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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Related Questions
Correct Answer is D
Explanation
A. Impaired ability to regulate body temperature: This condition is not characterized by jerking movements and twitching of the face and tongue. Impaired temperature regulation is more associated with conditions like neuroleptic malignant syndrome but does not specifically relate to the movements described.
B. Neuroleptic malignant syndrome: Neuroleptic malignant syndrome is a serious and potentially life-threatening condition that includes symptoms such as muscle rigidity, fever, autonomic instability, and altered mental status. While it can occur in patients taking antipsychotic medications, the movements described do not fit this diagnosis.
C. Extrapyramidal symptoms: Extrapyramidal symptoms (EPS) refer to a range of movement disorders caused by antipsychotic medications, including tremors, rigidity, and bradykinesia. However, the specific symptoms of jerking movements and twitching of the face and tongue are more characteristic of tardive dyskinesia rather than general EPS.
D. Tardive dyskinesia: Tardive dyskinesia is a condition often seen in individuals taking first-generation antipsychotic medications for an extended period. It is characterized by involuntary, repetitive movements, particularly in the face, tongue, and extremities. The client's symptoms of jerking movements and twitching align with this diagnosis.
Correct Answer is B
Explanation
A. Selective serotonin reuptake inhibitor: SSRIs are primarily used to treat depression and anxiety disorders. They are not effective in addressing symptoms such as delusions and hallucinations, which are often associated with psychotic disorders.
B. Dopamine antagonist: Dopamine antagonists, often referred to as antipsychotic medications, are the primary treatment for managing delusions and hallucinations. These medications work by blocking dopamine receptors in the brain, helping to reduce the severity of psychotic symptoms.
C. Benzodiazepine: While benzodiazepines may be used to manage anxiety or agitation, they do not directly treat delusions or hallucinations. Using them in clients with psychotic symptoms could potentially mask underlying issues without addressing the core problems.
D. Mood stabilizer: Mood stabilizers are primarily indicated for mood disorders, such as bipolar disorder. Although they can help manage mood swings and irritability, they do not specifically target the psychotic symptoms of delusions and hallucinations, making them less appropriate in this context.
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