A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.
Which of the following interventions is the nurse's priority?

Inquire about the client's bedtime routine.

Recommend that the client go for a walk every morning.

Instruct the client to turn off the television before bedtime.

Encourage the client to listen to soft music at the onset of stress.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Inquiring about the client's bedtime routine is the nurse's priority because it directly addresses the client's reported problem of insomnia due to increased stress. Understanding the client's routine can help identify factors contributing to sleep difficulties and guide the development of an appropriate plan of care.

Choice B rationale:

Recommending that the client go for a walk every morning may be a helpful intervention, but it does not directly address the client's immediate concern of insomnia. It's important to first assess the client's current situation and then provide tailored interventions.

Choice C rationale:

Instructing the client to turn off the television before bedtime is a good sleep hygiene practice, but it may not be the priority when the client is experiencing acute insomnia due to increased stress. The nurse should first gather information about the client's specific situation.

Choice D rationale:

Encouraging the client to listen to soft music at the onset of stress is a useful relaxation technique, but it may not be the priority in this case. The nurse should focus on addressing the client's insomnia by identifying contributing factors and implementing appropriate interventions.

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Correct Answer is D

Explanation

Choice A rationale:

Hyperglycemia is not typically associated with tranylcypromine, a monoamine oxidase inhibitor (MAOI) MAOIs can affect blood pressure regulation, but hyperglycemia is not a common adverse effect of this medication.

Choice B rationale:

Hematuria (blood in the urine) is not a known adverse effect of tranylcypromine. This symptom is not directly related to the use of MAOIs.

Choice C rationale:

Tinnitus (ringing in the ears) is not a common adverse effect of tranylcypromine. MAOIs can affect the cardiovascular system, but tinnitus is not a typical manifestation.

Choice D rationale:

Tranylcypromine, an MAOI, can cause hypertension (high blood pressure) as an adverse effect due to its ability to inhibit the breakdown of tyramine in the body. When tyramine-rich foods are ingested, there can be a sudden release of norepinephrine, leading to a hypertensive crisis. Therefore, monitoring for hypertension is essential when a client is taking tranylcypromine and has ingested tyramine-rich foods.

A. 8 oz fruit yogurt. B. 8 oz raw spinach. C. 8 oz chopped hard-boiled egg. D. 8 oz brown rice.

Correct Answer is C

Explanation

Choice A rationale:

8 oz of fruit yogurt contains protein, but it is not as protein-rich as the other options. Yogurt is more commonly consumed for its probiotic benefits and calcium content.

Choice B rationale:

8 oz of raw spinach contains some protein but is not a high source of protein compared to the other options. Spinach is often chosen for its high iron and fiber content.

Choice C rationale:

8 oz of chopped hard-boiled egg is a significant source of protein. Eggs are well-known for their high-quality protein content.

Choice D rationale:

8 oz of brown rice is not a high source of protein compared to the other options. While it does contain some protein, it is primarily a carbohydrate-rich food.

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A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods.The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

Correct Answer is D

Explanation

A nurse is assisting a client who has cancer to select high-protein foods. Which of the following foods should the nurse recommend as the highest source of protein?

Correct Answer is C

Explanation

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A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.
Which of the following interventions is the nurse's priority?