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 D
Explanation
Choice A Reason:
Scheduling the client for a therapeutic group session may not be appropriate as a priority action. Clients with catatonia often experience significant psychomotor disturbances, which can include immobility or stupor, making participation in group activities challenging and potentially distressing.
Choice B Reason:
Encouraging the client to walk in the hallway is not the most immediate concern. While mobility is important, the safety and medical stability of the client take precedence, especially considering the potential for immobility and resistance to movement in catatonic states.
Choice C Reason:
Encouraging the client to verbalize feelings at all times is not practical as a priority action. Catatonia can involve mutism or significantly reduced responsiveness, making it difficult for the client to express themselves verbally.
Choice D Reason:
Offering small, frequent fluids throughout the day is a priority action for a client with catatonia. Due to the potential for decreased oral intake and the risk of dehydration, ensuring the client receives adequate hydration is essential. This intervention addresses a basic physiological need and can prevent further complications.
Correct Answer is A
Explanation
Choice A reason:
The statement correctly identifies that a therapeutic milieu encompasses both the physical and psychosocial aspects of the environment. This holistic approach is designed to support the recovery and well-being of clients by ensuring that all aspects of the unit's environment are conducive to therapy.
Choice B reason:
While personalization of space can be part of a therapeutic milieu, this statement alone does not capture the full essence of the concept. Therapeutic milieu involves more than just personal items; it includes the structured management of the environment to promote positive interactions and therapeutic outcomes.
Choice C reason:
Positioning chairs around the perimeter of the day room may be a part of the environmental setup, but it does not fully represent the therapeutic milieu. The therapeutic milieu is about creating an environment that encourages interaction, communication, and community among clients, which may or may not involve specific furniture arrangements.
Choice D reason:
Unstructured programming is not a characteristic of therapeutic milieu. In fact, therapeutic milieu typically involves a structured schedule of activities and programs that are designed to promote therapeutic engagement, skill development, and social interaction among clients.
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