A nurse in an acute facility is assisting with the development of an in-service about reducing environmental stressors to improve client’s sleep. Which of the following instructions should the nurse include?

Turn on overhead lights briefly when checking IV line

Open curtains between clients semiprivate rooms

Conduct change-of-shift report near the clients’ rooms.

Wear shoes with rubber soles

Answer and Explanation

The Correct Answer is D

A) "Turn on overhead lights briefly when checking IV line.": Turning on overhead lights can disrupt the client’s sleep, especially if done during the night. Light exposure can interfere with the body’s natural circadian rhythm, making it harder for the client to fall asleep and stay asleep. A more appropriate action would be to use a dim light or portable light to minimize disturbance.

B) "Open curtains between clients’ semiprivate rooms.": Opening the curtains between semiprivate rooms could increase noise and visual distractions, which may disturb the client's sleep. Keeping the environment as calm and private as possible is essential to reduce stress and promote restful sleep. Curtains should ideally remain closed to promote privacy and minimize distractions.

C) "Conduct change-of-shift report near the clients’ rooms.": Conducting report near the client's rooms can create unnecessary noise and disturb the client’s sleep. The change-of-shift report should ideally take place in a designated area, away from patient rooms, to reduce noise and disturbances in the environment.

D) "Wear shoes with rubber soles.": Wearing shoes with rubber soles reduces noise when walking, which is particularly important in an acute care setting where patients need rest. Quiet movement helps to maintain a peaceful environment, reducing the environmental stressors that can impact sleep quality for clients.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Fear of abandonment: Clients with borderline personality disorder (BPD) often have an intense fear of abandonment, leading to unstable relationships and emotional outbursts. The client’s fluctuating behavior towards the nurse (from anger to admiration) suggests this pattern.

Emotional instability: BPD is characterized by rapid mood changes and intense emotional reactions. The client displays aggression, impulsivity, and mood shifts, as seen in their outbursts and sudden praise for the nurse.

Incorrect:

Elevated body temperature: Fever is not a characteristic of BPD. It is more commonly associated with infections or inflammatory conditions.

Tactile hallucinations: Hallucinations are more common in psychotic disorders or substance withdrawal rather than BPD.

Increased heart rate: Tachycardia is a physiological response to stress, anxiety, or substance use but is not a defining feature of BPD.

A. "You should expect to have blood work every 6 months while taking this medication." B. *You can safely take this medication if you become pregnant." C. "You might experience swollen gums while taking this medication." D. "You can skip a dose of this medication if you are nauseated."

Correct Answer is C

Explanation

A) "You should expect to have blood work every 6 months while taking this medication.": While it is important for clients on phenytoin to have regular blood work, especially to monitor drug levels and assess for potential side effects (e.g., liver function, complete blood count), the frequency of blood work is typically more frequent than every 6 months. Blood work is often performed at least every 3-6 months, or more frequently if there are concerns about phenytoin levels or side effects. Therefore, this statement is not accurate.

B) "You can safely take this medication if you become pregnant.": Phenytoin is classified as a Category D medication in pregnancy, meaning it has been shown to cause potential harm to the fetus. It is not considered safe during pregnancy, and women who are pregnant or planning to become pregnant should discuss alternative medications with their healthcare provider.

C) "You might experience swollen gums while taking this medication.": Gingival hyperplasia (swelling of the gums) is a common side effect of phenytoin. Clients taking this medication should be aware of this potential side effect and should be instructed on proper oral hygiene and regular dental checkups to help minimize this risk. This statement is accurate and should be included in the teaching.

D) "You can skip a dose of this medication if you are nauseated.": It is important not to skip doses of phenytoin, as maintaining therapeutic levels of the drug is crucial for its effectiveness in preventing seizures. If a client experiences nausea or difficulty taking the medication, they should contact their healthcare provider for guidance rather than skipping doses. Skipping doses could lead to breakthrough seizures.

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A nurse in an acute facility is assisting with the development of an in-service about reducing environmental stressors to improve client’s sleep. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. The nurse is collecting data from the client. Select words from the choices to fill in each blank in the following sentence The nurse should identify that ____ and ____ Indicate manifestations of borderline personality disorder

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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