A nurse in a long-term care facility is caring for a client who has dementia and reports difficulty falling asleep at night. Which of the following actions should the nurse take to promote adequate rest?

Schedule the client for a morning group fitness class at the facility.

Limit the client to no more than four caffeinated beverages a day.

Walk around the hallway with the client an hour before bedtime

Allow the client several hours in the afternoon to take a nap

Answer and Explanation

The Correct Answer is A

A. Schedule the client for a morning group fitness class at the facility: Regular morning exercise promotes healthy sleep patterns by helping regulate the body's circadian rhythm. Engaging in physical activity early in the day can reduce restlessness at night.

B. Limit the client to no more than four caffeinated beverages a day: While caffeine should be limited, the most effective approach is to avoid caffeine entirely in the afternoon and evening to prevent sleep disruption, rather than just limiting it to four beverages a day.

C. Walk around the hallway with the client an hour before bedtime: Although light physical activity can promote sleep, intense exercise or walking too close to bedtime can sometimes increase alertness and make it harder for the client to fall asleep.

D. Allow the client several hours in the afternoon to take a nap: Long naps, especially in the afternoon, can disrupt the client's sleep cycle and make it more difficult for them to fall asleep at night. Limiting naps during the day is typically more helpful.

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Correct Answer is D

Explanation

A. Aspiration: Succinylcholine is used during electroconvulsive therapy (ECT) to induce muscle relaxation, but it does not specifically prevent aspiration. Aspiration risk is generally minimized by using an endotracheal tube and appropriate airway management during the procedure, not just succinylcholine.
B. Decreased heart rate: Succinylcholine is not used to manage heart rate. While ECT can cause heart rate fluctuations, other medications, like atropine, are typically used if bradycardia is a concern.
C. Elevated blood pressure: Succinylcholine does not address blood pressure regulation. ECT can cause temporary increases in blood pressure, but succinylcholine is used to relax muscles and does not manage blood pressure.
D. Muscle distress: Succinylcholine is given during ECT to relax muscles and prevent muscle contractions or "muscle distress" during the procedure. Without muscle relaxation, muscle contractions during the procedure could cause injury or severe discomfort.

A. Provide information to the client about local support groups. B. Ask the client how they have dealt with stress in the past. C. Determine if the client is experiencing thoughts of self-harm D. Schedule a follow up visit with the client's primary provider.

Correct Answer is C

Explanation

A. Provide information to the client about local support groups: While this is helpful, it is not the first priority. The client's immediate safety and emotional well-being must be addressed first, especially to rule out any thoughts of self-harm or suicidal ideation.

B. Ask the client how they have dealt with stress in the past: While understanding past coping strategies is important, the first priority should be assessing for immediate risks, such as thoughts of self-harm, before discussing past coping mechanisms.

C. Determine if the client is experiencing thoughts of self-harm: This is the first priority. After an assault, clients are at increased risk for self-harm or suicide. The nurse must assess for these thoughts immediately to ensure the client's safety.

D. Schedule a follow-up visit with the client's primary provider: Scheduling follow-up care is important, but it is not the first step. Immediate assessment for safety, including thoughts of self-harm, should take precedence.

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A nurse in a long-term care facility is caring for a client who has dementia and reports difficulty falling asleep at night. Which of the following actions should the nurse take to promote adequate rest?

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Naxlex Comprehensive Predictor Exams

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Explanation

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