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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Disulfiram should be taken each morning, and it is recommended to start it 48 hours after the last drink of alcohol to prevent a severe reaction. This helps establish a clear association between the medication and alcohol avoidance.
B. While taking disulfiram with water is generally advisable, the crucial aspect is the timing and the initial 48-hour abstinence period.
C. Taking the medication at bedtime or limiting alcohol to one ounce daily does not address the specific timing requirement for disulfiram initiation.
D. Beginning the medication immediately and taking it daily, regardless of alcohol consumption, may not establish the necessary 48-hour alcohol-free period before starting disulfiram.
Correct Answer is D
Explanation
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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