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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should encourage the client to be assertive. Dependent Personality Disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. One of the treatment goals is to help the client develop assertiveness skills to reduce their dependence on others. Encouraging assertiveness allows the client to express their needs and make decisions for themselves, which is an essential aspect of their therapeutic journey toward independence.
Choice B rationale:
Assuming responsibility for making the client's decisions would not be appropriate. It would further reinforce the client's dependent behavior and hinder their progress towards independence. The goal of therapy is to promote autonomy and self-reliance, not to perpetuate dependency.
Choice C rationale:
Maintaining a verbal no-harm contract with the client may be necessary in some cases, especially if the client exhibits self-harming behaviors. However, it is not a primary teaching point when educating the caregiver about managing a client with Dependent Personality Disorder. The focus should primarily be on helping the client develop assertiveness and self-reliance.
Choice D rationale:
Limiting the client's social interactions is not an appropriate intervention. Social support can be beneficial for individuals with Dependent Personality Disorder, as it can help them build self-confidence and reduce their excessive reliance on one individual. Isolating the client would not be in their best interest.
Correct Answer is B
Explanation
Choice A rationale:
Hospice care is typically recommended for clients with a terminal illness who are no longer seeking curative treatment. It may not be suitable for an older adult with early onset dementia unless their condition is very advanced.
Choice B rationale:
Recommending an adult day care facility is appropriate in this situation. Adult day care centers provide a safe and stimulating environment for older adults who require supervision and socialization during the day. It can be a helpful resource for the client's care while the adult child is at work.
Choice C rationale:
Suggesting a community senior center is a good option for social engagement and activities, but it may not provide the level of supervision and care needed for an older adult with dementia, especially if the adult child works full-time.
Choice D rationale:
Recommending a long-term care facility is a more drastic step and is typically considered when a client's care needs cannot be met at home or in less restrictive settings. It may not be necessary for a client with early onset dementia who still has family support.
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