The nurse is caring for a client diagnosed with catatonia. Which of the following should be a priority action by the nurse?
Schedule the client for a therapeutic group session.
Encourage the client to walk in the hallway.
Encourage the client to verbalize feelings at all times.
Offer small, frequent fluids throughout the day.
The Correct Answer is D
Choice A Reason:
Scheduling the client for a therapeutic group session may not be appropriate as a priority action. Clients with catatonia often experience significant psychomotor disturbances, which can include immobility or stupor, making participation in group activities challenging and potentially distressing.
Choice B Reason:
Encouraging the client to walk in the hallway is not the most immediate concern. While mobility is important, the safety and medical stability of the client take precedence, especially considering the potential for immobility and resistance to movement in catatonic states.
Choice C Reason:
Encouraging the client to verbalize feelings at all times is not practical as a priority action. Catatonia can involve mutism or significantly reduced responsiveness, making it difficult for the client to express themselves verbally.
Choice D Reason:
Offering small, frequent fluids throughout the day is a priority action for a client with catatonia. Due to the potential for decreased oral intake and the risk of dehydration, ensuring the client receives adequate hydration is essential. This intervention addresses a basic physiological need and can prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Talking directly to the client and setting clear boundaries is a therapeutic approach. It respects the client's autonomy while also addressing the behavior that is affecting the therapeutic environment. By identifying specific limits, the nurse helps the client understand the consequences of their actions and the importance of maintaining a respectful and honest communication with others.
Choice B reason:
Discussing the problem in a community meeting could be helpful, but it should not be the initial action. This approach might inadvertently shame or embarrass the client in front of peers, which could exacerbate the situation. It's important to address the behavior privately before involving the larger group.
Choice C reason:
Escorting the client to their room each time they socialize could be seen as punitive and may not address the underlying reasons for the lying behavior. It could also isolate the client from social interactions that are an essential part of the healing process.
Correct Answer is A
Explanation
Choice A reason:
The statement correctly identifies that a therapeutic milieu encompasses both the physical and psychosocial aspects of the environment. This holistic approach is designed to support the recovery and well-being of clients by ensuring that all aspects of the unit's environment are conducive to therapy.
Choice B reason:
While personalization of space can be part of a therapeutic milieu, this statement alone does not capture the full essence of the concept. Therapeutic milieu involves more than just personal items; it includes the structured management of the environment to promote positive interactions and therapeutic outcomes.
Choice C reason:
Positioning chairs around the perimeter of the day room may be a part of the environmental setup, but it does not fully represent the therapeutic milieu. The therapeutic milieu is about creating an environment that encourages interaction, communication, and community among clients, which may or may not involve specific furniture arrangements.
Choice D reason:
Unstructured programming is not a characteristic of therapeutic milieu. In fact, therapeutic milieu typically involves a structured schedule of activities and programs that are designed to promote therapeutic engagement, skill development, and social interaction among clients.
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