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 C
Explanation
A. Comprehend spoken words: This is part of global aphasia, but it does not fully encompass the deficits associated with this condition. Global aphasia involves more extensive language impairment.
B. Form words that are understandable: This is part of global aphasia, but it alone does not fully capture the severity of the language deficit, as it also includes comprehension issues.
C. Form words that are understandable or comprehend spoken words: Global aphasia is the most severe form of aphasia, characterized by profound impairment in both the ability to produce understandable speech and comprehend spoken language. This choice accurately reflects the full scope of the language deficits in global aphasia.
D. Speak at all: Clients with global aphasia may still attempt to speak, but their speech is typically not understandable and is often meaningless. Therefore, saying they cannot "speak at all" is not entirely accurate.
Correct Answer is D
Explanation
A. Most restrictive: A most restrictive environment may not be necessary if the client does not require intensive supervision or care.
B. Least restrictive: A least restrictive environment is generally preferred if the client can function with less supervision and support. It supports independence while providing necessary care.
C. Nursing home: A nursing home may be appropriate for clients needing extensive care, but it is often more restrictive than needed for clients who do not require 24-hour nursing care.
D. Transitional care unit: A transitional care unit is designed to support clients transitioning from hospital to home or other settings, which may be suitable if the client needs further rehabilitation or adjustment.
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