A nurse working in a psychiatric unit plans to apply milieu therapy on a patient. Which intervention would the nurse include in the therapy?

Coordinate the implementation of the nursing care plan and documents.

Provide and maintain a safe and therapeutic environment in collaboration with others.

Apply current knowledge to assess the patient's response to medication.

Give anticipatory guidance to prevent or reduce menta illness and enhance mental health.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is C

Explanation

Choice A Reason:

"Your husband is making really good progress" This statement assumes a positive or negative judgment about the husband's progress without first understanding the spouse's concerns. It may not address the spouse's immediate emotional needs or allow them to express their feelings.

Choice B Reason:

"Crying helps us let things out and we feel better". While this statement acknowledges the act of crying as a way to express emotions, it doesn't directly address the specific concerns of the spouse or invite further communication about the issues causing distress.

Choice C Reason:

"Tell me what is concerning you. “This is a therapeutic nursing response because it encourages the spouse to express their concerns and share their feelings. It opens up communication and allows the nurse to better understand the specific issues or worries that the spouse is experiencing. This response demonstrates active listening and a genuine interest in the spouse's perspective, fostering a supportive and empathetic therapeutic relationship.

Choice D Reason:

"Did your husband say something to upset you?" This question assumes that the spouse's distress is solely related to something the husband said. It may not be the most open-ended or empathetic way to encourage the spouse to share their concerns and might direct the focus too narrowly.

A. Diffuse B. Clear C. Differentiation D. Rigid

Correct Answer is A

Explanation

Choice A Reason:

Diffuse is correct. In a diffuse or permeable family boundary, there is a lack of clear separation between family members. Decisions and responsibilities may be shared extensively, and individual autonomy is limited. The patient's behavior of consulting with family members before making treatment decisions suggests a diffuse boundary where decision-making involves significant input from various family members.

Choice B Reason:

Clear is incorrect. - In a clear or rigid boundary, there is a distinct separation between family members, and individual autonomy is highly emphasized. The described behavior does not align with a clear boundary.

Choice C Reason:

Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. The behavior described is more indicative of a diffuse boundary than a differentiation issue.

Choice D Reason:

Rigid is incorrect. A rigid boundary is characterized by strict rules and limited flexibility. The described behavior does not align with a rigid boundary where decision-making might be more centralized and less consultative.

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A nurse working in a psychiatric unit plans to apply milieu therapy on a patient. Which intervention would the nurse include in the therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says. "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

Correct Answer is C

Explanation

The nurse is caring for a patient who consults with family members before making every treatment decision. Based on the nurse's observation. which type of boundary exists within the family structure?

Correct Answer is A

Explanation

A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?

Which activity would happen first in the nurse-patient relationship?

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A nurse is caring for a group of clients on a mental health unit. Which of the following actions should the nurse implement to establish therapeutic relationships with the clients?

Which cause is responsible for a patient reacting to the nurse by saying, "You are indifferent and cold, just like my mother"?

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