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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Give PRN medications to treat increased hallucinations: While medication can be important in managing symptoms, the immediate priority is to ensure the client's safety and provide reassurance. Administering medication may not address acute confusion or distress effectively in the moment.
B. Ensure the client goes to group activities as planned: Encouraging participation in group activities may not be appropriate if the client is confused and experiencing distortions in thinking. Their current state could make group activities overwhelming or distressing.
C. Use distraction such as the television or music: Distraction can be helpful in some situations, but it does not address the client's underlying confusion or provide the necessary support for safety and reassurance.
D. Provide reassurance and comfort ensuring the client is safe: Ensuring the client's safety and providing comfort is the priority nursing intervention. This approach helps to reduce anxiety, supports emotional needs, and creates a stable environment, which is essential for clients experiencing confusion and distorted thinking.
Correct Answer is D
Explanation
A. Thought insertion: This delusion involves the belief that one's thoughts are not their own and have been placed in their mind by an external force. The client's belief of being a celebrity does not reflect this type of delusion.
B. Persecutory: Persecutory delusions involve the belief that one is being targeted or harassed by others. The client's delusion of being a celebrity does not indicate that they feel threatened or persecuted; rather, it reflects an inflated sense of self-importance.
C. Control: Delusions of control involve the belief that one's thoughts, feelings, or actions are being controlled by an external force. The client's behavior does not suggest they believe their actions are controlled by someone else but rather indicates a belief in their elevated status.
D. Grandiose: Grandiose delusions are characterized by an inflated sense of self-worth, power, or identity. The client's belief of being a celebrity exemplifies this type of delusion, as it involves an exaggerated perception of their own importance and status.
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