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. Administering disulfiram is not the priority in the immediate care of a client with a closed head injury and elevated blood alcohol level. The focus should be on ensuring the client's safety and preventing complications related to the head injury.
B. Placing the client in a side-lying position with the head of the bed elevated is crucial to prevent aspiration and maintain airway patency in a client who is difficult to arouse due to alcohol intoxication.
C. Giving lorazepam for signs of withdrawal may be necessary but does not address the immediate risk of aspiration in a client with altered consciousness.
D. Providing thiamine and folate supplements is important for clients with alcohol use disorders, but the priority in this scenario is airway protection and preventing complications related to the head injury.

A. Shielding the client from direct sunlight when outdoors. B. Gradually withdrawing the medication over several days. C. Enforcing a fluid restriction during dosage adjustment. D. Increasing the dosage if the white blood cell count drops.

Correct Answer is ["A","B"]

Explanation

A. Shielding the client from direct sunlight is important because some antipsychotic medications, including haloperidol, can increase sensitivity to sunlight, leading to sunburn.
B. Gradually withdrawing the medication over several days is a prudent approach to avoid withdrawal symptoms and potential worsening of symptoms.
C. Enforcing a fluid restriction is not typically necessary during dosage adjustment for antipsychotic medications like haloperidol.
D. Increasing the dosage if the white blood cell count drops is not a standard practice during the dosage adjustment of antipsychotic medications. Monitoring for adverse effects and adjusting the dosage accordingly is important, but the decision should be based on a comprehensive assessment rather than a single laboratory value.

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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

A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

Correct Answer is B

Explanation

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

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