A nurse in an acute care mental health unit is speaking with a client who reports that other clients leave trash in the lounge. Which of the following actions should the nurse take?

This statement implies that the nurse is taking sides and suggesting a specific course of action to the client. It is important for the nurse to remain neutral and non-directive during family therapy sessions. The nurse's role is to facilitate open communication, active listening, and understanding between the family members, rather than imposing their own opinions or suggesting specific solutions.

To ensure a therapeutic and unbiased approach, the nurse should intervene and provide feedback to the newly licensed nurse, reminding them to maintain a neutral stance and encourage the client to explore their own perspectives and feelings about the relationship.

Incorrect:

A. "We should invite your partner to be a part of our discussion." This statement suggests involving the partner, which is a common practice in family therapy. It recognizes the importance of including all relevant family members in the therapeutic process.

B. "Tell me about the concerns that you have regarding your relationship." This statement encourages the client to express their concerns and provides an opportunity for them to share their thoughts and feelings about the relationship. It promotes open communication and active listening.

D. "Relationship difficulties are stressful and require effort to resolve." This statement acknowledges the challenges in relationships and emphasizes the need for active participation and effort to address and resolve issues. It sets a realistic expectation for the client and supports their engagement in the therapeutic process.

From the given information, the nurse should include the following interventions in the plan of care for the client with dementia:
● Obtain client's weight weekly: Regular weight monitoring helps assess the client's nutritional status and detect any significant changes that may require intervention.
● Offer the client finger foods for meals: Finger foods can be easier for the client to handle and consume independently, promoting independence and self-feeding.
● Encourage the client to take deep breaths when feeling agitated: Deep breathing exercises can help the client manage their agitation and promote relaxation.
● Assess client's memory every shift: Regular assessment of the client's memory allows for monitoring any changes or decline, which helps in planning appropriate interventions and providing necessary support.
The following interventions should be avoided:

● Speak loudly when addressing the client: Speaking loudly may cause confusion or agitation in the client. Instead, it is recommended to use a calm and reassuring tone of voice.
● Give long tasks at a time to the client: Clients with dementia often have difficulty with concentration and memory. Providing long tasks may overwhelm them and contribute to their frustration. Breaking tasks into smaller, manageable steps is more appropriate.

● Turn the client's TV on at night when they are unable to sleep: It is generally recommended to create a quiet and calming environment for sleep. The TV may interfere with the client's sleep and contribute to increased agitation or confusion.