A nurse is caring for a client in the outpatient health clinic
For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.
Encourage a regular sleep-wake schedule.
Encourage naps during the day when client is tired.
Encourage client to sleep until later in the morning
Advise client to rise slowly from sitting position.
Advise client to notify provider if pregnant.
Encourage high-calorie finger foods.
Instruct client to avoid foods that have been fermented or aged.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"B"}}
A. Establishing a regular sleep-wake schedule can help regulate circadian rhythms and improve sleep quality, which is beneficial for managing insomnia. B. Napping during the day can disrupt the client's ability to sleep at night, exacerbating insomnia. It's generally recommended to avoid daytime naps for individuals experiencing difficulty sleeping. C. Sleeping in later in the morning can disrupt the client's sleep-wake cycle and contribute to difficulty falling asleep at night. Consistency in sleep-wake times is important for managing insomnia. D. Rising slowly from a sitting position can help prevent orthostatic hypotension, especially for clients taking trazodone, which can cause dizziness or lightheadedness upon standing. E. Trazodone is a medication that may have risks associated with use during pregnancy, so it's important for the client to inform their provider if they are pregnant or planning to become pregnant. F. Loss of appetite is a concern, but encouraging high-calorie finger foods may not address the underlying issue. It's important to address the root cause of the appetite loss and provide appropriate interventions, which may include dietary counseling and addressing stress. G. There is no indication in the scenario that fermented or aged foods would negatively affect the client's condition or interact with trazodone. It's important to focus on addressing the primary concerns of stress, difficulty sleeping, and loss of appetite.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.
Correct Answer is C
Explanation
A. Transdermal nicotine patches should be applied immediately after removal from the protective pouch, but waiting for up to 1 hour is acceptable according to most manufacturers' instructions.
B. Shaving hairy areas of skin is not necessary prior to applying a transdermal nicotine patch and may cause skin irritation.
C. Wearing gloves during the application of the transdermal nicotine patch helps to prevent nicotine absorption through the nurse's skin and reduces the risk of accidental exposure.
D. The nurse should properly dispose of the previous patch according to facility protocols rather than placing it in a tissue, as used nicotine patches can still contain active medication and pose a risk of exposure.
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