The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?
Family history of dementia.
Witness to an accident.
Alcohol use.
Inadequate diversional activity.
The Correct Answer is C
A. A family history of dementia may be relevant but is not typically associated with violent nightmares. Alcohol use is more directly related to this symptom.
B. Witness to an accident may be a traumatic experience, but it does not specifically address the symptom of violent nightmares.
C. Alcohol use can contribute to sleep disturbances, including nightmares. Exploring the client's alcohol use is essential in understanding the cause of the nightmares.
D. Inadequate diversional activity is a broad concept and may not be directly related to the specific symptom of violent nightmares.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Explain to the client that her behavior invades the rights of the nursing staff: This approach is confrontational and dismisses the client’s coping mechanism. It does not promote a therapeutic nurse-client relationship.
B. Teach the client strategies to control her obsessive-compulsive behavior: This is not the appropriate time for teaching behavioral strategies, especially when the client is experiencing stress related to an upcoming invasive procedure.
C. Ask the client to explain why she is keeping a detailed record of her nursing care: While this might offer insight, it can come across as intrusive or judgmental. It also shifts the focus away from emotional support.
D. Encourage the client to express her feelings regarding the upcoming procedure: Clients with obsessive-compulsive personality disorder often rely on control and orderliness to manage anxiety. The nurse should recognize that the client’s behavior may be a coping mechanism for procedure-related stress. Encouraging expression of feelings promotes trust and addresses the underlying anxiety.
Correct Answer is B
Explanation
A. Sitting in the chair next to the client may be a supportive action but does not address the immediate concern of the client's behavior.
B. Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, which can guide further interventions.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D. Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.
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