A client with PTSD experiences exaggerated startle response. The client is paranoid and hypervigilant. Which nursing intervention is most appropriate?

Refer the client to a support group for individuals with PTSD

Encourage the client to practice mindfulness meditation

Provide a structured environment with predictable routines, and consistent staff

Administer a PRN sedative medication as needed

Answer and Explanation

The Correct Answer is C

A. While support groups may be helpful, the immediate intervention for a client experiencing heightened anxiety and hypervigilance is to provide structure and safety.

B. Mindfulness meditation may be beneficial in the long term, but it is not the first intervention in an acute phase where anxiety and hypervigilance are prominent.

C. A structured environment with predictable routines and consistent staff can help clients with PTSD feel more secure and reduce feelings of anxiety, hypervigilance, and paranoia. Predictability and structure are key interventions for clients with PTSD.

D. Administering a PRN sedative medication should be a secondary intervention after providing a supportive and safe environment. Medications may be used as part of treatment, but they do not address the underlying anxiety and hypervigilance as effectively as a structured environment.

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Correct Answer is A

Explanation

A. Blurred vision and ataxia are signs of lithium toxicity. The nurse should withhold the medication and notify the healthcare provider immediately for further evaluation.

B. Administering the next dose of lithium could worsen the toxicity, as these are early signs of lithium overdose.

C. Propranolol is used for controlling tremors or anxiety but does not address lithium toxicity.

D. Levothyroxine is used for thyroid dysfunction, which is not indicated by these symptoms.

A. Reality testing B. Derealization C. Grandiosity D. Flight of ideas

Correct Answer is C

Explanation

A. Reality testing refers to the ability to distinguish between what is real and what is not. The client’s belief is a symptom of grandiosity, not a lack of reality testing.

B. Derealization refers to the sense that the external world is unreal or distorted, which is not the case here.

C. Grandiosity is an inflated sense of self-importance and unrealistic beliefs in one’s abilities, as demonstrated by the client’s statement about being able to fly and become a U.S. Senator.

D. Flight of ideas involves rapid, continuous speech with fragmented thoughts that jump from one topic to another. The client’s speech does not exhibit this pattern.

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A client with PTSD experiences exaggerated startle response. The client is paranoid and hypervigilant. Which nursing intervention is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings is this client exhibiting?

Correct Answer is C

Explanation

A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?

A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

A nurse is caring for a client who experiences severe anxiety when going to work. The nurse should identify that which of the following areas of the autonomic nervous system is stimulated when the client goes to work?

The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

A client with Premenstrual dysphoric disorder (PMDD) asks how her condition differs from premenstrual syndrome (PMS). What is the nurse's best response?

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)

A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following?

A nurse is caring for a client who is prescribed alprazolam to manage severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client?