A nurse is caring for a client who is receiving inpatient treatment for an eating disorder. The client states, "I just can't sleep soundly here because it's too noisy." Which of the following actions should the nurse take?

Tell the client that they will eventually get used to people talking at night.

Recommend that the client try to sleep during the day when it is quieter.

Keep conversations and activities to a minimum during the nighttime.

Turn on the client's television at night to cover up environmental noises.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Telling the client that they will eventually get used to people talking at night is not a supportive or effective response. It dismisses the client's current discomfort and does not address the immediate issue of noise disrupting their sleep. Clients in inpatient treatment for eating disorders often have heightened sensitivity to their environment, and dismissing their concerns can increase stress and anxiety.

Choice B reason:
Recommending that the client try to sleep during the day when it is quieter is not practical. It disrupts the client's natural circadian rhythm and can lead to further sleep disturbances. Encouraging a regular sleep schedule at night is more beneficial for overall health and recovery.

Choice C reason:
Keeping conversations and activities to a minimum during the nighttime is the most appropriate action. This approach directly addresses the client's concern about noise and helps create a quieter, more restful environment. Reducing noise levels at night can significantly improve sleep quality for clients in inpatient settings.

Choice D reason:
Turning on the client's television at night to cover up environmental noises is not advisable. While it might mask some noise, it can also introduce new disturbances and prevent the client from achieving deep, restorative sleep. The light and sound from the television can interfere with the body's natural sleep processes.

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Correct Answer is A

Explanation

Choice A reason:
Implementing seizure precautions is a critical intervention for a client with a history of alcohol use disorder who is admitted while intoxicated. Alcohol withdrawal can lead to seizures, which can be life-threatening. Seizure precautions include maintaining a safe environment, having emergency medication and equipment ready, and monitoring the client closely for signs of seizure activity.

Choice B reason:
Monitoring for orthostatic hypotension is important, especially if the client is experiencing withdrawal symptoms, as dehydration and electrolyte imbalances can occur. However, it is not as immediately critical as implementing seizure precautions for a client who is currently intoxicated.

Choice C reason:
Administering methadone hydrochloride is not an appropriate intervention for alcohol intoxication or withdrawal. Methadone is used for opioid use disorder, not alcohol use disorder, and could be harmful if given to a client with alcohol intoxication.

Choice D reason:
Acidifying the client's urine is not a standard intervention for alcohol intoxication or withdrawal. This intervention is more commonly associated with managing certain drug overdoses or poisonings to increase the elimination of the substance.

A. Allow the client to focus on the delusion for as long as they want. B. Reinforce the importance of controlling impulses with the client. C. Contradict the client's delusional beliefs. D. Ask the client to describe their beliefs about the delusion.

Correct Answer is D

Explanation

Choice A reason:
Allowing the client to focus on the delusion for as long as they want is not recommended. This approach can reinforce the delusion and make it more entrenched. It is important to engage the client in reality-based activities and conversations to help them connect with the world around them.

Choice B reason:
Reinforcing the importance of controlling impulses is a general strategy that can be beneficial for clients with schizophrenia. However, it does not directly address the issue of delusions. Impulse control is more about managing behaviors that could be harmful or disruptive.

Choice C reason:
Contradicting the client's delusional beliefs can be confrontational and may lead to increased anxiety or aggression. It is generally not effective to argue with a client about their delusions because these beliefs are very real to them. The nurse should acknowledge the client's experience without agreeing with the delusion.

Choice D reason:
Asking the client to describe their beliefs about the delusion can be a therapeutic approach. It allows the nurse to understand the client's perspective and build a therapeutic relationship based on empathy and trust. This approach does not validate the delusion but rather opens a dialogue that can be used to gently challenge the delusion with evidence from the client's environment.

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A nurse is caring for a client who is receiving inpatient treatment for an eating disorder. The client states, "I just can't sleep soundly here because it's too noisy." Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing a delusion. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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