A nurse is caring for a client on the Mental Health Unit. The client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. Which of the following responses should the nurse make?
“You should rest until you feel able to join the group.”
“I will help you get ready, and then you can rest after activities.”
“If you do not get out of bed, you will not receive your meal.”
“You really need to follow the rest of the unit and get out of bed.”
The Correct Answer is B
Choice A Reason: While this response may seem compassionate, it does not encourage the client to engage in activities that could benefit their mental health. Allowing the client to remain isolated may reinforce feelings of helplessness or depression. It is important to motivate clients to participate in therapeutic activities to promote their recovery.
Choice B Reason: This response is supportive and offers a compromise. It acknowledges the client’s current state and provides assistance, while also gently encouraging participation in activities. By offering help and allowing for rest afterward, the nurse is using an empathetic approach to facilitate the client’s involvement in the unit’s programs.
Choice C Reason: This response is coercive and could be considered a threat. It is not therapeutic to withhold basic needs such as meals as a form of punishment or to force compliance. Such an approach can damage the nurse-client relationship and is not conducive to the client’s recovery.
Choice D Reason: This response may come across as dismissive and demanding. It does not offer support or acknowledge the client’s feelings. Telling the client what they “need” to do without offering help or understanding can lead to resistance and a lack of trust in the nurse-client relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
While a mental health unit that includes milieu therapy may focus on stabilizing clients, it is not limited to those in an acute phase of mental illness. Milieu therapy is a comprehensive approach that can benefit individuals at various stages of their treatment.
Choice B reason:
Milieu therapy is not necessarily less intensive nor does it focus solely on one psychiatric illness or substance abuse disorder. It is a versatile treatment method that can be applied to a range of conditions and is integrated into the daily life of the unit.
Choice C reason:
This choice accurately reflects the essence of milieu therapy. It is a therapeutic approach where the environment is used as an integral part of treatment. The goal is to create a stable, adaptive reality through routines, boundaries, and open communication, fostering a sense of safety and support for therapeutic change.
Choice D reason:
Milieu therapy is not exclusively focused on long-term care but is adaptable to the needs of clients, whether they require short-term stabilization or long-term treatment. It is designed to help individuals learn healthier ways of thinking and behaving within a supportive community setting.
Correct Answer is A
Explanation
Choice A Reason:
Offering false reassurance occurs when a nurse or healthcare provider dismisses a patient's concerns with general comforting statements without addressing the reality of the situation or the patient's feelings. In this case, the nurse's response of "Don't worry, no one will harm your family" is an attempt to alleviate the patient's anxiety without acknowledging the patient's fear or providing a realistic plan to ensure the safety of the patient's family. This type of communication can undermine trust and prevent the patient from feeling heard and supported.
Choice B Reason:
Offering sympathy involves sharing feelings of pity or sorrow for someone else's misfortune. While the nurse's response may seem sympathetic, it does not directly express shared emotions or an understanding of the patient's distress. Therefore, it does not represent offering sympathy as a communication breakdown in this context.
Choice C Reason:
Providing a passive response would involve the nurse not actively engaging with the patient's concerns or failing to provide any response. Since the nurse in the scenario does respond to the patient's statement, this does not constitute a passive response.
Choice D Reason:
Showing disapproval would involve the nurse expressing judgment or criticism of the patient's feelings or actions. The nurse's response does not contain elements of judgment or criticism; rather, it is an attempt to reassure the patient, albeit falsely.
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