A nurse is caring for a client who has a depressive disorder. The client states, "I don't always go to bed at night, so I get in trouble for falling asleep at work." Which of the following interventions should the nurse recommend?

"Take a 1-hour nap every day."

"Exercise late in the day, preferably before bedtime."

"Keep a sleep diary to promote a consistent sleep schedule."

"Discontinue any medication until your sleep disruption is addressed."

Answer and Explanation

The Correct Answer is C

Choice A reason: Taking a 1-hour nap every day is not recommended for individuals with sleep disruptions, especially due to depressive disorder, as it can further disrupt nighttime sleep patterns.

Choice B reason: Exercising late in the day can be stimulating and may make it harder to fall asleep. It is generally advised to exercise earlier in the day to improve sleep quality.

Choice C reason: Keeping a sleep diary is a beneficial intervention for individuals with sleep disruptions. It can help identify patterns and behaviors that affect sleep and is a step towards establishing a consistent sleep schedule.

Choice D reason: Discontinuing medication without medical advice is not safe. Medications for depressive disorder should be managed by a healthcare provider, especially as abrupt changes can have serious consequences.

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Correct Answer is C

Explanation

Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.

Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.

Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.

Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.

A. "If you attend counseling, you will get your child back." B. "We can ask the physician to prescribe a sedative." C. "Have you thought about harming yourself?" D. "Can a family member try to obtain temporary custody of your child?"

Correct Answer is C

Explanation

Choice A reason: This response is not therapeutic as it provides false assurance and may not be accurate. The return of the child depends on many factors beyond just attending counseling.

Choice B reason: While sedatives may be used to manage acute distress, this response does not address the client's expressed feelings of hopelessness and the risk of self-harm.

Choice C reason: This response directly addresses the client's statement about not wanting to live, which could indicate suicidal ideation. It is important to assess for the risk of self-harm or suicide.

Choice D reason: This response may be helpful in a long-term plan but does not address the immediate risk of harm to the client. It is also not guaranteed that a family member can obtain custody.

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A nurse is caring for a client who has a depressive disorder. The client states, "I don't always go to bed at night, so I get in trouble for falling asleep at work." Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has a substance use disorder. The client states, "The state took my child away after my overdose. I don't want to go on living without them." Which of the following therapeutic responses should the nurse make?

Correct Answer is C

Explanation

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