A nurse is assessing the sleep pattern of a client who has an anxiety disorder. The client reports having difficulty sleeping most nights. Which of the following recommendations should the nurse make?

"Watch television to facilitate falling asleep."

"Exercise at least 3 hours before bedtime."

"Consume your evening meal 1 hour before bedtime."

"Take an hour-long nap daily."

Answer and Explanation

The Correct Answer is B

Choice A reason: Watching television before bedtime can be stimulating and interfere with the ability to fall asleep. The blue light emitted by screens can also disrupt the body's natural sleep-wake cycle.

Choice B reason: Regular exercise, particularly when done earlier in the day, can help reduce anxiety and improve sleep quality. However, it's important to avoid vigorous exercise close to bedtime as it can be too stimulating.

Choice C reason: Consuming the evening meal too close to bedtime can cause indigestion and interfere with sleep. It's better to finish eating at least 2-3 hours before going to bed.

Choice D reason: Taking long naps, especially later in the day, can make it more difficult to fall asleep at night. If naps are necessary, they should be short and not too close to bedtime.

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Correct Answer is C

Explanation

Choice A reason: Telling a client that their experience is not real can be invalidating and may damage the therapeutic relationship between the nurse and the client. It is essential to acknowledge the client's experience as real to them and provide support without reinforcing the hallucination.

Choice B reason: While it is important not to reinforce hallucinations, avoiding direct questions about the client's experience can hinder the nurse's ability to assess the client's condition fully. It is better to ask open-ended questions that allow the client to describe their experience without feeling judged.

Choice C reason: Focusing the client on reality-based activities can help distract them from the hallucinations and ground them in the present moment. Activities such as listening to music, engaging in conversation, or participating in a physical activity can help reduce the intensity of hallucinations and provide a sense of control.

Choice D reason: Conveying sympathy for the client's experience is compassionate and can help build trust. However, it is crucial to balance empathy with encouragement to engage in reality-based activities and strategies to manage the hallucinations effectively.

A. Assist the client to use new coping strategies. B. Establish confidentiality guidelines with the client. C. Help the client to make behavioral changes. D. Share information with the client about their disorder.

Correct Answer is B

Explanation

Choice A reason: Assisting the client to use new coping strategies is an important part of managing bipolar disorder, but it is not the first action a nurse should take when establishing a nurse-client relationship. Coping strategies will be more effective once a trusting relationship has been established and the client feels secure in sharing personal information.

Choice B reason: Establishing confidentiality guidelines with the client is the first and most crucial step in forming a therapeutic nurse-client relationship. It sets the foundation for trust and openness, ensuring the client understands that their personal information will be protected and shared only with those directly involved in their care.

Choice C reason: Helping the client to make behavioral changes is a goal in the treatment of bipolar disorder. However, before any interventions can be planned or implemented, the nurse must first establish a rapport and trust with the client, which begins with ensuring confidentiality.

Choice D reason: Sharing information with the client about their disorder is essential for their understanding and participation in care. However, this should occur after establishing a relationship in which the client feels comfortable and secure, knowing their privacy is respected.

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A nurse is assessing the sleep pattern of a client who has an anxiety disorder. The client reports having difficulty sleeping most nights. Which of the following recommendations should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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