A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply)

Choice A Reason:

Wife/mother is incorrect. The wife/mother expresses that she is not skillful in conflict resolution, but her concerns are related to her own abilities rather than exhibiting specific problematic behaviors that are disruptive or distressing to the family system.

Choice B Reason:

Daughter is correct. The daughter, who is rebellious and in academic trouble, is most likely to be listed as the "identified patient" because her behavior is presenting visible challenges and concerns. In family systems therapy, addressing and understanding the dynamics surrounding the identified patient can provide insights into the broader family issues and interactions.

Choice C Reason:

Son is incorrect. The son is conflicted about where to attend college, which is a common developmental decision. While it may cause some family stress, it doesn't necessarily indicate the presence of disruptive or problematic behavior warranting the label of "identified patient."

Choice D Reason:

Husband/father is incorrect. The husband/father is skeptical of the idea that talking can be helpful, but skepticism or reluctance to engage in therapy does not necessarily make him the identified patient. His behavior doesn't present as a disruptive symptom within the family.

Choice A Reason:

Coordinating the implementation of the nursing care plan and documents is inappropriate. This choice is more related to general nursing responsibilities and care coordination. Milieu therapy specifically focuses on creating a therapeutic environment rather than coordinating care plans and documents.

Choice B Reason:

Providing and maintaining a safe and therapeutic environment in collaboration with others is appropriate. Milieu therapy involves creating a therapeutic environment that promotes the patient's mental health and well-being. This includes ensuring safety, providing structure, and creating a supportive atmosphere for patients. The nurse, in collaboration with the healthcare team, is responsible for establishing and maintaining this therapeutic milieu.

Choice C Reason:

Applying current knowledge to assess the patient's response to medication is inappropriate.

Assessing the patient's response to medication is an important nursing responsibility, but it is not the primary focus of milieu therapy. Milieu therapy is more concerned with the overall environment and its impact on the patient's mental health.

Choice D Reason:

Giving anticipatory guidance to prevent or reduce mental illness and enhance mental health is inappropriate. While anticipatory guidance is important in nursing care, it may not capture the essence of creating and maintaining a therapeutic environment, which is the core of milieu therapy. This choice is more related to health education and preventive measures rather than the overall therapeutic environment.