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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason:
The nurse's response is therapeutic because it clearly communicates the expectations of the treatment setting in a firm yet non-confrontational manner. By stating "it is time for group therapy and we expect everyone to attend," the nurse is providing structure and clarity, which can help orient the client to the reality of the situation and the routine of the therapeutic environment.

Choice B reason:
While the nurse's response does include a statement of understanding, it does not primarily demonstrate empathy. Empathy would involve acknowledging the client's feelings and concerns more directly, rather than focusing on the expectations of the therapy session.

Choice C reason:
Reflection is a therapeutic communication technique where the nurse repeats or paraphrases what the client has said to show that they are listening and to encourage further discussion. In this case, the nurse does not use reflection but rather responds with a statement of expectation.

Choice D reason:
The nurse's response does not set limits on manipulative behavior, as there is no indication that the client's behavior is manipulative. The client expresses a delusional belief, and the nurse addresses this by redirecting the client to the scheduled group therapy session.

A. The client is unwilling to accept that treatment is needed. B. The client states that she plans to move out of the state immediately. C. The client states that she does not like the neighbor. D. The client is a danger to herself or others.

Correct Answer is D

Explanation

Choice A reason:
An unwillingness to accept that treatment is needed is not, by itself, a condition that can legally justify extending a hospital hold beyond the initial 72 hours. Treatment refusal can be a complex issue and may require a deeper understanding of the client's capacity to make informed decisions.

Choice B reason:
The client's intention to move out of the state does not constitute a legal basis for extending a hospital hold. The focus of continued hospitalization would be on immediate safety concerns rather than future living arrangements.

Choice C reason:
Disliking a neighbor is not a condition that warrants an extended hospital hold. Personal feelings or disputes do not equate to a risk that justifies involuntary hospitalization.

Choice D reason:
If the client poses a danger to themselves or others, this is a condition under which the hospital can legally extend the hold beyond 72 hours. The primary concern is the safety of the client and those around them, and if there is a risk of harm, the client may be held involuntarily until it is deemed safe for them to be discharged.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?

Correct Answer is D

Explanation

A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?

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