A nurse is caring for a client in the outpatient health clinic.
Encourage naps during the day when client is tired.
Advise client to rise slowly from sitting position.
Instruct client to avoid foods that have been fermented or aged.
Encourage client to sleep until later in the morning.
Encourage a regular sleep-wake schedule.
Advise client to notify provider if pregnant.
Encourage high-calorie finger foods.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}
Rationale:
• Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep quality and reduce trazodone’s effectiveness in reestablishing a normal sleep pattern.
• Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension, particularly when therapy is initiated. Educating the client to change positions slowly helps prevent dizziness and potential falls caused by sudden drops in blood pressure.
• Instruct client to avoid foods that have been fermented or aged: This instruction applies to MAOIs due to the risk of hypertensive crisis from tyramine, but trazodone is a serotonin antagonist and reuptake inhibitor, not an MAOI.
• Encourage client to sleep until later in the morning: Oversleeping disrupts the circadian rhythm and may worsen fatigue. The goal is to maintain a stable sleep-wake cycle to enhance mood and energy regulation.
• Encourage a regular sleep-wake schedule: Establishing consistent sleep routines supports trazodone’s sedative effects and helps regulate the client’s circadian rhythm, improving overall sleep quality without disrupting normal activity patterns.
• Advise client to notify provider if pregnant: Trazodone is classified as pregnancy category C, meaning potential fetal risks exist. The client should notify the provider to evaluate the safety of continuing or adjusting medication during pregnancy.
• Encourage high-calorie finger foods: The client’s BMI has decreased, and trazodone may cause appetite suppression. Offering convenient, calorie-dense snacks helps maintain adequate nutrition and prevents further weight loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.
B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.
C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.
D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices
• Compartment syndrome: The child’s nondisplaced midshaft fracture of the radius and ulna places them at risk for compartment syndrome, whereby increased pressure within the muscle compartments impairs circulation and tissue perfusion. Early recognition is crucial to prevent permanent nerve or muscle damage.
• Paresthesia: The child reports tingling in the fingers, which indicates nerve involvement or compression—an early warning sign of compartment syndrome. Monitoring for paresthesia helps the nurse identify worsening neurovascular compromise promptly.
Rationale for Incorrect Choices
• Osteomyelitis: Infection of the bone is unlikely immediately after a closed nondisplaced fracture without open wounds or surgical intervention. There is no evidence of systemic infection at this stage.
• Nonunion: Fracture nonunion is a long-term complication that occurs if healing fails over weeks to months. The child’s fracture is recent, so immediate risk is low.
• Physical damage: While trauma caused the fracture, “physical damage” is a broad term and does not specify a complication requiring acute monitoring.
• Ecchymosis: Bruising indicates soft tissue injury but does not predict compartment syndrome or other severe complications.
• Type of fracture: While important for diagnosis and treatment planning, the fracture type (nondisplaced) does not directly indicate the acute risk for neurovascular compromise.
• Location of fracture: The midshaft location contributes to fracture management but is not as clinically relevant as the early signs of compartment syndrome, such as paresthesia.
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