A nurse in an acute care mental health facility is creating a plan of care for a newly admitted client. Which of the following interventions should the nurse plan to include in the working phase of the nurse-client relationship?

Summarize the objectives the client achieved during the relationship.

Present issues regarding confidentiality.

Promote the client's problem-solving skills.

identify the responsibilities of the client and nurse.

Answer and Explanation

The Correct Answer is C

A. Summarize the objectives the client achieved during the relationship:
This intervention is more appropriate for the termination phase of the nurse-client relationship. During termination, the nurse summarizes the progress made, goals achieved, and skills learned during the therapeutic relationship. This helps both the nurse and the client reflect on the journey and celebrate accomplishments.

B. Present issues regarding confidentiality:
Discussing confidentiality is crucial and typically occurs in the orientation phase of the nurse-client relationship. Establishing trust and clarifying the boundaries of confidentiality early in the relationship helps the client feel secure and promotes open communication. This choice is relevant during the initial stages of the therapeutic relationship.

C. Promote the client's problem-solving skills:
This is the correct choice for the working phase of the nurse-client relationship. In this phase, the focus is on active problem-solving, exploring feelings and thoughts, and encouraging the client to develop coping strategies. The nurse supports the client in identifying problems, generating solutions, and implementing effective strategies. Promoting the client's problem-solving skills is a central aspect of therapeutic work during this phase.

D. Identify the responsibilities of the client and nurse:
Clarifying the responsibilities of both the client and nurse is essential to establish clear roles and expectations. This usually occurs in the orientation phase. During this phase, the nurse explains the purpose of the therapeutic relationship, the roles of both parties and the boundaries of the nurse-client interaction. Establishing clear responsibilities helps create a foundation for a respectful and effective therapeutic alliance.

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Correct Answer is C

Explanation

A. Liraglutide 0.6 mg subcutaneously daily:
Liraglutide is a medication used to treat type 2 diabetes and obesity. It works by regulating blood sugar levels and reducing appetite. It has no direct relevance to the treatment of schizophrenia or psychosis. Schizophrenia is a mental health disorder, and antipsychotic medications are typically used to manage its symptoms.

B. Selegiline 6 mg transdermal patch daily:
Selegiline is primarily used to treat Parkinson's disease by enhancing the effects of dopamine in the brain. It is not indicated for schizophrenia or psychosis. While dopamine dysregulation is involved in both Parkinson's disease and schizophrenia, the mechanisms and treatments are different. Antipsychotic medications, not selegiline, are used to manage psychosis in schizophrenia.

C. Aripiprazole 400 mg IM every 4 weeks:
This is the correct choice. Aripiprazole is an atypical antipsychotic medication commonly used to treat schizophrenia and other psychotic disorders. The intramuscular (IM) formulation provides extended release, making it suitable for clients who may have difficulty adhering to daily oral medications. It helps manage psychosis, a common symptom of schizophrenia.

D. Lithium 600 mg PO three times per day:
Lithium is a mood stabilizer commonly used to treat bipolar disorder by preventing or reducing the intensity of manic episodes. It is not a first-line treatment for schizophrenia or psychosis. Antipsychotic medications are the primary choice for managing the symptoms of psychosis in schizophrenia. Lithium is not typically used to address the hallucinations and delusions associated with schizophrenia.

A. Long-term isolation B. Dysthymic disorder C. Alcohol intoxication D. Schizoid personality disorder

Correct Answer is C

Explanation

A. Long-term isolation: Long-term isolation, or social isolation, can lead to feelings of loneliness and depression. While prolonged isolation can contribute to mental health issues, it is not a direct risk factor for violent behavior. People who are socially isolated might suffer from emotional distress, but it doesn't necessarily make them violent.

B. Dysthymic disorder: Dysthymic disorder, also known as persistent depressive disorder, is a type of chronic depression. While individuals with dysthymic disorder may experience low moods and a lack of interest in activities, it doesn't inherently make them prone to violence. Depression is more likely to cause self-directed harm (such as self-harm or suicide) rather than violent behavior towards others.

C. Alcohol intoxication: Alcohol is a substance that impairs judgment and reduces inhibitions. When a person is intoxicated, they may act aggressively or violently, even in situations where they wouldn't normally do so. Alcohol intoxication can lead to a loss of control, impaired decision-making, and aggressive behavior, making it a significant risk factor for violent actions.

D. Schizoid personality disorder: Schizoid personality disorder is characterized by a lack of interest in social relationships, emotional coldness, and detachment. While individuals with this disorder may prefer to be alone and avoid social interactions, they are not necessarily prone to violent behavior. Schizoid personality disorder primarily affects social functioning rather than predisposing someone to violence.

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A nurse in an acute care mental health facility is creating a plan of care for a newly admitted client. Which of the following interventions should the nurse plan to include in the working phase of the nurse-client relationship?

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