A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

Request a team member to assist with seclusion and restraint.

Administer lorazepam 1.5 mg intramuscularly twice daily as needed.

Confirm the client’s identity and orientation to time and place.

Inspect the area for objects that can be used in a dangerous manner.

None

Answer and Explanation

The Correct Answer is D

Rationale for A: While seclusion and restraint may be necessary, this should be considered after assessing the environment for immediate safety concerns.

Rationale for B: Administering medication may help calm the client but does not address immediate safety concerns.

Rationale for C: Confirm the client’s identity and orientation to time and place is a therapeutic intervention that helps ground the client during a dissociative episode. However, in a situation where physical aggression is present, ensuring safety takes precedence over reorientation.

Rationale for D. Inspect the area for objects that can be used in a dangerous manner is the first and most critical action. When a client becomes physically aggressive, the nurse's priority is to maintain safety for the client, staff, and others in the environment. Removing or securing potentially harmful objects minimizes the risk of injury and creates a safer setting for subsequent interventions.

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Correct Answer is B

Explanation

A. Helping clients identify areas of problem in their lives is more characteristic of the orientation phase of group development, where the group establishes trust and defines the purpose and goals.
B. Discussing ways to use new coping skills learned is appropriate during the working phase.
This phase focuses on problem-solving, decision-making, and achieving the goals identified in the orientation phase.
C. Establishing a rapport with group members is crucial during the orientation phase to build trust and create a safe environment for group members to share their experiences.
D. Clarifying the nurse’s role and clients’ responsibilities is more relevant in the orientation phase as the group establishes structure and guidelines.

A. Determine the client’s reason for attempting suicide. B. Obtain the client’s serum hydrocodone/acetaminophen level. C. Encourage the client to increase fluid intake. D. Observe the client for further narcotic effects.

Correct Answer is D

Explanation

A. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.

B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.

C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.

D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.

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A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

Correct Answer is B

Explanation

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Correct Answer is D

Explanation

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