Chapter 12: The Therapeutic Environment

Morrison-Valfre: Foundations of Mental Health Care, 7th Edition

Multiple Choice

1. Crisis stabilization provides care to clients in treatment settings with the purpose of reestablishing homeostasis; it usually lasts for: a. 1 to 2 days. b. 2 to 4 days. c. 4 to 6 days. d. 6 to 8 days.

ANS: A

Intensive counseling is given to assist clients with the immediate problem that is causing the crisis. This usually is accomplished within 1 to 2 days, and the client is discharged with follow-up care.

DIF: Cognitive Level: Knowledge REF: p. 129

OBJ: 1

TOP: Crisis Stabilization KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity a. The client likes the security and comfort of the mental health facility. b. The client feels that he is no longer able to cope with life stressors or maintain control of his behavior. c. A client’s behavior becomes unusual. d. The client suffers from depression.

2. Which is an accepted criterion for inpatient admission to a mental health facility?

ANS: B

This situation meets the criteria for an inpatient admission. Other criteria include being a threat to one’s safety or the safety of others and having people who are a part of the client’s environment who are not willing or able to support him. The other options do not meet the criteria.

DIF: Cognitive Level: Comprehension REF: p. 129 OBJ: 1

TOP: Use of the Inpatient Setting KEY: Nursing Process Step: Planning

MSC: Client Needs: Psychosocial Integrity a. Milieu b. Chronicity c. Noncompliance d. Recidivism

3. A male client with a diagnosis of schizophrenia refuses to take his medication because of his paranoia that the medication may be poisoned. Frequent inpatient readmissions to the facility occur as a result. Which term is given to repeated inpatient admissions?

ANS: D

Recidivism often occurs as a result of noncompliance with prescribed therapy, as in the case of this client who is not taking his medications. Adequate community resources help to prevent recidivism. Milieu refers to the mental health care environment; chronicity refers to a long duration, such as occurs with a chronic illness like schizophrenia; and noncompliance describes a situation in which the client does not follow the prescribed plan of care, often resulting in recidivism.

DIF: Cognitive Level: Comprehension REF: p. 130

TOP: The Chronically Mentally Ill Population

OBJ: 2

KEY: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity a. Promise the client that the staff would not do anything to harm her. b. Let the client watch the medication preparation process. c. Administer medications to the client in unit dose packages so that she can open the packages herself. d. Allow the client to retrieve the medications out of the medication cart with supervision.

4. An adult female inpatient client with a diagnosis of paranoid schizophrenia will not take her medications from the nurse. She states, “I know you are poisoning that medicine.” Which nursing action is most appropriate?

ANS: C

Administering medications in unit dose packages would help to prevent the client from thinking that the nurse is poisoning the medications. The client would be allowed to open the packages herself. Promising the client that the staff would not harm her will not alleviate her paranoia. Letting the client watch the medication preparation process may help, but if she feels that the poisoning is happening when the nurse is placing the medication in the cup, the client will remain paranoid. Allowing the client to retrieve medications from the medication cart would go against facility policy.

DIF: Cognitive Level: Application REF: p. 131

OBJ: 3

TOP: Physiological Needs KEY: Nursing Process Step: Intervention MSC: Client Needs: Psychosocial Integrity a. Ask the client to “Please eat one meal for me.” b. Leave food with the client at mealtime and offer snacks frequently. c. Give the client information on the benefits of good nutrition. d. Remove client privileges every time the client doesn’t eat.

5. A male inpatient client who is experiencing depression has no interest in eating. He skips meals frequently and has been losing weight. What is the best nursing action in this situation?

ANS: B

Trying not to make an ordeal out of mealtime and food may allow the client to choose to eat, especially as his condition improves. Asking the client to “please eat one meal for me” is not an appropriate request and does not focus on the need to discover which, if any, medications are effecting a desire to eat as well as how the client’s mood may be affecting the interest in eating. Giving the client information about nutrition is not important to this client; his refusal to eat is not related to good or bad nutrition. Removing client privileges each time the client doesn’t eat goes against the client’s rights.

DIF: Cognitive Level: Application REF: p. 131 OBJ: 3

TOP: Physiological Needs

MSC: Client Needs: Psychosocial Integrity

KEY: Nursing Process Step: Intervention

6. Encouragement for clients to practice good hygiene habits not only meets basic physiological needs, but it also meets the hierarchal need of: a. love and belonging. b. safety and security. c. infection control. d. self-care.

