A nurse is caring for an older adult client admitted to the hospital following a cerebrovascular accident. The client's daughter tells the nurse, "I wish I could stay with my father, but I need to go home to my family." Which of the following responses should the nurse make?

Determining if the client has thoughts of self-harm: This is the priority action for the nurse in this situation. Assessing the client's risk of self-harm or suicide is crucial to determine the level of immediate intervention required. It helps identify the severity of the crisis and enables the nurse to implement appropriate measures to ensure the client's safety.

In the context of a client with generalized anxiety disorder who is exhibiting signs of distress and seeking to be taken care of, it is essential to assess for suicidal ideation or intent. Clients with mental health disorders, especially when experiencing high levels of stress, may be at an increased risk of self-harm or suicide. Therefore, it is vital for the nurse to prioritize the assessment of the client's safety and risk of self-harm in order to provide appropriate care and interventions.

Incorrect:

A- Asking the client to identify the cause of the crisis: While it is important to gather information about the cause of the crisis to understand the client's situation, it is not the nurse's priority at this moment. Assessing the client's safety and immediate risk of self-harm takes precedence.

C- Identifying if friends or family are available to help: While social support from friends and family can be valuable in managing a crisis, it is not the nurse's priority in this situation. The immediate concern is to assess the client's safety and risk of self-harm.

D-Identifying the client's coping skills: Assessing the client's coping skills is an important aspect of the overall assessment process, but it is not the priority at this moment. The nurse needs to first ensure the client's safety and address any immediate risks.

Establishing a consistent bedtime routine and sleep schedule can promote better sleep hygiene and help regulate the client's sleep-wake cycle. By getting the client ready for sleep at the same time each night, the nurse helps create a predictable and calming routine that signals to the body that it is time to sleep.

Incorrect:

B. Move the client to a room next to the open nurses' station: This measure may increase noise and disturbances, which can further disrupt the client's sleep. Providing a quiet and peaceful environment is generally more conducive to restful sleep.

C. Encourage the client to take a 1-hour nap each afternoon: While short daytime naps can be beneficial for some individuals, they may interfere with the client's ability to fall asleep or stay asleep at night. It is generally recommended to limit daytime napping, especially if the client is having trouble sleeping at night.

D. Play the client's favorite music in the room while the client is sleeping: While some individuals find soothing music helpful for relaxation and sleep, it is essential to consider the client's preferences. Not everyone finds music helpful for sleep, and it is important to respect the client's preferences and individual needs. Some clients may find silence or white noise more conducive to sleep.