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 A

Explanation

A. Hematologic spread: Hematologic spread (through the bloodstream) is a common mechanism for metastasis to distant organs like bones and liver. This is the most likely mechanism for the spread described.

B. Lymphatic circulation: Lymphatic spread often leads to regional lymph nodes rather than distant organs like bones and liver.

C. Invasion: Invasion involves local spread into adjacent tissues but does not typically account for distant metastasis.

D. Angiogenesis: Angiogenesis refers to the formation of new blood vessels to supply the tumor, not the mechanism by which cancer cells spread to distant sites.

A. Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug. B. Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination. C. Advising the client to report weight gain and skin rashes to the health care provider immediately. D. Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects. E. Administering the medication subcutaneously when the client is unable to swallow effectively.

Correct Answer is ["A","B","C","D"]

Explanation

A. Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug. Neuroleptic malignant syndrome (NMS) is a rare but serious adverse effect of antipsychotic medications. Monitoring for NMS, especially during the first few months of treatment, is crucial.

B. Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination. Some antipsychotics, particularly second-generation antipsychotics, are associated with an increased risk of metabolic syndrome, including diabetes. Clients should be educated to report symptoms suggestive of hyperglycemia.

C. Advising the client to report weight gain and skin rashes to the health care provider immediately. Weight gain is a common side effect, particularly with second-generation antipsychotics. Skin rashes could indicate an allergic reaction, including serious conditions like Stevens-Johnson syndrome, requiring immediate medical attention.

D. Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects. The AIMS scale is used to assess for tardive dyskinesia and other extrapyramidal symptoms, which are potential adverse effects of antipsychotic medications.

E. Administering the medication subcutaneously when the client is unable to swallow effectively. Antipsychotic medications are generally not administered subcutaneously. If a client cannot swallow, an alternative route such as intramuscular injection or an orally disintegrating tablet might be used.

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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?

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Naxlex Comprehensive Predictor Exams

A client's most recent diagnostic imaging has revealed that lung cancer has metastasized to the bones and liver. What is the most likely mechanism by which the client's cancer cells spread?

Correct Answer is A

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Correct Answer is ["A","B","C","D"]

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