ANS: A

Good hygiene meets the need for love and belonging by conveying to others a willingness for social interaction. Safety and security needs relate more to the client’s feeling secure in his environment and providing measures to keep clients safe; infection control and self-care are not actually needs, but the concepts fall into the category of physiological needs.

DIF: Cognitive Level: Comprehension REF: p. 131 OBJ: 3

TOP: Physiological Needs

MSC: Client Needs: Psychosocial Integrity

KEY: Nursing Process Step: Planning

7. With regard to the environment, it is important for the nurse to be aware of lighting for some clients. Clients with a diagnosis of schizophrenia may be bothered by lights that are flickering because this may trigger: a. overstimulation. b. hallucinations. c. aggressive behaviors. d. photophobia.

ANS: B

The flickering of a lightbulb can trigger hallucinations and delusions; therefore, it is important for the nurse to monitor the physical environment. Overstimulation, aggressive behaviors, and photophobia usually occur when light is too bright.

DIF: Cognitive Level: Comprehension REF: p. 132 OBJ: 3

TOP: Physiological Needs KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity a. Remind her of the time of day every time she asks. b. Assist her to keep a written schedule, including her day of admission, on a calendar posted in her room and a clock beside the calendar. c. Tell her it doesn’t really matter what day she came to the facility; what matters is what day and time it is now. d. Instruct the staff to not answer her repetitive questions because she has been told numerous times her day of admission, and there is a clock on the wall.

8. A female client on the mental health unit experiences periods of psychosis at intervals. She often asks what day she came to the facility and what day it is now, and she seems never to be aware of the time. Which nursing intervention would help this client the most?

ANS: B

A written schedule in her room and a clock will assist her in learning to monitor this information on her own, and this will help to keep her oriented and will foster independence. Reminding her of the time will not help the client monitor the time on her own; it allows the ineffective cycle to continue. Telling the client that it doesn’t matter when she entered the facility and instructing the staff not to answer her questions are belittling to the client.

DIF: Cognitive Level: Application REF: p. 130 OBJ: 3

TOP: Safety and Security Needs KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity a. Encourage her to join in on a group activity and actively participate in the activity with her until she feels more comfortable on her own. b. Keep encouraging her to participate in the group activity. c. Offer her rewards, such as extended television privileges, for joining in a group activity. d. Offer her support as she tries to become more involved in activities.

9. A 15-year-old female client is noted to often sit alone in the activity room of the facility while watching television. She often begins to join in activities on the unit but then retreats back to her room. Which intervention is most appropriate in this situation?

ANS: A

Encouraging the client to join the activity and participating with her will offer her security and will help her to meet others in the group and feel less alone. Love and belonging needs are met by socializing with others. Offering encouragement to participate in the group activity and supporting her as she tries to become more involved are helpful, but these actions do not give her the same sense of security as she receives with encouragement and participation in the group activity until she is comfortable. Offering her rewards defeats the purpose of instilling motivation and the improvement in self-esteem that results from participating according to her own desire.

DIF: Cognitive Level: Application REF: p. 131 OBJ: 6

TOP: Love and Belonging Needs KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity

10. The nurse can assist a client best in meeting his or her needs for self-esteem and/or self-actualization by: a. setting rules and regulations. b. allowing the client to set rules and regulations for the inpatient unit. c. informing the client what the treatment team has decided regarding the plan of care. d. allowing the client to make choices involving his or her care when appropriate.

ANS: D

Self-esteem needs must be met before self-actualization can occur, but this is also a part of self-actualization. This intervention allows the client to practice decision-making skills and assists in improving his or her self-esteem. Rules and regulations are necessary for limit-setting, but the nurse can include the client and improve his or her self-esteem by informing the client of the rules and regulations, so the client is able to follow them. Allowing the client to set rules is difficult in that the ability for limit-setting often is lacking in clients with mental health disorders. Sharing with the client should reflect a combined effort between the client and the treatment team.

DIF: Cognitive Level: Application REF: p. 134 OBJ: 3

TOP: Self-Esteem Needs KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity

11. The nurse is aware that during the admission process to a mental health facility, the anxious client: a. is acutely aware of his or her surroundings. b. often forgets some of what is said in the unfamiliar surroundings. c. has a keen memory in his or her heightened state of awareness. d. frequently has no recollection of what is said by the staff during admission.

