The night nurse reports that the client, who is hospitalized with major depressive disorder, has been unable to sleep until late at night.
The client gets up, paces the hallway, wrings their hands, and appears teary.
Which interventions should the nurse advocate to add to the care plan? Select all that apply.
Encourage the client to take naps during the day to make up for lost sleep.
Have the client engage in physical exercise just before bedtime.
Arrange for the client to receive 20 minutes of natural sunlight each day.
Serve the client a glass of warm milk in the evening.
Tell the client to take a warm bath before going to bed.
Correct Answer : C,D,E
Choice A rationale
Encouraging the client to take naps during the day to make up for lost sleep can interfere with normal sleep patterns. Therefore, this is not a recommended intervention.
Choice B rationale
Having the client engage in strenuous physical exercise just before bedtime can increase brain metabolic activity and wakefulness. Hence, this is not a suitable intervention.
Choice C rationale
Arranging for the client to receive at least 20 minutes of natural sunlight each day can improve sleep patterns. This is a recommended intervention.
Choice D rationale
Serving the client a glass of warm milk in the evening can promote comfort and relaxation to aid sleepiness. This is a recommended intervention.
Choice E rationale
Suggesting that the client take a warm bath before going to bed can be a part of a relaxing activity before bedtime. This is a recommended intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. Therapeutic communication in nursing is patient-centered and should involve a holistic approach, including aspects of psychological, physiological, spiritual, and environmental care of the patient.
Choice B rationale
Focusing on the attitude of the client is not the main goal of therapeutic communication. While understanding the client’s attitude can provide valuable insights into their feelings and perspectives, the primary goal is to build a rapport and focus on the client.
Choice C rationale
Focusing on the client and building a rapport is the main goal of therapeutic communication in nursing. It helps nurses build trust with patients while also helping establish collaborative efforts to promote efficient and effective patient care, improving patient outcomes.
Choice D rationale
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The focus should be on the client, their needs, and their experiences.
Correct Answer is B
Explanation
Step 1 is to determine the amount of medication to administer. The order is for Haldol 2mg IM stat. The available medication is Haldol 5mg/ml. To find out how many ml’s to administer, you would divide the ordered dose by the available dose. So, 2mg ÷ 5mg/ml = 0.4 ml.
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