a client with post traumatic stress disorder ptsd is experiencing a flashback what is the nurses priority action
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Nursing Elites

HESI LPN

Mental Health HESI 2023

1. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the nurse's priority action?

Correct answer: B

Rationale: The priority action is to help the client focus on the present (B), which can reduce the intensity of the flashback. Encouraging discussion of the trauma (A) should be done when the client is not actively experiencing a flashback. While medication (C) may be necessary, it is not the first priority in this situation. Leaving the client alone (D) is not appropriate as they need support to manage the flashback.

2. A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose:

Correct answer: B

Rationale: The correct answer is B: 'At the same time each evening.' Sertraline should be administered at the same time each evening to maintain steady drug levels and effectiveness. Choice A is incorrect because sertraline can be taken with or without food. Choice C is incorrect as sertraline does not need to be spaced around the clock. Choice D is incorrect as sertraline is a scheduled medication and should not be taken on an as-needed basis for complaints of depression.

3. The client with schizophrenia believes the news commentator is her lover and speaks to her. What is the best response for the nurse to make?

Correct answer: A

Rationale: The correct response is to ask the client what she believes the news commentator said, as it helps the nurse assess the client's perception and delve into her delusions without being confrontational. Choice B is not helpful in addressing the client's delusions. Choice C jumps to conclusions about potential harm without assessing the client's beliefs. Choice D is dismissive and does not address the client's reality.

4. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

Correct answer: B

Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.

5. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?

Correct answer: B

Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.

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