A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?

"You should drink a glass of wine 1 hour before you go to bed."

"You should take a nap after lunch."

"You should eat a meal just prior to bedtime."

"You should limit yourself to two caffeinated beverages per day."

Correct choice is D

Answer and Explanation

The Correct Answer is D

A.   Consuming alcohol close to bedtime can disrupt sleep patterns. While alcohol may initially induce drowsiness, it often leads to fragmented and poor-quality sleep later in the night. Therefore, advising the client to drink alcohol before bedtime is not recommended.
B.   Taking long or late-afternoon naps can interfere with nighttime sleep patterns, especially for individuals experiencing insomnia or sleep disturbances related to depression. Napping can make it harder to fall asleep or stay asleep at night, thereby exacerbating sleep problems rather than improving them.
C.   Eating a large or heavy meal just before bedtime can lead to discomfort, indigestion, and even heartburn, which can interfere with falling asleep and staying asleep. It's generally advisable to avoid heavy meals close to bedtime to promote better sleep quality.
D.   Caffeine is a stimulant that can interfere with sleep. Consuming caffeinated beverages, especially in the afternoon or evening, can make it difficult for individuals with depression to fall asleep and can contribute to fragmented sleep. Limiting caffeine intake earlier in the day can help promote better sleep hygiene.

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Correct Answer is C

Explanation

A. Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B. When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C. Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D. Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

A. Excessively anxious B. Exploitive of others C. Withdrawn behaviors D. Blunted affect

Correct Answer is B

Explanation

A. This is not typically associated with antisocial personality disorder. People with ASPD often exhibit a lack of remorse and guilt, and they may be prone to impulsive and risk-taking behaviors rather than excessive anxiety.
B. Exploitation of others is a hallmark feature of antisocial personality disorder. Individuals with ASPD may manipulate, exploit, or deceive others for personal gain without regard for others' feelings or rights.
C. Withdrawn behaviors, where individuals tend to isolate themselves or avoid social interactions, are not characteristic of antisocial personality disorder. In fact, individuals with ASPD tend to be socially charming and may seek out social situations to manipulate or exploit others.
D. Blunted affect refers to a reduced emotional expression, which is not typically a prominent feature of antisocial personality disorder. Individuals with ASPD may exhibit superficial charm and can be engaging, although they may lack empathy or genuine emotional responsiveness.

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A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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