A client with post-traumatic stress disorder (PTSD) is admitted to the psychiatric unit. Which intervention is most important for the nurse to include in this client's plan of care?

Provide a quiet room away from the recreational area.

Acquaint the client with the rules of the unit.

Ensure that the client eats a well-balanced diet.

Introduce the client to other clients with a similar diagnosis.

Answer and Explanation

The Correct Answer is A

A.   Providing a quiet room is important. This is because individuals with PTSD are often hypersensitive to noise and other stimuli, which can trigger flashbacks or other
symptoms. A quiet environment can help to reduce anxiety and promote relaxation.
B.   Acquainting the client with the unit rules is important, but connecting the client with peers who understand their experiences can be more therapeutic initially.
C.   Ensuring a well-balanced diet is essential but might not be the priority in the immediate plan of care for someone newly admitted with PTSD.
D.   Introducing the client to others with similar diagnoses helps foster a sense of belonging.
However, this is a long-term rather than an immediate intervention.

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Correct Answer is B

Explanation

A. Familial history of mental illness is important but might not directly impact the initiation of sertraline treatment.
B. Medication history is the most important information to obtain before starting sertraline. This includes any current medications the client is taking, especially other antidepressants, anticoagulants, or medications that may interact with sertraline. Sertraline is a selective serotonin reuptake inhibitor (SSRI), and it can interact with other medications, such as monoamine oxidase inhibitors (MAOIs) or other serotonergic drugs, leading to serious side effects like serotonin syndrome.

C. While current weight may be important for monitoring side effects such as weight gain, it is not as immediately critical as understanding the client’s medication history, particularly regarding potential drug interactions.

D. A history of heart disease is relevant to the overall health assessment, but sertraline is generally considered safe for most individuals with heart disease. However, the medication history is more crucial because of potential drug interactions.

A. Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety. B. Should be encouraged as representative of the client's non-destructive method of fear expression. C. Unacceptable, and limits should be set to encourage the client to maintain her independence. D. Should be accepted by staff as the first step the client must experience in the grieving process. E. Should be accepted by staff as the first step the client must experience in the grieving process.

Correct Answer is A

Explanation

A. This behavior can be seen as a regression aimed at reducing anxiety during a stressful time, which is a relatively common psychological response to stress or trauma.
B. While it may be a way for the client to cope, encouraging dependency might not necessarily be the best approach to fostering independence.
C. While independence is important, setting rigid limits might not address the underlying emotional needs during a period of distress.
D. Acknowledging and understanding the client's behavior as a coping mechanism within the grieving process can help the staff provide appropriate support and care.

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A client with post-traumatic stress disorder (PTSD) is admitted to the psychiatric unit. Which intervention is most important for the nurse to include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

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