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: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.

Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.

Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.

Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.

A. "Since you are trying to follow the treatment plan, we can submit your request to the provider." B. "We are concerned about you and need to keep you safe." C. "If you complete a contract that states you will not harm yourself, you can be alone." D. "Until your medication has reached therapeutic levels, you will need constant observation."

Correct Answer is B

Explanation

Choice A reason: This statement may seem supportive, but it does not address the immediate safety concerns for a client with suicidal ideations and a verbalized plan. Submitting a request for privacy does not mitigate the risk of harm the client may pose to themselves.

Choice B reason: This is the most appropriate response because it directly addresses the safety of the client, which is the primary concern in this situation. It communicates care and concern while also reinforcing the need for observation due to the risk of suicide.

Choice C reason: While safety contracts can be a part of a comprehensive treatment plan, they are not foolproof and should not replace close observation for a client who has expressed suicidal ideations and has a plan. Relying solely on a contract in this situation could be dangerous.

Choice D reason: This statement is factual in that medication levels need to be therapeutic; however, it does not directly address the immediate risk of suicide. Constant observation is required regardless of medication levels if a client has verbalized a plan for suicide.

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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

A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

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