A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

Choice A Reason:
A client exhibiting psychotic behavior may not be the best candidate for group therapy initially, as they might be experiencing delusions, hallucinations, or disorganized thinking that could disrupt the group process and might not be able to participate effectively. Individual therapy might be more appropriate until the client's symptoms are better managed.

Choice B Reason:
A client who was admitted 5 hours ago for acute mania is likely still experiencing heightened levels of energy, impulsivity, and possibly erratic behavior. They may not be able to engage in group therapy effectively and could benefit from stabilization before participating in a group setting.

Choice C Reason:
A client who has been taking lithium for 2 weeks for depression is likely to have achieved some level of stabilization of their mood. Lithium is a mood stabilizer used to treat bipolar disorder and depression, and after 2 weeks, the client may be ready to engage with others in a therapeutic group setting.

Choice D Reason:
A client who is in a manic state, similar to the client in choice B, may not be suitable for group therapy due to potential disruptive behavior and difficulty focusing on the group process. It's important for the client to receive individual attention to manage the mania before joining group therapy.
Question 43

Choice A Reason:
Assessing the client's readiness for therapy is a crucial role of the nurse in CBT. It involves determining whether the client is willing and able to participate in therapy, understands the CBT process, and is motivated to engage in the cognitive and behavioral changes that CBT requires. This assessment helps ensure that the therapy is client-centered and tailored to the individual's specific needs and readiness level.

Choice B Reason:
While involving the client's family can be beneficial in therapy, implementing therapeutic techniques that involve only the client's family does not align with the primary goals of CBT. CBT focuses on the individual's patterns of thinking and behavior, and while family support can be part of the process, the nurse's role is not limited to family involvement alone.

Choice C Reason:
Educating the client to identify and challenge negative thoughts is a fundamental aspect of CBT. The nurse helps the client recognize their automatic negative thoughts, understand the impact these thoughts have on their emotions and behavior, and learn to challenge and reframe these thoughts in a more positive and realistic way.

Choice D Reason:
Evaluating to determine the effectiveness of the actions is part of the nurse's role in CBT. This involves monitoring the client's progress, assessing the outcomes of the interventions, and making necessary adjustments to the treatment plan. Evaluation is an ongoing process that ensures the therapy is effective and meets the client's needs.

Choice E Reason:
Collaborating with the client to set achievable goals is essential in CBT. The nurse works with the client to establish clear, measurable, and attainable goals that guide the therapy process. These goals provide direction and motivation, and they help the client focus on making specific changes that will improve their mental health.