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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A common symptom of panic attacks is the intense feeling of fear of impending doom, which can overwhelm the individual during an attack. The client may feel like something catastrophic is going to happen, even if no actual threat exists.
B. Obsessions are more commonly associated with obsessive-compulsive disorder (OCD), not panic attacks.
C. Apathy, or lack of emotion or interest, is typically not associated with panic attacks but may be seen in depression or certain other mental health conditions.
D. Fever is not a symptom of panic attacks but could be indicative of an infection or illness.
Correct Answer is B
Explanation
A. While gastrointestinal side effects are common with fluoxetine, they are not the priority concern in the context of bipolar disorder.
B. Fluoxetine (Prozac) is an SSRI used to treat depression, but in patients with bipolar disorder, it can trigger a manic episode. Therefore, the nurse's priority is to monitor for signs of mania, such as increased energy, euphoria, or impulsivity.
C. Administering the medication as ordered is essential, but the nurse must be vigilant for signs of mania, especially with SSRIs in bipolar patients.
D. Educating about weight gain is important but does not address the immediate risk of precipitating mania with fluoxetine in a bipolar patient.
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