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 B
Explanation
A: Placing the bedside table at the foot of the bed may not directly reduce the risk of injury for a client with dementia.
B: Assisting the client to the toilet frequently can prevent falls and accidents associated with incontinence, which are common concerns for clients with dementia.
C: Raising the side rails up can potentially increase the risk of injury if the client attempts to climb over them, leading to falls or entrapment.
D: Keeping the television on during the night may not directly address the risk of injury for the client.
Correct Answer is A
Explanation
A. Setting a routine, including a toileting schedule, helps manage incontinence and reduces confusion and anxiety for a client with dementia. Regular schedules provide structure and can improve cooperation and quality of life.
B. Simplifying clothing with easy fasteners like Velcro instead of buttons and zippers can help maintain independence in dressing for a person with dementia.
C. Physical activity should be encouraged as it can help reduce agitation, improve mood, and promote better sleep patterns.
D. Excessive sensory stimulation can be overwhelming and confusing for clients with dementia; activities should be calming and familiar.
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