Milieu Therapy—The Therapeutic Community

1. An angry client on an inpatient unit approaches a nurse stating, “Someone took my lunch! People need to respect others, and you need to do something about this now!” The nurse’s response should be guided by which basic assumption of milieu therapy?
1. Conflict should be avoided at all costs on inpatient psychiatric units.
2. Conflict should be resolved by the nursing staff.
3. On inpatient units, every interaction is an opportunity for therapeutic intervention.
4. Conflict resolution should only be addressed during group therapy.

ANS: 3
Rationale: The nurse’s response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can use milieu therapy to effect behavioral change and improve psychological health and functioning.

Cognitive Level: Application
Integrated Process: Implementation

2. A client on an inpatient unit angrily says to a nurse, “Peter is not cleaning up after himself in the community bathroom. You need to address this problem.” Which is the appropriate nursing response?
1. “I’ll talk to Peter and present your concerns.”
2. “Why are you overreacting to this issue?”
3. “You should bring this to the attention of your treatment team.”
4. “I can see that you are angry. Let’s discuss ways to approach Peter with your concerns.”

ANS: 4
Rationale: The most appropriate nursing response involves restating the client’s feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

Cognitive Level: Application
Integrated Process: Implementation

3. A newly admitted client asks, “Why do we need a unit schedule? I’m not going to these groups. I’m here to get some rest.” Which is the most appropriate nursing response?
1. “The purpose of group therapy is to learn and practice new coping skills.”
2. “Group therapy is mandatory. All clients must attend.”
3. “Group therapy is optional. You can go if you find the topic helpful and interesting.”
4. “Group therapy is an economical way of providing therapy to many clients concurrently.”

ANS: 1
Rationale: The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. The client owns his or her environment and can make decisions to attend group or not.

Cognitive Level: Application
Integrated Process: Implementation

4. A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment?
1. Peer pressure
2. Structured programming
3. Visitor restrictions
4. Mandated activities

ANS: 2
Rationale: The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. Time is also devoted to personal problems and focus groups.

Cognitive Level: Application
Integrated Process: Evaluation

5. To promote self-reliance, how should a psychiatric nurse best conduct medication administration?
1. Encourage clients to request their medications at the appropriate times.
2. Refuse to administer medications unless clients request them at the appropriate times.
3. Allow the clients to determine appropriate medication times.
4. Take medications to the clients’ bedside at the appropriate times.

ANS: 1
Rationale: The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units, but nurses must work with clients to encourage self-reliance and responsibility, which may result in independent decision-making, leading to medication adherence.

Cognitive Level: Application
Integrated Process: Implementation

6. A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic?
1. Dream analysis
2. Creative cooking
3. Paint by number
4. Stress management

ANS: 4
Rationale: The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client’s learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication adherence.

Cognitive Level: Application
Integrated Process: Planning

7. What is the best rationale for including family in the client’s therapy within the inpatient milieu?
1. To structure a program of social and work-related activities
2. To facilitate discharge from hospitalization
3. To provide a concrete demonstration of caring
4. To encourage the family to model positive behaviors

ANS: 2
Rationale: The nurse should include the client’s family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment.

Cognitive Level: Application
Integrated Process: Planning

8. How does a democratic form of self-government in the milieu contribute to client therapy?
1. By setting punishments for clients who violate the community rules
2. By dealing with inappropriate behaviors as they occur
3. By setting expectations wherein all clients are treated on an equal basis
4. By interacting with professional staff members to learn about therapeutic interventions

ANS: 3
Rationale: A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input.

Cognitive Level: Application
Integrated Process: Evaluation

9. A client is to undergo psychological testing. Which member of the interdisciplinary team should a nurse consult for this purpose?
1. The psychiatrist
2. The psychiatric social worker
3. The clinical psychologist
4. The clinical nurse specialist

ANS: 3
Rationale: The nurse should consult with the clinical psychologist to obtain psychological testing for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process.

Cognitive Level: Application
Integrated Process: Planning

10. In the role of milieu manager, which activity should the nurse prioritize?
1. Setting the schedule for the daily unit activities
2. Evaluating clients for medication effectiveness
3. Conducting therapeutic group sessions
4. Searching newly admitted clients for hazardous objects

ANS: 4
Rationale: The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others always takes priority. Nurses are responsible for ensuring that the client’s safety and physiological needs are met.

Cognitive Level: Analysis
Integrated Process: Evaluation

Multiple Response

11. A nurse attends an interdisciplinary team meeting regarding a newly admitted client. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? (Select all that apply.)
1. Respiratory therapist and psychiatrist
2. Occupational therapist and psychologist
3. Recreational therapist and art therapist.
4. Social worker and hospital volunteer
5. Mental health technician and chaplain

ANS: 2, 3, 5
Rationale: The interdisciplinary treatment team in psychiatry consists of a psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. In addition, a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, psychodramatist, and dietitian also participate in the interdisciplinary treatment team. Respiratory therapists and hospital volunteers are not included in the interdisciplinary treatment team in psychiatry.

Cognitive Level: Application
Integrated Process: Assessment

12. Which of the following conditions promote a therapeutic community? (Select all that apply.)
1. The unit schedule includes unlimited free time for personal reflection.
2. Unit responsibilities are assigned according to client capabilities.
3. A flexible schedule is determined by client needs.
4. The individual is the sole focus of therapy.
5. A democratic form of government exists.

ANS: 2, 5
Rationale: A therapeutic community is promoted when unit responsibilities are assigned according to client capability and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills.

Cognitive Level: Application
Integrated Process: Implementation

Fill-in-the-Blank

13. A scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual is defined as ________________________ therapy.

ANS: milieu
Rationale: Milieu therapy is defined as a scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual. The goal of milieu therapy is to manipulate the environment so that all aspects of the client’s hospital experience are considered therapeutic.

Cognitive Level: Application
Integrated Process: Assessment