mutism or significantly reduced responsiveness, making it difficult for the client to express themselves verbally.
Choice D Reason:
Offering small, frequent fluids throughout the day is a priority action for a client with catatonia. Due to the potential for decreased oral intake and the risk of dehydration, ensuring the client receives adequate hydration is essential. This intervention addresses a basic physiological need and can prevent further complications.
Correct Answer is C
Explanation
Choice A reason:
Bleeding is not commonly associated with the use of haloperidol. While antipsychotic medications can have a wide range of side effects, bleeding is not typically reported as an adverse effect of haloperidol.
Choice B reason:
Pancreatitis is not a recognized adverse effect of haloperidol. This condition involves inflammation of the pancreas and is more commonly associated with medications that affect the gastrointestinal system directly.
Choice C reason:
Dysrhythmias, or abnormal heart rhythms, are known adverse effects of haloperidol. This medication can affect the electrical activity of the heart, potentially leading to serious cardiac events.
Choice D reason:
Cataracts are not a direct adverse effect of haloperidol. While long-term use of some medications can increase the risk of developing cataracts, haloperidol is not specifically linked to this condition.
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