A nurse is caring for a client who has a dissociative disorder. Which of the following actions should the nurse take first?

Administer a benzodiazepine to the client.

Establish rapport with the client.

Teach the client grounding techniques.

Educate the client about their disorder.

Answer and Explanation

The Correct Answer is B

A. Administer a benzodiazepine to the client: While benzodiazepines may be useful for managing anxiety, the first step in caring for a client with a dissociative disorder is to build a trusting relationship. Medications should not be prioritized over establishing rapport.
B. Establish rapport with the client: Building rapport is crucial in creating a safe environment for the client. It allows the nurse to gain the client’s trust, facilitating effective communication and treatment. A strong therapeutic alliance is essential for the client's willingness to engage in further interventions.
C. Teach the client grounding techniques: While grounding techniques can be beneficial for clients experiencing dissociation, they are most effective when the client feels safe and supported. Establishing rapport first will help the client be more receptive to learning and practicing these techniques.
D. Educate the client about their disorder: Education is important, but it should come after establishing a trusting relationship. The client may not be open to education about their disorder until they feel comfortable with the nurse and the therapeutic process.

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Correct Answer is C

Explanation

A. Stage 2 (moderate): In this stage of alcohol withdrawal, symptoms may include increased anxiety, tremors, and elevated vital signs, but hallucinations and severe disorientation are not typically present. The client's current condition exceeds the expectations of moderate withdrawal, indicating a more severe level.
B. Stage 1 (mild): Mild withdrawal symptoms are generally characterized by anxiety, insomnia, and mild tremors. The presence of hallucinations, significant changes in vital signs, and severe disorientation suggests that the client is experiencing more than just mild withdrawal symptoms.
C. Stage 3 (severe): Severe alcohol withdrawal is characterized by the presence of hallucinations, severe agitation, confusion, and autonomic instability, as indicated by the client's elevated blood pressure and heart rate. The client’s experience of seeing spiders and disorientation about their location indicates severe withdrawal, which may lead to complications like delirium tremens if not properly managed.
D. The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal: While hallucinations can be indicative of a psychotic disorder, the context of recent alcohol use and the accompanying withdrawal symptoms strongly suggest that the client is experiencing severe alcohol withdrawal rather than a separate psychotic disorder.

A. When attending dialectical behavior therapy B. When attending narrative therapy C. When discharged from the hospital D. When getting married

Correct Answer is C

Explanation

A. When attending dialectical behavior therapy: While individuals with borderline personality disorder may experience emotional distress during therapy sessions, attending dialectical behavior therapy (DBT) typically provides skills and support to manage emotions and reduce self-harm risks. Therefore, this situation is not considered the highest risk.
B. When attending narrative therapy: Narrative therapy focuses on helping individuals reframe their stories and experiences, which can be beneficial. While any therapeutic setting can evoke emotions, attending narrative therapy does not significantly increase the risk of self-harm compared to other situations.
C. When discharged from the hospital: This situation is often associated with the highest risk for self-harm. The transition from a controlled environment to the challenges of everyday life can lead to feelings of abandonment, loss of support, and increased stress, making individuals vulnerable to self-harming behaviors.
D. When getting married: While significant life changes, such as marriage, can evoke anxiety, they do not typically represent the highest risk for self-harm. The supportive context of a marriage and the associated positive emotions usually outweigh the potential for increased risk at that moment.

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A nurse is caring for a client who has a dissociative disorder. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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