ANS: B

High levels of anxiety can prevent an individual from remembering things that he has been told. It is helpful to limit the amount of information thrust on a client during the early admission process. Written information about rules, regulations, and expectations on the unit is often helpful. The anxious client is not acutely aware of his or her surroundings and does not have a keen memory during this time. Having no recollection of what the staff has said is an extreme reaction.

DIF: Cognitive Level: Comprehension REF: p. 135

OBJ: 7

TOP: Admission and Discharge KEY: Nursing Process Step: Planning

MSC: Client Needs: Psychosocial Integrity

12. Bright colors in the environment of the client are often: a. depressing. b. stimulating. c. calming. d. frightening.

ANS: B

Colors are important to consider, depending on the needs of the client. Bright colors can be stimulating to clients. Mental health settings often have warm, more neutral colors because these colors promote calm emotions and behavior. Dark colors are considered more depressing. Color usually is not associated with eliciting fright.

DIF: Cognitive Level: Comprehension REF: p. 132

OBJ: 3

TOP: Physiological Needs KEY: Nursing Process Step: Assessment

MSC: Client Needs: Psychosocial Integrity

13. The nurse should monitor the temperature of the environment of a client who becomes easily agitated, with awareness that increased temperatures sometimes may cause the client to become: a. calm. b. confused. c. cooperative. d. more distressed.

ANS: D

Increased environmental temperatures often cause easily agitated clients to become more agitated. It is important for the nurse to monitor a client’s individual response to his or her environment.

DIF: Cognitive Level: Comprehension REF: p. 132 OBJ: 3

TOP: Physiological Needs KEY: Nursing Process Step: Assessment

MSC: Client Needs: Psychosocial Integrity

14. A male client is in the process of being admitted to a mental health facility. He is sure that the nurse is the administrator of the hospital, despite the nurse’s insistence that he is a staff nurse on the unit. This client is experiencing: a. acute confusion. b. visual hallucinations. c. delusions. d. auditory hallucinations.

ANS: C

Delusions are thoughts or beliefs that cannot be changed by rational explanations. Acute confusion is seen as disorientation to person, place, time, or purpose. A visual hallucination involves seeing something that is not there, and an auditory hallucination is hearing something that is not present.

DIF: Cognitive Level: Comprehension REF: p. 132 OBJ: N/A

TOP: Admission and Discharge KEY: Nursing Process Step: Assessment

MSC: Client Needs: Psychosocial Integrity

15. When establishing a client’s level of consciousness, the nurse is aware that this is determined by assessing the client’s: a. level of awareness. b. ability to tell the nurse where he or she is at any given time. c. accuracy in expressing the current month, date, or year. d. capability to explain why he or she is in the facility.

ANS: A

Level of awareness determines the client’s level of consciousness. The other options refer to other aspects of the client’s level of orientation.

DIF: Cognitive Level: Comprehension REF: p. 136 | Box 12.3

OBJ: N/A TOP: Admission and Discharge

KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity a. Turn up the volume on the television to distract the client. b. Bring him to sit at the nurses’ station while the staff is doing shift report. c. Keep him in the lounge and attempt to converse with him. d. Accompany him to a room where soft music is playing.

16. A 16-year-old client is in the lounge with other clients on the inpatient unit when he suddenly becomes agitated. Which action by the nurse would be most appropriate in this situation?

ANS: D

High noise levels can lead to distorted perceptions, altered thinking, and sensory overload. Calm music, the sound of ocean waves, or a light rain can produce relaxation. When noise levels become too intense, clients tend to become distracted and agitated. Turning up the volume on the television, bringing the client to a crowded nurses’ station, and keeping the client in the lounge do not decrease noise levels and may increase the client’s agitation.

DIF: Cognitive Level: Comprehension REF: p. 132 OBJ: 4

TOP: Therapeutic Environment and Client Needs

KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity a. Increased use of psychotherapeutic medications b. Increased lengths of stay on the inpatient unit c. Increased commitment to the plan of care by the client d. Group residential homes with vocational training

17. The goal in treating a client with a chronic mental illness is to prevent recidivism. Which factor is crucial in this effort?

ANS: D

One of the most important factors in preventing recidivism is adequate community resources where clients receive support and educational and vocational opportunities. With the focus on the “least restrictive environment,” many chronically mentally ill clients now live in small, homelike, sheltered group settings within the community.

