A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?

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.

Choice A Reason:

Formulating a nursing diagnosis is incorrect. This occurs after a comprehensive assessment of the patient's needs, and it helps guide the planning and implementation of nursing care.

Choice B Reason:

Planning for continued care is incorrect. Once the nursing diagnosis is formulated, the nurse can develop a plan of care, including interventions and goals for the patient.

Choice C Reason:

Promoting patient's insight is incorrect. This is a part of the ongoing therapeutic process and involves helping the patient gain self-awareness and understanding of their thoughts, feelings, and behaviors. It typically occurs after the initial assessment and planning.

Choice D Reason:

Examining personal biases is correct. In the nurse-patient relationship, examining personal biases is a foundational and essential step that should happen first. It involves the nurse being self-aware and acknowledging any personal biases or prejudices that might affect the therapeutic relationship. Recognizing and addressing personal biases is crucial for providing unbiased and patient-centered care.