During the interview of a client, the client states, "I have trouble falling asleep." Which action would be appropriate for a nurse to do next?
Report the finding so a sleep medication can be prescribed.
Clarify what the client means by trouble falling asleep.
Ask the client what they do before going to bed.
Question the client about their use of caffeine.
The Correct Answer is B
A. Report the finding so a sleep medication can be prescribed. While this might eventually be necessary, it's premature to suggest medication without further assessing the problem. Other interventions could be tried first.
B. Clarify what the client means by trouble falling asleep. Clarifying the client's statement is essential to understand the specific nature of the sleep problem, such as how long it takes to fall asleep, how often it occurs, and whether there are any contributing factors. This is a critical step in assessment before any further action.
C. Ask the client what they do before going to bed. This is a good follow-up question, but it should come after clarification of what the client means by trouble falling asleep. Understanding pre-bedtime routines is important but secondary to defining the issue.
D. Question the client about their use of caffeine. While this is a relevant question that could affect sleep patterns, it should follow after understanding the client's specific sleep issues.
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Related Questions
Correct Answer is D
Explanation
A. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. This is not appropriate as it could exacerbate the client’s anxiety rather than alleviate it. The nurse should remain calm and provide reassurance.
B. Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. Leaving the client alone during a panic attack could increase their feelings of fear and isolation, worsening the situation.
C. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. While this information is correct, it does not directly address the client's immediate need for reassurance and safety during the panic attack.
D. Stay with the client, emphasizing that he is safe and that you will remain with him. This is the most appropriate intervention as it provides the client with a sense of safety and security, which is crucial during a panic attack.
Correct Answer is A
Explanation
A. drowsiness: Drowsiness is a common side effect of many antianxiety medications, especially benzodiazepines. This can impair the client’s ability to safely drive or perform tasks requiring alertness, making this the most appropriate choice.
B. confusion: While confusion can occur with some antianxiety drugs, it is less common than drowsiness and typically occurs at higher doses or with prolonged use.
C. behavior changes: Behavior changes can occur but are less common and are not the primary reason for caution with activities requiring mental alertness.
D. sleep disorders: Sleep disorders are not a typical side effect of antianxiety medications; in fact, these drugs are often used to treat sleep disturbances.
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