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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Dental procedures: Fear of dental procedures is more indicative of a specific phobia, not social phobia.
B. Meeting strangers: Social phobia (social anxiety disorder) involves intense fear and anxiety in social situations where one might be judged, embarrassed, or scrutinized by others. Meeting strangers is a common fear for those with social phobia.
C. Being bitten by a dog: This is more consistent with a specific phobia related to animals, not social phobia.
D. Having a car accident: Fear of car accidents is not typically related to social phobia but could be linked to a specific or generalized anxiety disorder.
Correct Answer is D
Explanation
A. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.
B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.
C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.
D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.
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