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Zorluk: OrtaMental Health Concepts

A client recovering from surgery has an established diagnosis of post-traumatic stress disorder. Suddenly, a heavy equipment cart crashes loudly in the adjacent hallway. The client immediately drops to the floor, curls into a tight position, and begins hyperventilating. Which action is the priority for the practical nurse (PN) to take?

  1. A
    Explain logically that the loud noise was just equipment falling in the hallway
  2. Stay in the room, keep a non-threatening stance, and calmly orient the client to the current settingCevap
  3. C
    Inquire about what specific past trauma the loud noise has reminded them of
  4. D
    Reassure the client by stating that there is absolutely nothing to be afraid of

Cevap

The priority action is to remain in the room, maintain a non-threatening posture, and use a calm voice to orient the client to their current surroundings.
During an acute flashback or severe panic episode, the client's psychological grounding is the immediate priority. By remaining in the room, maintaining a safe posture, and calmly orienting the client to the present, the nurse provides a safe environment. This therapeutic approach helps the client regain a sense of reality without introducing physical touch, which could be misinterpreted as a threat, and establishes trust without invalidating their intense emotional experience.

Adım Adım Çözüm

1
Assess the client's immediate behavioral and physiological response to the trigger.
The client is exhibiting signs of an acute flashback and severe anxiety, indicated by dropping to the floor and hyperventilating.
Identifying the severity of the stress reaction determines the level of intervention required.
2
Determine the safest and most therapeutic initial nursing intervention.
The nurse must prioritize psychological grounding and safety over investigation, logic, or physical contact.
Clients experiencing acute trauma responses may perceive sudden movements, logical reasoning, or physical touch as an active threat.
3
Select the option that provides presence and reality orientation.
Staying in the room with a non-threatening stance and orienting the client to the present environment is the correct choice.
This approach uses the therapeutic technique of offering self and reality grounding without forcing rationalization or minimizing the client's feelings.

Anahtar Kavram

Crisis Intervention and Grounding Techniques in PTSD
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Konular

Mental Health Concepts

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