When describing the continuum of care for mental health, which would the nurse identify as the primary goal?

Choice A reason:
Honking the car horn to get the client’s attention could startle the client and potentially escalate the situation. It is important to avoid actions that could provoke a violent response or increase the client’s agitation. Safety is the primary concern, and honking the horn does not ensure the nurse’s or the client’s safety.

Choice B reason:
Stopping the car in the client’s driveway and calling the authorities is not the safest immediate action. While calling the authorities is necessary, stopping in the driveway could put the nurse in a vulnerable position. It is safer to move away from the immediate vicinity before making the call.

Choice C reason:
Keeping driving in a path that is going away from the client’s house is the safest immediate action. This ensures the nurse’s safety by creating distance from the potentially dangerous situation. Once at a safe distance, the nurse can then call the authorities to handle the situation appropriately.

Choice D reason:
Calmly speaking the client’s name out of the car window could also escalate the situation. The client may perceive this as a threat or intrusion, leading to unpredictable behavior. It is safer to avoid direct interaction and ensure personal safety first.

Choice A reason:

“It is now time for you to bathe. Do you want to wear the red or green shirt?” This statement is therapeutic as it provides clear instructions and offers the client a choice, promoting autonomy and cooperation. It addresses the need for hygiene in a respectful and supportive manner.

Choice B reason:

“Do you really think it is okay not to bathe? What is going on with you?” This statement is confrontational and judgmental. It may make the client feel defensive or ashamed, which can hinder the therapeutic relationship and the client’s willingness to engage in self-care.

Choice C reason:

“This is it! You are getting a bath! There are three of us here to bathe you!” This statement is coercive and does not respect the client’s autonomy. Forcing the client to bathe without their consent can escalate the situation and damage trust between the client and the nurse.

Choice D reason:

“I’m going to ignore your lack of self-care because it is an aspect of the disorder.” Ignoring the client’s hygiene issues is not therapeutic. While it is important to understand that self-care deficits can be part of the disorder, the nurse should still address these issues in a supportive and respectful manner.