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:
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.

A. "Antidepressants are not your solution, but this therapy group is." B. "I notice you keep clenching your fists. This needs to stop." C. "Let's discuss what you mean when you say that you cannot ever return to work." D. "You need to work hard on resolving conflict with those closest to you."

Correct Answer is C

Explanation

Choice A reason:
This statement may come across as dismissive of the potential benefits of medication, which can be an important part of treatment for some individuals. It's essential to consider and respect each client's unique treatment needs, including medication.

Choice B reason:
Pointing out physical manifestations of stress in a confrontational way may make the client feel self-conscious or defensive. It's important to address such observations with sensitivity and in the context of exploring feelings.

Choice C reason:
Inviting the client to discuss their concerns about returning to work opens up a dialogue about their fears and challenges. It's a supportive approach that encourages expression and exploration of feelings.

Choice D reason:
While resolving conflicts is important, this directive statement may feel overwhelming to a client who is already dealing with a new cancer diagnosis. It's better to offer support and guidance in navigating interpersonal issues.

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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

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

Correct Answer is D

Explanation

A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements 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?

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A charge nurse is providing an in-service to a group of nurses about the benefits of an interprofessional team. Which of the following information should the nurse include?

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?