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Difficulty: MediumMental Health Concepts

A practical nurse (PN) enters the room of a client with post-traumatic stress disorder (PTSD) who was admitted for pneumonia. The client is crouching in the corner, trembling, and shouting, "Get down! They are coming over the wall!" Which action should the PN take first?

  1. Maintain a safe distance near the doorway and calmly state the nurse's name and purpose.Answer
  2. B
    Inquire why the client believes someone is coming over the wall.
  3. C
    Apply physical restraints immediately to ensure the client does not run out of the room and fall.
  4. D
    Prepare and administer an intravenous push sedative medication to rapidly decrease the client's agitation.

Answer

Maintain a safe distance near the doorway and calmly state the nurse's name and purpose.
When a client is experiencing an active flashback or severe agitation, the primary focus is on safety. By maintaining a safe distance and staying near the door, the nurse ensures a clear exit route. Calmly identifying oneself and one's purpose helps ground the client in the present reality without directly confronting or arguing with their distorted perception.

Step-by-Step Solution

1
Analyze the clinical scenario to identify the client's current state.
The client is experiencing an active flashback or severe panic related to PTSD, posing a potential safety risk to themselves and staff.
Understanding the nature of the crisis dictates the appropriate therapeutic intervention.
2
Evaluate the proposed nursing actions against the principles of safety, therapeutic communication, and PN scope of practice.
Restraints are premature, 'why' questions are non-therapeutic, and IV push medications are out of scope. Providing space and calm orientation prioritizes safety and de-escalation.
Safety (for both the client and the nurse) is the absolute first priority in any psychiatric emergency.

Key Concept

Prioritizing safety and utilizing de-escalation techniques during an active PTSD flashback or crisis.
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Mental Health Concepts

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