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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. A desire to initiate conversation with roommates. Clients with depression typically withdraw socially and may not seek to initiate conversations or engage with others.

B. Expansive and dramatic movements. Expansive and dramatic movements are more characteristic of mania, not depression.

C. Decelerated movements and flat affect. Depression often leads to psychomotor retardation, where the client’s movements are slow and their affect is flat, showing a lack of emotional expression.

D. Overly excited interest in the admission. An overly excited interest would be inconsistent with the symptoms of depression, which often include a lack of interest or enthusiasm.

A. Assisting the client with meals B. Placing food on the affected side of the mouth C. Testing the gag reflex before offering food or fluids D. Allowing ample time to eat

Correct Answer is B

Explanation

A. Assisting the client with meals: Assisting the client with meals is appropriate, as clients with dysphagia may need help to ensure safe swallowing and to avoid choking or aspiration.

B. Placing food on the affected side of the mouth: This is contraindicated because placing food on the affected side could increase the risk of choking or aspiration, as the client may not have adequate control over swallowing on the affected side.

C. Testing the gag reflex before offering food or fluids: Testing the gag reflex is appropriate for ensuring that the client has an intact protective reflex before eating or drinking, reducing the risk of aspiration.

D. Allowing ample time to eat: Allowing the client ample time to eat is important to prevent rushing, which could increase the risk of choking or aspiration. It ensures that the client can safely swallow their food.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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