A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?
Remain with the client.
Give to client a PRN sleeping medication,
Encourage the client to go back to bed.
Explore alternatives to pacing the floor with the client.
The Correct Answer is A
Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.
B. Give the client a PRN sleeping medication:
Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.
C. Encourage the client to go back to bed:
Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.
D. Explore alternatives to pacing the floor with the client:
Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Schedule regular weigh-in times: Monitoring the client's weight on a regular schedule is important in managing anorexia nervosa. It helps track progress and any potential complications related to weight loss.
B. Allow the client to eat at any time: For individuals with anorexia nervosa, there is typically a structured meal plan that is carefully monitored by healthcare professionals. Allowing the client to eat at any time might disrupt the planned nutritional intake.
C. Provide privacy when friends visit: Privacy is important, but it should be balanced with ensuring the client's safety and adherence to the treatment plan. Visitors might need to be supervised to prevent any behaviors that could exacerbate the disorder.
D. Compliment the client for weight gain: While support and encouragement are important, complimenting a client for weight gain might inadvertently reinforce a focus on body image and reinforce disordered eating behavior. It's crucial to provide positive reinforcement for adherence to the treatment plan and progress in recovery, rather than emphasizing weight changes.
Correct Answer is A
Explanation
Lithium is a commonly used medication for treating bipolar disorder, and therapeutic drug monitoring is crucial to ensure its effectiveness and prevent potential toxicity. Monitoring the client's lithium levels in the blood is important because lithium has a narrow therapeutic range, meaning that levels that are too low might not provide the desired therapeutic effect, while levels that are too high can lead to toxicity.
B) "This medication is addictive, so you will need to discontinue it in six months."
Lithium is not considered addictive. It's important to provide accurate information about the nature of the medication to avoid unnecessary concerns.
C) "Weight gain should be reported to your provider as an indication of lithium toxicity."
While weight gain can be a side effect of some medications, it's not a specific indicator of lithium toxicity. Lithium toxicity is characterized by a range of symptoms including tremors, confusion, nausea, vomiting, and excessive thirst, among others.
D) "Your provider may prescribe a diuretic if you have trouble urinating while taking lithium."
Diuretics are generally not recommended with lithium because they can increase the risk of lithium toxicity. Lithium can affect kidney function, and using diuretics may exacerbate this effect. The client should be advised not to use diuretics without consulting their healthcare provider.
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