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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Naloxone is an opioid antagonist used to reverse opioid overdoses, not benzodiazepines.
B. Diphenhydramine is an antihistamine, not an antagonist for benzodiazepines.
C. Protamine is used to reverse the effects of heparin (an anticoagulant), not benzodiazepines.
D. Flumazenil is a benzodiazepine antagonist used to reverse the effects of benzodiazepine overdose or sedation.
Correct Answer is A
Explanation
A. The client’s physical symptoms (chest pain, headache, shortness of breath) and statements about not understanding why his wife left indicate a panic level of anxiety, which is marked by intense physical and emotional distress.
B. Moderate anxiety involves increased nervousness or slight discomfort but does not cause the severe physical symptoms seen in panic anxiety.
C. Mild anxiety presents with slight restlessness or tension, without significant physical symptoms.
D. Severe anxiety would involve significant impairment in thinking or perception but is more focused on a sense of being overwhelmed or immobilized, rather than exhibiting full panic symptoms.
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