A nurse is assisting in the care of a client who has chronic stress. The client states. i always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime." Which of the following responses should the nurse make?
Exercising right before bed may help you to sleep better."
Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep"?
A glass of wine in the evening is a good way to take the edge off and help you to rest."
You should speak with your provider about prescribing a sedative to help you sleep,
The Correct Answer is B
Explanation:
A. While exercise can be beneficial for promoting sleep, suggesting it right before bedtime may not be the most practical advice, as vigorous exercise close to bedtime can sometimes have the opposite effect.
B. "Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep?"
This response acknowledges the potential issue with using alcohol as a sleep aid and opens the door for further discussion about alternative methods to promote better sleep. Alcohol can disrupt sleep patterns and lead to dependency, so it's important for the nurse to address this concern and explore healthier sleep-promoting strategies.
C. Encouraging the use of alcohol as a way to "take the edge off" is not the best approach, as it may reinforce the client's reliance on alcohol for sleep, which can lead to dependency and other health issues.
D. Suggesting that the client speak with their provider about prescribing a sedative should not be the initial response. It's essential to explore non-pharmacological interventions and lifestyle changes before considering medications, especially sedatives, due to the potential for dependence and side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client taking olanzapine who experiences dizziness upon standing: While dizziness is a potential side effect, it is not as immediately concerning as the symptoms in the client taking clozapine. Orthostatic hypotension is a known side effect of some antipsychotic medications, and the client may need to be assessed for orthostatic changes.
B. A client taking clozapine who has a sore throat and mild fever.
Clozapine is an atypical antipsychotic that can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. A sore throat and mild fever can be early signs of infection, and it's crucial to evaluate the client promptly for any indications of agranulocytosis. Regular monitoring of complete blood counts is essential for clients taking clozapine.
C. A client taking risperidone who has gained 5 lb in 3 weeks: Weight gain is a side effect of many antipsychotic medications, including risperidone. While it's important to monitor weight changes, gaining 5 lb in 3 weeks is not as urgent as potential signs of agranulocytosis in the client taking clozapine.
D. A client taking chlorpromazine who is napping frequently throughout the day: Frequent napping may be related to sedation, a common side effect of chlorpromazine. While it's important to assess and address sedation, it is not as urgent as potential signs of infection or agranulocytosis in the client taking clozapine
Correct Answer is D
Explanation
A. Requesting an appointment to discuss depression is an indication that the client is seeking help, which is a positive step. It does not necessarily indicate an immediate risk of suicide.
B. Stating that they are stopping their medication raises concerns about treatment compliance, but it does not provide a clear indication of suicidal intent. It is important to assess the reasons for discontinuing medication and address any concerns.
C. Sleeping 12 hours a day can be a symptom of depression, but it does not necessarily indicate an immediate risk of suicide. It is crucial to assess the client's overall mental health and functioning.
D. A client who is giving away their possessions.
Giving away possessions can be a warning sign of suicidal intent. This behavior may indicate that the individual is preparing for the possibility of not needing those belongings in the future. It is crucial for the nurse to assess and intervene promptly if a client is exhibiting signs of suicidality.
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