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 D

Explanation

Choice A reason:

An illusion is a misinterpretation of a real external stimulus. The client’s statement does not indicate a misinterpretation of reality but rather a direct expression of intent to harm themselves.

Choice B reason:

A hallucination is a perception of something that is not present, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.

Choice C reason:

Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement may draw attention, it is more indicative of a serious risk of self-harm rather than merely seeking attention.

Choice D reason:

Self-mutilation refers to deliberate self-injury without suicidal intent. The client’s statement about using a pen to cut the pain out of their chest indicates a risk of self-harm, which requires immediate intervention to ensure their safety.

A. Hallucinations B. Depression C. Delusions D. Catatonia E. Tinnitus

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason:

Hallucinations, particularly if they are distressing or command hallucinations, can increase the risk of suicide attempts.

Choice B reason:

Depression is a major risk factor for suicide. Clients with a history of depression are at higher risk for attempting suicide again.

Choice C reason:

Delusions, especially those that are paranoid or persecutory, can contribute to suicidal thoughts and behaviors.

Choice D reason:

Catatonia, a state of psychomotor disturbance, can be associated with severe depression and increase the risk of suicide.

Choice E reason:

Tinnitus, while distressing, is not typically a direct risk factor for suicide attempts. It may contribute to overall distress but is not a primary indicator of suicide risk.

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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 caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Correct Answer is D

Explanation

A nurse is caring for a client who has a history of suicide attempts. Which of the following findings places the client at risk for another suicide attempt? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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