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 A

Explanation

A. The client's statements about having an IQ of 400+, being married to a movie star, and suspecting his brother's intentions may indicate a distorted perception of reality, suggesting disturbed sensory perception. This priority addresses the potential psychosis and immediate safety concerns.
B. Compromised family coping, while important, is a secondary consideration. Addressing the client's altered sensory perception takes precedence to ensure their safety and
stabilization.
C. Ineffective sexual patterns are not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.
D. Impaired environmental interpretation is not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.

A. Help the client identify thoughts that may be triggers. B. Explore past behaviors that have provided relief. C. Attempt to distract to another focus or activity. D. Speak calmly to the client stating assurance of safety.

Correct Answer is D

Explanation

A. Identifying triggers may be beneficial, but the client is currently in a state of severe anxiety, and immediate intervention to address the symptoms is needed.
B. Exploring past behaviors can be addressed later; the immediate focus should be on managing the acute symptoms of anxiety.
C. Attempting to distract the client can be helpful, but providing reassurance and addressing safety concerns take precedence.
D. Speaking calmly to the client and providing assurance of safety is an appropriate first step in managing severe anxiety. Once the client is more settled, other interventions can be explored.

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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

Naxlex Comprehensive Predictor Exams

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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