During the interview of a client, the client states, "I have trouble falling asleep." Which action would be appropriate for a nurse to do next?

Report the finding so a sleep medication can be prescribed.

Clarify what the client means by trouble falling asleep.

Ask the client what they do before going to bed.

Question the client about their use of caffeine.

Answer and Explanation

The Correct Answer is B

A. Report the finding so a sleep medication can be prescribed. While this might eventually be necessary, it's premature to suggest medication without further assessing the problem. Other interventions could be tried first.

B. Clarify what the client means by trouble falling asleep. Clarifying the client's statement is essential to understand the specific nature of the sleep problem, such as how long it takes to fall asleep, how often it occurs, and whether there are any contributing factors. This is a critical step in assessment before any further action.

C. Ask the client what they do before going to bed. This is a good follow-up question, but it should come after clarification of what the client means by trouble falling asleep. Understanding pre-bedtime routines is important but secondary to defining the issue.

D. Question the client about their use of caffeine. While this is a relevant question that could affect sleep patterns, it should follow after understanding the client's specific sleep issues.

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Correct Answer is B

Explanation

A. "I feel like everyone depends on me too much." This statement indicates a sense of responsibility and connection to others, which may not directly indicate suicidal ideation.

B. "Life has lost its meaning for me." This statement is a strong indicator of hopelessness, which is a key risk factor for suicide. The client feels that life is meaningless, which could indicate a desire to end their life.

C. "I wish I could just take a vacation and get away from it all." While this statement may indicate stress or a desire to escape, it does not directly suggest suicidal intent.

D. "I feel like a failure and wish one thing would just go right." This statement indicates frustration and low self-worth, but it doesn't necessarily indicate an immediate risk of suicide as clearly as statement B.

A. Baked chicken B. Bagels C. A factory-sealed box of chocolates D. Fresh fruit basket

Correct Answer is D

Explanation

A. Baked chicken: Baked chicken, if cooked thoroughly, is generally safe for a client with neutropenia (low WBC count) as it does not pose a high risk for infection.

B. Bagels: Bagels, if they are from a safe, uncontaminated source, are generally considered safe for neutropenic clients.

C. A factory-sealed box of chocolates: Factory-sealed chocolates are usually safe as they are unlikely to be contaminated.

D. Fresh fruit basket: Fresh fruits can carry bacteria, especially on the skin or peel, and pose a risk of infection for a client with neutropenia. Therefore, this is the item that should be prohibited.

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During the interview of a client, the client states, "I have trouble falling asleep." Which action would be appropriate for a nurse to do next?

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Naxlex Comprehensive Predictor Exams

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