A nurse is providing teaching to the caretakers of a client who has Alzheimer’s disease with mild cognitive decline. The client is beginning to experience sleep disturbances. Which of the following instructions should the nurse include?

Give the client a cup of hot black tea before bed.

Wake the client at the same time each morning.

Take the client for a walk 2 hours before bedtime each night.

Allow the client to take a 90-minute nap immediately after lunch.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Giving the client a cup of hot black tea before bed is not advisable. Black tea contains caffeine, which can interfere with sleep and exacerbate sleep disturbances. It is important to avoid stimulants before bedtime to promote better sleep quality.

Choice B reason:

Waking the client at the same time each morning helps establish a consistent sleep-wake cycle, which is beneficial for managing sleep disturbances. Regular wake times can help regulate the body’s internal clock and improve overall sleep patterns.

Choice C reason:

Taking the client for a walk 2 hours before bedtime can be beneficial as physical activity can promote better sleep. However, it is not as crucial as maintaining a consistent wake time, which directly influences the sleep-wake cycle.

Choice D reason:

Allowing the client to take a 90-minute nap immediately after lunch may interfere with nighttime sleep. Long naps during the day can reduce the drive to sleep at night, leading to further sleep disturbances.

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Correct Answer is B

Explanation

Choice A reason:

ECT is not contraindicated in clients with psychotic symptoms. In fact, it is often used to treat severe depression with psychotic features, as well as other conditions such as mania and catatonia. ECT can be highly effective in reducing symptoms of psychosis when other treatments have failed.

Choice B reason:

ECT is delivered through electrodes attached to the head. During the procedure, a small amount of electrical current is passed through the brain to induce a controlled seizure, which can help alleviate symptoms of severe depression and other mental health conditions.

Choice C reason:

ECT can be administered to clients with suicidal ideation. It is often considered when rapid symptom relief is needed, such as in cases of severe depression with a high risk of suicide. ECT can provide quick and significant improvement in mood and functioning.

Choice D reason:

ECT is conducted under general anesthesia, not regional anesthesia. General anesthesia ensures that the client is unconscious and does not feel pain during the procedure. Muscle relaxants are also administered to prevent physical convulsions during the induced seizure.

A. Document the client’s behavior once every hour. B. Keep the client in restraints until the prescription expires. C. Conduct a debriefing regarding the client with the unit staff. D. Request an evaluation of the client within 12 hours of application of restraints.

Correct Answer is D

Explanation

Choice A reason: Documenting the client’s behavior once every hour is important for monitoring the client’s condition and ensuring their safety. However, it is not the most immediate action to take after applying restraints.

Choice B reason: Keeping the client in restraints until the prescription expires is not appropriate. Restraints should be used for the shortest duration necessary and should be removed as soon as the client is no longer a threat to themselves or others.

Choice C reason: Conducting a debriefing with the unit staff is important for reviewing the incident and planning future care. However, it is not the immediate action required after applying restraints.

Choice D reason: Requesting an evaluation of the client within 12 hours of applying restraints is crucial. This ensures that the client’s condition is reassessed, and the need for continued restraints is evaluated. It also helps in planning further interventions to manage the client’s aggressive behavior.

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A nurse is providing teaching to the caretakers of a client who has Alzheimer’s disease with mild cognitive decline. The client is beginning to experience sleep disturbances. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

Correct Answer is D

Explanation

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