The nurse is caring for a patient who consults with family members before making every treatment decision. Based on the nurse's observation. which type of boundary exists within the family structure?
Diffuse
Clear
Differentiation
Rigid
The Correct Answer is A
Choice A Reason:
Diffuse is correct. In a diffuse or permeable family boundary, there is a lack of clear separation between family members. Decisions and responsibilities may be shared extensively, and individual autonomy is limited. The patient's behavior of consulting with family members before making treatment decisions suggests a diffuse boundary where decision-making involves significant input from various family members.
Choice B Reason:
Clear is incorrect. - In a clear or rigid boundary, there is a distinct separation between family members, and individual autonomy is highly emphasized. The described behavior does not align with a clear boundary.
Choice C Reason:
Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. The behavior described is more indicative of a diffuse boundary than a differentiation issue.
Choice D Reason:
Rigid is incorrect. A rigid boundary is characterized by strict rules and limited flexibility. The described behavior does not align with a rigid boundary where decision-making might be more centralized and less consultative.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Triage and stabilization of the acute symptoms are a priority describes the focus of psychiatric emergency care. Psychiatric emergency care focuses on the rapid assessment, triage, and stabilization of individuals experiencing acute psychiatric symptoms or crises. The primary goal is to address immediate safety concerns, stabilize the individual's condition, and determine the appropriate level of care or intervention. This may involve crisis intervention, brief assessment, and referral to appropriate services.
Choice B Reason:
A nurse visits one to three times a week to assess for extreme agitation does not describe the focus of psychiatric emergency care. This describes a more routine or outpatient assessment schedule rather than the urgent and immediate focus of psychiatric emergency care.
Choice C Reason:
Overnight short-term observations are 1 to 3 days in duration does not describe the focus of psychiatric emergency care. This refers to a short-term observation period, which might occur in various psychiatric settings, but it does not specifically address the urgency of psychiatric emergencies.
Choice D Reason:
Antipsychotic medications are administered does not describe the focus of psychiatric emergency care. Administering antipsychotic medications is a treatment approach that may be part of the overall psychiatric care plan, but it does not specifically capture the immediate triage and stabilization focus of psychiatric emergency care.
Correct Answer is B
Explanation
Choice A Reason:
Coordinating the implementation of the nursing care plan and documents is inappropriate. This choice is more related to general nursing responsibilities and care coordination. Milieu therapy specifically focuses on creating a therapeutic environment rather than coordinating care plans and documents.
Choice B Reason:
Providing and maintaining a safe and therapeutic environment in collaboration with others is appropriate. Milieu therapy involves creating a therapeutic environment that promotes the patient's mental health and well-being. This includes ensuring safety, providing structure, and creating a supportive atmosphere for patients. The nurse, in collaboration with the healthcare team, is responsible for establishing and maintaining this therapeutic milieu.
Choice C Reason:
Applying current knowledge to assess the patient's response to medication is inappropriate.
Assessing the patient's response to medication is an important nursing responsibility, but it is not the primary focus of milieu therapy. Milieu therapy is more concerned with the overall environment and its impact on the patient's mental health.
Choice D Reason:
Giving anticipatory guidance to prevent or reduce mental illness and enhance mental health is inappropriate. While anticipatory guidance is important in nursing care, it may not capture the essence of creating and maintaining a therapeutic environment, which is the core of milieu therapy. This choice is more related to health education and preventive measures rather than the overall therapeutic environment.
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