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. Avoiding discussing subjects that upset the client may hinder therapeutic communication and exploration of feelings, making it less effective for the client's recovery.
B. Encouraging activities that allow the client to exert control over his environment helps empower the client and regain a sense of agency, which is important for improving mental health.
C. Allowing the client time alone may be appropriate at times, but encouraging activities that promote control is a more proactive and empowering intervention.
D. Encouraging interaction with persons recovering from depression may be beneficial, but the client's need for control over his environment takes precedence in this scenario.

A. Level of activity. B. The interactions with others. C. The emotional quality of attitude. D. Appetite.

Correct Answer is C

Explanation

A. Level of activity, interactions with others, and appetite are important aspects, but the emotional quality of attitude is central in assessing the effectiveness of an antidepressant.
Changes in mood and affect are critical indicators of the drug's impact on the client's mental health.
B. Interactions with others provide valuable information but may not capture the internal emotional experience of the client.
C. The emotional quality of attitude reflects the client's internal state and is a key indicator of the antidepressant's impact on their depressive symptoms.
D. Appetite is a relevant aspect, but it may not be as direct an indicator of the antidepressant's efficacy as changes in the emotional quality of attitude.

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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?

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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