A nurse in a hospital is caring for a client who has agoraphobia.
Which of the following statements by the client indicates understanding of the goals of treatment?

The correct answer is choice c. “In my dreams, all I can see are the wounded reaching out and trying to grab me.”

Choice A rationale:

This statement indicates hypervigilance and paranoia, which can be symptoms of PTSD, but it is more indicative of a delusional disorder or severe anxiety.

Choice B rationale:

This statement reflects a possible delusion of grandeur or a coping mechanism to deal with trauma, but it does not directly indicate PTSD.

Choice C rationale:

This statement describes a recurring nightmare, which is a common symptom of PTSD. Individuals with PTSD often relive traumatic events through nightmares or flashbacks.

Choice D rationale:

This statement suggests a belief in a cause-and-effect relationship that may not be accurate. It could indicate guilt or a misunderstanding of the situation, but it is not a direct symptom of PTSD.

Choice A rationale:

Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:

1. Imminent Risk of Harm:

Acute anxiety can significantly impair judgment and impulse control, escalating the risk of self-harm or harm to others. It's crucial to prevent any actions that could result in physical injury, even if unintended.

2. Physiological Manifestations:

Anxiety can trigger physiological responses that heighten the potential for harm, such as: Increased heart rate and blood pressure

Hyperventilation Diaphoresis

Agitation and restlessness Dissociation

These physiological changes can contribute to accidents, falls, or other injuries.

3. Impaired Decision-Making:

Acute anxiety often clouds rational thinking and decision-making abilities.

Individuals may engage in behaviors they wouldn't consider in a calmer state, such as running away, lashing out, or attempting self-harm.

The nurse's role is to safeguard the client from potential consequences of these impulsive actions.

4. Establishing Safety as a Foundation for Care:

Ensuring physical safety creates a necessary foundation for subsequent interventions.

Once safety is established, the nurse can proceed with assessing coping skills, identifying anxiety triggers, and implementing therapeutic strategies.

5. Protecting Others:

In rare cases, acute anxiety can manifest in aggression towards others.

The nurse must protect not only the client but also other individuals who may be at risk.

6. Ethical and Legal Obligations:

Nurses have a professional duty to protect clients from harm, upholding ethical principles and legal standards of care.

7. Preventing Trauma:

Physical injuries sustained during a crisis can exacerbate anxiety and complicate recovery. Proactive safety measures aim to prevent further trauma and promote healing.

I'll provide detailed rationales for the other choices in separate messages to ensure clarity and comprehensiveness.