A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

Dizziness reported after initial dose.

A change in the sleep-wake cycle.

Mild sedation.

Somnambulism.

Answer and Explanation

The Correct Answer is D

A)   Incorrect- Dizziness is a common side effect of ramelteon and may occur initially as the body adjusts to the medication. While it's important to monitor and address dizziness, it may not require immediate reporting unless it's severe or persistent.

B)   Incorrect- A change in the sleep-wake cycle is expected when using medications to treat sleep disorders. Ramelteon is designed to help regulate sleep patterns, so a change in the sleep-wake cycle is an anticipated effect.
C)   Incorrect- Mild sedation is a common side effect of ramelteon and is usually well-tolerated.

It's important to educate the client about potential sedation effects and advise them not to engage in activities that require full alertness until they know how the medication affects them.
D) Correct- Somnambulism, also known as sleepwalking, is a potentially dangerous side effect that needs immediate attention from the healthcare provider. The client's safety is at risk due to the potential for injury during sleepwalking episodes.

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Correct Answer is D

Explanation

The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.

Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.

The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.

While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.

A. Check the client's level of consciousness. B. Determine the depth of the slashes. C. Estimate the amount of blood loss. D. Find the object used to cause the injuries.

Correct Answer is A

Explanation

Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.

Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.

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A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?

Correct Answer is A

Explanation

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