A client, who was diagnosed with Post Traumatic Stress Disorder (PTSD), is now experiencing flashbacks and is displaying irritable behavior. The nurse would:
leave the client alone to work out the problem, then tell the physician about the incident.
tell the client to return to room and write their thoughts in a journal.
give the prescribed flumazenil 5 mg IM
remain with the client and ensure safety.
The Correct Answer is D
a. Leave the client alone: Leaving the client alone during a flashback could be dangerous.
b. Journaling: While journaling can be helpful for managing PTSD, it's not appropriate during a crisis situation.
c. Flumazenil: Flumazenil is used to reverse benzodiazepine overdose, not for PTSD flashbacks.
d. remain with the client and ensure safety: A PTSD flashback can be overwhelming and lead to self-harm or aggression. The nurse's priority is to ensure the client's safety and the safety of others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
a. Observation during and after meals: To prevent the client from engaging in purging behaviors, such as vomiting or hiding food.
b. Adherence to scheduled meal times: To establish a regular eating pattern and help normalize the client’s relationship with food.
c. Trips to the local fast food restaurant for foods are not appropriate as they can promote unhealthy eating behaviors and do not align with the structured, therapeutic environment necessary for recovery.
d. Monitoring during bathroom trips: To prevent purging behaviors, especially right after meals when the temptation to vomit might be higher.
e. Weekly weight checks are important for monitoring progress, but daily or more frequent weight checks are often necessary to ensure safety and appropriate weight gain or stabilization.
Correct Answer is B
Explanation
a. Anticipate the behavior and restrain when pacing begins: Restraint should be a last resort. Pacing might not necessarily lead to screaming, and early intervention should focus on de-escalation techniques.
b. Assess environmental triggers and potential unmet needs. De-escalation strategies should prioritize understanding why the client's behavior is escalating. Identifying environmental triggers or unmet needs (like pain, hunger, thirst) can help prevent further agitation.
c. Assess for potential injury: While assessing for injury is important, it should come after ensuring the safety of both the client and the staff by addressing the cause of the outburst.
d. Consult the psychologist regarding behavior modification techniques: Consultation is valuable, but immediate intervention to de-escalate the situation and understand the cause is the priority.
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