A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr. after attacking a neighbor.
To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?
Whether the client is unable to make arrangements to stay with someone.
Whether the client is financially incapable of paying for medications.
Whether the client is in danger of harming herself or others.
Whether the client is unwilling to accept that treatment is needed.
The Correct Answer is C
Involuntary admission to a mental health unit is done when an individual poses a threat to themselves or others due to a mental health condition. The initial hold is usually for 72 hours, during which the client's condition is assessed and an appropriate treatment plan is developed. If the client is still deemed to be a danger to themselves or others after the initial hold, the healthcare provider may request an extension of the hold or seek a court order to continue treatment.
In order to keep the client in the hospital, it must be determined that they continue to pose a threat to themselves or others.
Factors such as the client's ability to make arrangements to stay with someone or financial capability to pay for medications are not relevant to the decision of whether to continue the hold.
Similarly, unwillingness to accept treatment is not the determining factor, as involuntary treatment can be provided to clients who do not recognize their need for treatment if they are deemed to be a danger to themselves or others.
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Correct Answer is C
Explanation
The nurse’s ability to listen and observe the client’s verbal and non-verbal messages. Effective communication in the mental health setting requires the nurse to actively listen to the client and to pay close attention to their verbal and non-verbal cues. By doing so, the nurse can better understand the client’s needs and concerns and can provide appropriate support and guidance.
While the nurse’s understanding of mental health disorders (b) and their relationship with the client (d) can also play a role in effective communication, the ability to listen and observe is a fundamental skill that is essential for effective therapeutic communication. The client’s ability to communicate (a) is also important, but it is ultimately the nurse’s responsibility to use effective communication techniques to facilitate the therapeutic process.
Correct Answer is D
Explanation
This response is empathetic and allows the client to express her feelings openly. It demonstrates active listening and validates the client's emotions.
Option A ("I know exactly how you feel") can come across as dismissive or assuming, and it may not accurately reflect the client's unique experience.
Option B ("Most people experience depressed feelings after a divorce") may also come across as dismissive and minimizes the client's feelings.
Option C ("Look on the bright side, you will be glad you divorced him in a couple of years") is not empathetic and does not acknowledge the client's current emotional state.
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