A nurse is caring for a client with a blood alcohol level of 36%. Which of the following should be included in the priority risk assessment for a client with acute alcohol intoxication? (Select all that apply)

Choice A reason:
This statement reflects hypervigilance and a persistent sense of threat, which are symptoms associated with PTSD. Individuals with PTSD may feel constantly on edge as if danger is always imminent, leading to behaviors such as checking rooms repeatedly.

Choice B reason:
While this statement indicates a traumatic experience, it does not directly suggest symptoms of PTSD. PTSD is characterized by specific symptoms such as intrusive thoughts, flashbacks, and avoidance behaviors related to the traumatic event.

Choice C reason:
This statement may be indicative of a distressing combat experience but does not directly align with the symptoms of PTSD. It does not reflect the re-experiencing, avoidance, or arousal symptoms typically seen in PTSD.

Choice D reason:
This statement is a clear example of re-experiencing symptoms, which is a core feature of PTSD. Nightmares about the traumatic event and intrusive, distressing memories are common in individuals with PTSD. The vivid and distressing nature of such dreams can significantly impact an individual's well-being.

Choice A reason:
Escorting the client to the common area is not the priority action during a panic attack. The common area may have too much stimulation and could potentially worsen the client's anxiety. It is important to provide a quiet and safe environment for the client during a panic attack.

Choice B reason:
Contacting security for possible restraints is not the priority action and should only be considered if the client is a danger to themselves or others. Restraints can increase the client's anxiety and agitation, and the goal is to de-escalate the situation in a non-threatening manner.

Choice C reason:
Staying with the client is the priority action. The presence of a nurse can provide reassurance and a sense of safety. The nurse should use a calm and soothing voice, maintain a non-threatening posture, and stay with the client until the panic attack subsides. Offering support and using relaxation techniques can help the client regain control.

Choice D reason:
Staying away from the client is not the priority action. Isolation can increase the client's fear and anxiety. The nurse should remain with the client, offering reassurance and monitoring the client's condition throughout the panic attack.