To ensure safety when a client with PTSD awakens from a nightmare and threatens to strangle the roommate, what is the first nursing intervention?

To ensure safety when a client with PTSD awakens from a nightmare and threatens to strangle the roommate, what is the first nursing intervention?

• A. Remain with the client until the agitation is under control
• B. Arrange for anti anxiety medication to be administered as prescribed
• C. Institute homicide precautions at night
• D. Remove the roommate from the room

Answer: (D)

Safety of others takes priority when a client with PTSD awakens from a nightmare and threatens to harm someone. The first action is to remove the roommate from the room to eliminate the immediate risk of strangulation or injury. This creates a safer environment so staff can use de-escalation techniques, monitor the situation, and implement further interventions as needed. While medications or more formal precautions may be required later, they aren’t the immediate step in this moment. After safety is established, continue to de-escalate, stay with the client as appropriate, and involve the care team to plan subsequent care.

Safety of others takes priority when a client with PTSD awakens from a nightmare and threatens to harm someone. The first action is to remove the roommate from the room to eliminate the immediate risk of strangulation or injury. This creates a safer environment so staff can use de-escalation techniques, monitor the situation, and implement further interventions as needed. While medications or more formal precautions may be required later, they aren’t the immediate step in this moment. After safety is established, continue to de-escalate, stay with the client as appropriate, and involve the care team to plan subsequent care.