When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

“Mental illnesses do run in families, and I’ve had a lot of experience caring for people with mental illness.”

“Mental illness can be family related. Let’s focus the discussion on you and how you’re doing today.”

“It sounds like you are concerned that there may be a family connection to your current problem.”

“Yes, it does. I have a sister who was diagnosed several years ago with severe major depression.”

Answer and Explanation

The Correct Answer is D

Choice A reason:
This response provides general information about the hereditary nature of mental illnesses and reassures the client of the nurse’s experience. It maintains a professional boundary and does not disclose personal information, making it a therapeutic response.

Choice B reason:
This response acknowledges the client’s concern about the hereditary nature of mental illness and redirects the focus back to the client’s current situation. It is a therapeutic response that maintains professional boundaries and keeps the conversation client-centered.

Choice C reason:
This response validates the client’s concern and encourages further discussion about their feelings and experiences. It is a therapeutic response that promotes open communication and understanding.

Choice D reason:
Disclosing personal information about the nurse’s family can blur professional boundaries and shift the focus away from the client. It is considered nontherapeutic because it may make the client feel uncomfortable or distract from their own issues.

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Correct Answer is A

Explanation

Choice A reason:
Respite residential care provides temporary relief for caregivers by offering short-term care for individuals with chronic conditions like schizophrenia. This option allows the parents to take a break while ensuring that their child receives the necessary supervision and care in a safe environment. Respite care can help prevent caregiver burnout and provide a much-needed rest for the family.

Choice B reason:
Acute inpatient care is designed for individuals experiencing severe psychiatric crises that require immediate and intensive treatment. While it provides comprehensive care, it is not typically used for respite purposes. This option is more appropriate for situations where the client poses a danger to themselves or others and needs stabilization.

Choice C reason:
An intensive outpatient program (IOP) offers structured treatment while allowing the client to live at home. It is suitable for clients who need more support than traditional outpatient care but do not require 24-hour supervision. However, it does not provide the temporary relief that respite care offers to caregivers.

Choice D reason:
Partial hospitalization programs (PHP) provide intensive treatment during the day, allowing clients to return home in the evening. While PHPs offer substantial support, they do not address the need for temporary relief for caregivers. Respite care is specifically designed to give caregivers a break from their responsibilities.

A. Anticipate removing the restraints every 4 hours. B. Secure the restraints to the lowest bar of the side rail. C. Secure the restraints using a quick-release tie. D. Ensure four fingers fit under the restraints to prevent constriction.

Correct Answer is C

Explanation

Choice A reason:

Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.

Choice B reason:

Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.

Choice C reason:

Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.

Choice D reason:

Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.

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When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

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Correct Answer is A

Explanation

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply)

During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

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