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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Related Questions
Correct Answer is D
Explanation
A. Isolating the client is not appropriate, as it can increase anxiety and exacerbate the compulsive behaviors.
B. Setting strict limits can lead to increased anxiety and resistance, making it harder to manage the compulsive behaviors.
C. Confronting the client about the senselessness of their compulsions can increase anxiety and worsen the behavior. It is more helpful to provide a supportive environment that allows for the rituals, gradually decreasing their frequency and intensity.
D. Clients with OCD often perform compulsive rituals to reduce anxiety. Planning time for rituals helps to manage the behavior while maintaining the therapeutic structure and routine on the unit.
Correct Answer is A
Explanation
A. Alprazolam is a benzodiazepine that can cause drowsiness, dizziness, and impair motor coordination. Therefore, the nurse should advise the client to avoid activities that require alertness until they understand how the medication affects them.
B. Alprazolam provides relatively quick relief of anxiety symptoms, often within hours, rather than requiring weeks of therapy like some other medications.
C. Foods high in tyramine are a concern for clients taking monoamine oxidase inhibitors (MAOIs), not alprazolam.
D. Increasing the dose without guidance from a healthcare provider is unsafe. The client should not adjust their medication dosage without consulting the provider.
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