A nurse is caring for a client in the outpatient health clinic
For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.
Encourage a regular sleep-wake schedule.
Encourage naps during the day when client is tired.
Encourage client to sleep until later in the morning
Advise client to rise slowly from sitting position.
Advise client to notify provider if pregnant.
Encourage high-calorie finger foods.
Instruct client to avoid foods that have been fermented or aged.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"B"}}
A. Establishing a regular sleep-wake schedule can help regulate circadian rhythms and improve sleep quality, which is beneficial for managing insomnia. B. Napping during the day can disrupt the client's ability to sleep at night, exacerbating insomnia. It's generally recommended to avoid daytime naps for individuals experiencing difficulty sleeping. C. Sleeping in later in the morning can disrupt the client's sleep-wake cycle and contribute to difficulty falling asleep at night. Consistency in sleep-wake times is important for managing insomnia. D. Rising slowly from a sitting position can help prevent orthostatic hypotension, especially for clients taking trazodone, which can cause dizziness or lightheadedness upon standing. E. Trazodone is a medication that may have risks associated with use during pregnancy, so it's important for the client to inform their provider if they are pregnant or planning to become pregnant. F. Loss of appetite is a concern, but encouraging high-calorie finger foods may not address the underlying issue. It's important to address the root cause of the appetite loss and provide appropriate interventions, which may include dietary counseling and addressing stress. G. There is no indication in the scenario that fermented or aged foods would negatively affect the client's condition or interact with trazodone. It's important to focus on addressing the primary concerns of stress, difficulty sleeping, and loss of appetite.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.
Correct Answer is A
Explanation
A. Encouraging the use of assistive devices like canes can help improve stability and prevent falls in individuals with multiple sclerosis who may experience balance issues. This statement promotes safety and independence in mobility.
B. While exercise is beneficial for individuals with multiple sclerosis, recommending a rigorous program may not be appropriate initially and could potentially exacerbate symptoms.
C. Hot baths can exacerbate symptoms in individuals with multiple sclerosis due to heat sensitivity, so this advice may not be suitable.
D. Scatter rugs can pose a tripping hazard, especially for individuals with mobility issues, so this statement is incorrect and may increase the risk of falls.
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