A nurse is caring for a client who states, "I have been having trouble sleeping for the last several months." Which of the following responses should the nurse make?
"You should avoid stressful activities prior to going to sleep."
"You should plan to exercise 2 hours before going to sleep."
"You should take a 2-hour nap during the afternoon."
"You should relax by watching a television show in bed before going to sleep."
The Correct Answer is A
Choice A reason: Engaging in stressful activities before bedtime can increase alertness and make it difficult to fall asleep. The nurse's recommendation to avoid stress before sleep is in line with good sleep hygiene practices that promote relaxation and readiness for sleep.
Choice B reason: Exercising too close to bedtime can be stimulating and may hinder the ability to fall asleep. It is generally recommended to finish exercising at least 3 hours before bedtime to allow the body to wind down.
Choice C reason: Taking long naps, especially in the afternoon, can disrupt nighttime sleep patterns. For individuals with insomnia, it is better to avoid naps or limit them to early in the day and for short durations.
Choice D reason: Watching television in bed can negatively impact sleep due to the light from the screen and the content, which can be stimulating. It is recommended to keep the bedroom environment conducive to sleep, which means no screens before bedtime.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement may seem supportive, but it does not address the immediate safety concerns for a client with suicidal ideations and a verbalized plan. Submitting a request for privacy does not mitigate the risk of harm the client may pose to themselves.
Choice B reason: This is the most appropriate response because it directly addresses the safety of the client, which is the primary concern in this situation. It communicates care and concern while also reinforcing the need for observation due to the risk of suicide.
Choice C reason: While safety contracts can be a part of a comprehensive treatment plan, they are not foolproof and should not replace close observation for a client who has expressed suicidal ideations and has a plan. Relying solely on a contract in this situation could be dangerous.
Choice D reason: This statement is factual in that medication levels need to be therapeutic; however, it does not directly address the immediate risk of suicide. Constant observation is required regardless of medication levels if a client has verbalized a plan for suicide.
Correct Answer is B
Explanation
Choice A reason: Decreased taste is not commonly associated with olanzapine. While some antipsychotic medications can cause changes in sensory experiences, taste reduction is not a typical side effect of olanzapine.
Choice B reason: Increased thirst can be a side effect of olanzapine, as it can cause hyperglycemia, which in turn may lead to polydipsia, or increased thirst. It's important for the nurse to ask about thirst to monitor for potential underlying issues like diabetes.
Choice C reason: Unintentional weight loss is generally not associated with olanzapine. In fact, weight gain is a more common side effect of this medication, so losing weight without trying would be unusual and warrant further investigation.
Choice D reason: Ringing in the ears, or tinnitus, is not a reported side effect of olanzapine. If a patient experiences this symptom, it would likely be related to another condition or medication.
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