Patty is admitted to the inpatient unit after she has cut her wrists. Which is the most important nursing intervention?

Building a trusting relationship

Searching her belongings

Orienting her to the unit

Helping her settle into her room

Answer and Explanation

The Correct Answer is B

A. Building a trusting relationship: Establishing trust is essential in therapeutic relationships, especially with clients at risk for self-harm. However, ensuring the client’s immediate safety by searching belongings takes precedence to protect the client from further harm.

B. Searching her belongings: This is the first priority to ensure Patty’s immediate safety and prevent access to any objects she could use to harm herself. This action addresses the immediate risk and creates a safer environment for her.

C. Orienting her to the unit. Orientation to the unit helps the client feel more comfortable and understand the rules and layout of the facility, but it is not as urgent as ensuring her safety upon admission.

D. Helping her settle into her room: Assisting Patty in getting comfortable is important for her overall well-being but is secondary to securing her environment by removing any potentially harmful items.

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Correct Answer is D

Explanation

Choice A Reason:

Encourages staff to provide frequent negative feedback to patient is incorrect. A therapeutic milieu typically focuses on positive reinforcement and constructive feedback to support patients' growth and development.

Choice B Reason:

Enforces rules and behavioral limits flexibly is incorrect. While establishing rules and limits is important for maintaining safety, flexibility in enforcing them allows for individualized care and consideration of the patient's unique needs.

Choice C Reason:

Permits additional privileges for voluntary admitted patients is incorrect. Additional privileges may be granted based on the patient's progress and participation in their treatment. However, it should be done thoughtfully and as part of a therapeutic plan rather than as a blanket permission for all voluntary admitted patients.

Choice D Reason:

Provides patients a sense of security and comfort is correct. A therapeutic milieu refers to the therapeutic environment or surroundings in a psychiatric setting that promotes the patient's well-being, safety, and recovery. This environment should be supportive, safe, and conducive to healing. Providing patients with a sense of security and comfort is essential for their overall well-being and progress in treatment.

A. "People in the mental health category of the continuum do not experience stress." B. “People can shift along various points of the mental health continuum.” C. "Most people are on some point of the mental health continuum. D. "Mental health is an important point of the mental heat continuum.

Correct Answer is A

Explanation

Choice A Reason:

"People in the mental health category of the continuum do not experience stress." This statement indicates a misunderstanding about the mental health continuum. Mental health does not imply the absence of stress; rather, it is about one's overall psychological well-being. Even individuals with good mental health may experience stress at times. The mental health continuum recognizes that people can move along different points, experiencing fluctuations in mental health based on various factors.

Choice B Reason:

“People can shift along various points of the mental health continuum. “This statement acknowledges the dynamic nature of mental health, indicating that individuals can move between different points on the continuum based on their mental well-being.

Choice C Reason:

"Most people are on some point of the mental health continuum. “This statement recognizes that mental health is a spectrum, and most individuals fall somewhere along this continuum.

Choice D Reason:

"Mental health is an important point of the mental heat continuum. “This statement reinforces the significance of mental health as a key aspect of overall well-being, which aligns with the concept of the mental health continuum.

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Patty is admitted to the inpatient unit after she has cut her wrists. Which is the most important nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is a characteristic of therapeutic milieu when caring for a patient in the psychiatric healthcare setting?

Correct Answer is D

Explanation

The nurse is educating a patient with depression about the mental health continuum. Which statement made by the patient indicates the need for additional teaching?

Correct Answer is A

Explanation

According to Maslow's hierarchy of needs, which situation on an inpatient mental health unit would require priority intervention?

Which style of leadership is demonstrated when an advanced practice nurse running a group on the adolescent unit makes no attempt to control the topic or the member's behavior and makes no comment unless asked a direct question?

Patty is admitted to the inpatient unit after she has cut her wrists. Which is the most important nursing intervention?

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)

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A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states. "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states. "I don't know what I will do if they find I have cancer." Which of the following responses should the nurse make?

Which activity would a nurse perform in an inpatient psychiatric unit? Select all that apply. (Select All that Apply.)