DIF: Cognitive Level: Comprehension REF: p. 130 OBJ: 2

TOP: The Chronically Mentally Ill Population

KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity a. Aggression b. Paranoia c. Depression d. Anxiety

18. The use of therapeutic touch as a relaxation technique in the mental health setting is beneficial for clients displaying which symptoms?

ANS: C

People with suspicious feelings usually feel more comfortable when caregivers are outside their intimate space. Depressed persons may need touch and physical contact an excellent opportunity for therapeutic touch. Aggressive clients may interpret the close presence of a caregiver as threatening. Touch must be used cautiously as a therapeutic tool and with the client’s best interest in mind.

DIF: Cognitive Level: Comprehension REF: p. 133

OBJ: 4

TOP: Safety and Security Needs KEY: Nursing Process Step: Assessment

MSC: Client Needs: Psychosocial Integrity a. Physiologic b. Love and belonging c. Self-actualization d. Safety and security

19. A 22-year-old woman is brought to the inpatient unit for attempting suicide. Her clothes are clean and her general appearance is neat and well groomed. She appears to be well nourished. In considering Maslow’s hierarchy of needs, which is a priority for this client?

ANS: D

The safety and security of the therapeutic environment is one of the most important factors in mental health care. Safety and security needs within the therapeutic environment include the feeling of physical safety, the security of a limited setting, and the ability to feel secure with others. For clients who are depressed or suicidal, the therapeutic environment offers special protection from self-harm and with the client’s best interest in mind.

DIF: Cognitive Level: Comprehension REF: p. 133

OBJ: 4

TOP: Safety and Security Needs KEY: Nursing Process Step: Assessment

MSC: Client Needs: Psychosocial Integrity

Multiple Response

1. Inpatient services provide care mainly for mental health clients who are experiencing which conditions? (Select all that apply.)

a. Acute mental or emotional problems b. Chronic mental or emotional problems c. Depression d. Crisis e. Bipolar disorder

ANS: A, B, D

Inpatient services provide intensive therapy and support for clients with acute and chronic mental health disorders as well as those in crisis situations, and they usually require short stays. The goal is to transition the client from the facility to the community. Depression and bipolar disorder are specific disorders that are not necessarily seen more frequently than other disorders within an inpatient setting.

DIF: Cognitive Level: Comprehension REF: p. 129

OBJ: 2

TOP: Use of the Inpatient Setting KEY: Nursing Process Step: Intervention

MSC: Client Needs: Psychosocial Integrity a. Financial concerns b. Lack of support by family c. Staff dislike of a client d. Inability to understand the treatment plan e. Lack of access to treatment services

2. Which are common causes for client noncompliance in the plan of care? (Select all that apply.)

ANS: A, B, D, E

Financial concerns, lack of family support, and lack of access to treatment often make the client feel that he or she is unable to continue in the planned treatment. The social worker is the best person to contact in these instances because he or she is aware of programs that may meet needs in these problem areas. Education and involvement of other caregivers will assist the client in eliminating the problem of inability to understand the treatment plan. Staff dislike of a patient should never be a reason for client noncompliance.

DIF: Cognitive Level: Comprehension REF: p. 136 OBJ: 8

TOP: Compliance KEY: Nursing Process Step: Evaluation

MSC: Client Needs: Psychosocial Integrity a. Conduct the admission interview with a team of health care providers. b. Answer any questions the client may have. c. Support the client in being oriented to the unit. d. Provide simple, clear instructions and repeat if needed. e. Communicate concern for the client.

3. Admission to an inpatient mental health unit is often a stressful event. Which actions on the part of the health care provider will help to decrease the anxiety of the client? (Select all that apply.)

ANS: B, C, D, E

People with high anxiety levels seldom remember what was said, especially when they are in an unfamiliar setting. Therefore, approach clients in a calm and respectful manner. Give simple but clear explanations, and repeat them as necessary. Provide simple written instructions that allow clients to read about the rules after their anxiety decreases. Answer any questions the client may have. Make sure that the client is more important than the admission form you must complete. Take the time to behaviorally communicate that you are concerned for his or her welfare. Make efforts to support the client in becoming familiar with the therapeutic environment. Having one person perform the initial admission interview prevents confusion and added stress for the client.

DIF: Cognitive Level: Comprehension REF: p. 129 OBJ: 8

TOP: Compliance KEY: Nursing Process Step: Evaluation

MSC: Client Needs: Psychosocial Integrity