Examkin

Question

Difficulty: Very hardMental Health Concepts

A client is recovering from a complicated urinary tract infection in a subacute care facility. The client has a history of post-traumatic stress disorder (PTSD). At 0300, the practical nurse (PN) enters the dimly lit room and observes the client backed against the wall, trembling, pointing at a coat rack, and yelling that an attacker is standing there. Which action should the PN take first?

  1. Turn on the overhead lights, maintain a safe distance, and calmly reassure the client of their immediate safety.Answer
  2. B
    Attribute the sudden hallucination to the onset of dementia and update the care plan to reflect permanent cognitive decline.
  3. C
    Apply a soft chest restraint to secure the client in bed and prevent a potential fall or elopement.
  4. D
    Ask the client, "Why are you yelling when it is obvious that no one else is in this room?"

Answer

The correct action is to turn on the overhead lights, maintain a safe distance, and calmly reassure the client of their immediate safety.
The client is experiencing a severe fear response, likely triggered by a visual illusion (misinterpreting the shadowed coat rack) secondary to acute delirium from the infection and exacerbated by a PTSD history. The priority is ensuring safety through the least restrictive means. Turning on the lights alters the sensory environment to eliminate the visual trigger, while maintaining distance and offering calm reassurance provides therapeutic de-escalation without provoking a physical altercation.

Step-by-Step Solution

1
Analyze the clinical presentation.
The client is experiencing a sudden onset of severe fear and visual misinterpretation (illusion/hallucination) in the context of an active infection (UTI) and a dimly lit environment.
Identifying the nature of the crisis determines the priority intervention.
2
Differentiate the underlying physiological and psychological factors.
The acute presentation points to delirium (secondary to infection) complicated by PTSD trauma responses, rather than a permanent cognitive decline like dementia.
Accurate clinical recognition prevents inappropriate documentation and guides safe, immediate care.
3
Select the safest, least restrictive intervention.
Turning on the lights alters the sensory environment to eliminate the visual trigger (the shadowed coat rack).
Environmental modification must precede chemical or physical restraints, and maintaining distance ensures staff safety during a psychological crisis.

Key Concept

Crisis De-escalation and Delirium Recognition
Rate this question

Topics

Mental Health Concepts

More questions from this topic