A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

Request a team member to assist with seclusion and restraint.

Administer lorazepam 1.5 mg intramuscularly twice daily as needed.

Confirm the client’s identity and orientation to time and place.

Inspect the area for objects that can be used in a dangerous manner.

None

Answer and Explanation

The Correct Answer is D

Rationale for A: While seclusion and restraint may be necessary, this should be considered after assessing the environment for immediate safety concerns.

Rationale for B: Administering medication may help calm the client but does not address immediate safety concerns.

Rationale for C: Confirm the client’s identity and orientation to time and place is a therapeutic intervention that helps ground the client during a dissociative episode. However, in a situation where physical aggression is present, ensuring safety takes precedence over reorientation.

Rationale for D. Inspect the area for objects that can be used in a dangerous manner is the first and most critical action. When a client becomes physically aggressive, the nurse's priority is to maintain safety for the client, staff, and others in the environment. Removing or securing potentially harmful objects minimizes the risk of injury and creates a safer setting for subsequent interventions.

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Correct Answer is B

Explanation

A. Instructing the client to reduce the volume of his voice may not be effective during a manic episode and could escalate the situation.
B. Accompanying the client to a quiet area of the unit provides a more supportive and calming environment, allowing the client to deescalate.
C. Encouraging the client to attend a support group is a positive intervention but may not be immediately effective during an agitated state.
D. Administering a PRN sedative by injection may be considered, but less restrictive interventions should be attempted first to promote a therapeutic environment.

A. Encourage the client to weigh herself daily at bedtime. B. Recommend exercise and recreation in the morning. C. Allow the client to select an arts and crafts activity. D. Put the client in charge of choosing snacks for the unit.

Correct Answer is C

Explanation

A. Encouraging daily weigh-ins may exacerbate anxiety and fixation on weight, which is not therapeutic.
B. Exercise and recreation recommendations should align with the treatment plan and be individualized; morning activities are not universally indicated.
C. Allowing the client to select an arts and crafts activity provides a positive outlet for expression and engagement in non-food-related activities.
D. Putting the client in charge of choosing snacks for the unit may not be appropriate, as it could contribute to unhealthy food-related behaviors.

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A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

Nursing Test Bank

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