A nurse working in a mental health facility is utilizing milieu therapy to provide a therapeutic environment for their clients. Which of the following steps of the nursing process is the nurse demonstrating?
Evaluation
Planning
Assessment
Implementation
The Correct Answer is D
Choice A reason:
Evaluation is the final step in the nursing process, where the nurse determines the effectiveness of the nursing care plan and whether the client's goals and outcomes have been met. In the context of milieu therapy, evaluation would involve assessing the client's progress within the therapeutic environment.
Choice B reason:
Planning involves setting goals and expected outcomes for the client's care and then determining the specific interventions that will be used to achieve those goals. In milieu therapy, planning would include designing the structure and activities of the therapeutic environment to meet the needs of the clients.
Choice C reason:
Assessment is the first step in the nursing process, where the nurse collects comprehensive data pertinent to the client's health and the situation. In milieu therapy, assessment would include understanding the client's mental health status, personal history, and specific needs within the therapeutic environment.
Choice D reason:
Implementation is the step where the nurse puts the care plan into action. In the context of milieu therapy, implementation refers to the nurse's role in actively creating and maintaining the therapeutic environment, facilitating group activities, and ensuring that the daily routine is therapeutic for all clients.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Taking away TV privileges and placing the client in seclusion could be perceived as punitive rather than therapeutic. It may escalate the situation and does not address the immediate need to ensure safety and de-escalate the aggression.
Choice B reason:
Stating that hitting others is unacceptable is a clear and direct way to address the behavior. It sets a firm boundary and communicates the expectations for behavior within the unit, which is essential in managing aggressive situation.
Choice C reason:
Saying that the behavior will disappoint the provider personalizes the issue and may not be effective in the moment. The focus should be on the immediate safety of all clients and the unacceptability of the behavior, rather than on the potential emotional response of the provider.
Choice D reason:
Asking why the client hit another client immediately after the incident may not be productive and could lead to further justification of the behavior or additional aggression. It's important to first address the behavior and ensure safety before exploring the reasons behind it.
Correct Answer is B
Explanation
Choice A Reason:
Laughing inappropriately, such as when watching a sad movie, can be a symptom of schizophrenia, but it is not specific to the catatonic subtype. Inappropriate affect may occur in schizophrenia but does not solely characterize catatonic behavior.
Choice B Reason:
Catatonic schizophrenia is marked by periods of immobility or stupor. A client who maintains an immobilized state for several hours is displaying a classic sign of catatonia. During these periods, the client may be mute, rigid, and resistant to movement, which are key features of this condition.
Choice C Reason:
Refusing to eat certain types of food is not specifically indicative of catatonic schizophrenia. While individuals with schizophrenia may have unusual preferences or fears related to food, this behavior could be related to a variety of factors and is not a definitive sign of catatonia.
Choice D Reason:
Using a rhyming form of speech, known as clang associations, can be seen in schizophrenia but is more characteristic of disorganized thinking associated with the disorder rather than catatonia. Catatonia involves motoric symptoms rather than speech patterns.
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