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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sit with the client for a few minutes. While providing comfort is important, it does not address the immediate need to evaluate and manage a potentially serious condition.
B. Administer an analgesic. Administering analgesics without assessing the cause of the headache might mask symptoms of a serious issue. This is not the priority action.
C. Inform the nurse manager. Informing the nurse manager is important but does not directly address the client’s immediate needs or potential emergency.
D. Call the health care provider immediately. Reporting severe headache in a client with a cerebral aneurysm is critical as it could indicate worsening of the condition, such as aneurysm rupture or increased intracranial pressure. Immediate action is required to prevent further complications.
Correct Answer is B
Explanation
A. Elevated blood glucose: Elevated blood glucose is a common side effect of prednisone due to its glucocorticoid activity. However, this does not indicate the effectiveness of treatment for rheumatoid arthritis.
B. Improved range of motion: Improved range of motion is an indication that the inflammation and pain associated with rheumatoid arthritis are being effectively managed by prednisone, making this the best indicator of treatment effectiveness.
C. Increased blood pressure: Increased blood pressure is another potential side effect of prednisone but does not indicate the effectiveness of the treatment for rheumatoid arthritis.
D. Improved mood: While prednisone can sometimes improve mood, this is not a direct indicator of its effectiveness in treating rheumatoid arthritis.
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