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 C

Explanation

A. Reality testing refers to the ability to distinguish between what is real and what is not. The client’s belief is a symptom of grandiosity, not a lack of reality testing.

B. Derealization refers to the sense that the external world is unreal or distorted, which is not the case here.

C. Grandiosity is an inflated sense of self-importance and unrealistic beliefs in one’s abilities, as demonstrated by the client’s statement about being able to fly and become a U.S. Senator.

D. Flight of ideas involves rapid, continuous speech with fragmented thoughts that jump from one topic to another. The client’s speech does not exhibit this pattern.

A. Walking with the nurse in the courtyard B. Watching a video with a group in the day room C. Participating in a basketball game in the gym D. Joining a group discussion about a local election.

Correct Answer is A

Explanation

A. Walking with the nurse in the courtyard provides a simple, safe, and structured activity that promotes physical exercise and reduces excess energy in a way that is appropriate for someone in a manic state. This also gives the nurse an opportunity to observe the client's behavior and provide supervision.

B. Watching a video with a group might not engage the client sufficiently and could be too passive for someone experiencing mania who might need a more stimulating activity.

C. Participating in a basketball game could be too physically demanding and might escalate the client's manic behavior, especially if they have high energy or impulsivity.

D. Joining a group discussion about a local election may not be stimulating enough for the client in a manic state, as it requires focus and attention that might be difficult for the client to maintain during acute mania.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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