A client with PTSD experiences exaggerated startle response. The client is paranoid and hypervigilant. Which nursing intervention is most appropriate?

Refer the client to a support group for individuals with PTSD

Encourage the client to practice mindfulness meditation

Provide a structured environment with predictable routines, and consistent staff

Administer a PRN sedative medication as needed

Answer and Explanation

The Correct Answer is C

A. While support groups may be helpful, the immediate intervention for a client experiencing heightened anxiety and hypervigilance is to provide structure and safety.

B. Mindfulness meditation may be beneficial in the long term, but it is not the first intervention in an acute phase where anxiety and hypervigilance are prominent.

C. A structured environment with predictable routines and consistent staff can help clients with PTSD feel more secure and reduce feelings of anxiety, hypervigilance, and paranoia. Predictability and structure are key interventions for clients with PTSD.

D. Administering a PRN sedative medication should be a secondary intervention after providing a supportive and safe environment. Medications may be used as part of treatment, but they do not address the underlying anxiety and hypervigilance as effectively as a structured environment.

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Correct Answer is D

Explanation

A. Seclusion should be avoided unless absolutely necessary for safety, as it may increase agitation in a manic client.

B. A stimulating environment could worsen mania, leading to increased agitation and impulsivity.

C. While maintaining a regular sleep-wake cycle is important, discouraging naps could increase irritability and fatigue, which may worsen manic symptoms.

D. Consistent routines help provide structure and security for clients in the manic phase, reducing confusion and promoting stability.

A. Provide a structured activity schedule for the dent B. Instruct the client on relaxation techniques for use when anxiety increases. C. Identify precipitating factors for ritualistic behaviors. D. Discuss alternative coping strategies with the client

Correct Answer is C

Explanation

A. Providing a structured activity schedule can be beneficial but comes after understanding the triggers of the behaviors.

B. Relaxation techniques are helpful but would be more effective after understanding the client's specific rituals and triggers.

C. The first step in managing obsessive-compulsive disorder (OCD) is understanding the triggers or precipitating factors for the client's ritualistic behaviors. This helps the nurse identify patterns and understand the client's anxiety, which is essential for planning further interventions.

D. Discussing alternative coping strategies is important but should follow an assessment of the factors that drive the compulsive behaviors.

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A client with PTSD experiences exaggerated startle response. The client is paranoid and hypervigilant. Which nursing intervention is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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