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A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?
- A. You should drink a glass of wine 1 hour before you go to bed.
- B. You should eat a meal just prior to bedtime.
- C. You should take a nap after lunch.
- D. You should limit yourself to two caffeinated beverages per day.
Correct Answer: D
Rationale: Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with falling asleep and staying asleep, especially if consumed later in the day. This instruction supports improved sleep quality.
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A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?
- A. I may be more sensitive to the sun while taking this medication.
- B. The medication may cause urinary incontinence.
- C. I may experience a metallic taste while taking this medication.
- D. The medication may cause ringing in my ears.
Correct Answer: A
Rationale: Haloperidol can increase photosensitivity, causing the skin to be more sensitive to sunlight, potentially leading to sunburn. Patients should be advised to use sunscreen and wear protective clothing. This statement shows the client understands a key side effect.
A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse
- A. This baby constantly cries. My partner works all the time
- B. and I can't take any more.' Which of the following responses is the nurse’s priority?
- C. Have you discussed this with your partner.
- D. Do you have a friend who could help you.
- E. Tell me about your baby.
- F. Have you tried any soothing techniques for your baby.
Correct Answer: C
Rationale: Asking about the baby’s current condition immediately assesses safety and well-being, which is the nurse’s priority. This ensures potential risks, like postpartum depression or infant harm, are addressed first.
A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect?
- A. Preoccupation with details.
- B. Manipulative behaviors.
- C. Impulsiveness.
- D. Splitting.
Correct Answer: B
Rationale: Manipulative behaviors are a common finding in individuals with antisocial personality disorder. These individuals often use manipulation to gain control or achieve their own goals without regard for others, aligning with the disorder’s characteristics.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake
- B. and I won't let it take all of my blood.' Which of the following responses should the nurse make?
- C. I don’t see a snake, but that must be scary for you.
- D. I’m using a syringe to obtain your blood, not a snake.
- E. Your provider requires this blood specimen.
- F. You must be mistaken.
Correct Answer: A
Rationale: Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety. This empathetic response supports the client’s emotional state.
A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?
- A. Place a lock at the top of doors leading outside.
- B. Use light restraints while the client is in bed.
- C. Administer an antianxiety medication before bedtime.
- D. Encourage the client to nap during the day.
Correct Answer: A
Rationale: Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety. This is a practical, non-restrictive measure to manage nighttime wandering in Alzheimer’s.