The spouse of a client tells the nurse about the client's ...

[B]

The spouse of a client tells the nurse about the client's twitching and jerking shortly after lying down and says it stops after the client goes into a deep sleep. Which response is the most appropriate from the nurse?
 
  1. Suggest the client see a sleep specialist to obtain medication for restless leg syndrome.
  2. Reassure the spouse that this might be a part of the normal sleep cycle.
  3. Explain that the client should not drink caffeinated beverages immediately before bedtime.
  4. Suggest the client take measures to assist sleepiness, such as sleep in a dark, quiet room.

Question 2

The client is diagnosed with post-traumatic stress disorder (PTSD). What will the nurse assess in this client?
 
  Standard Text: Select all that apply.
  1. Tachycardia
  2. Extreme nervousness or panic attacks
  3. A fear of crowds
  4. A fear of exposure to germs
  5. Hallucinations, nightmares, or flashbacks

[flexer1n1]

Answer to Question 1

Correct Answer: 2
Rationale 1: Since the twitching stops after the client falls into a deep sleep, restless leg syndrome is not likely a concern.
Rationale 2: During Stage I of NREM sleep, muscle twitches and jerks are normal.
Rationale 3: Drinking caffeinated beverages immediately before bedtime might cause difficulty getting to sleep, but that does not address the muscle twitches and jerks.
Rationale 4: Taking measures to assist in going to sleep will not reduce the twitches and jerks.
Global Rationale: During Stage I of NREM sleep, muscle twitches and jerks are normal. Since the twitching stops after the client falls into a deep sleep, restless leg syndrome is not likely a concern. Drinking caffeinated beverages immediately before bedtime might cause difficulty getting to sleep, but that does not address the muscle twitches and jerks. Taking measures to assist in going to sleep will not reduce the twitches and jerks.

Answer to Question 2

Correct Answer: 1,2,5
Rationale 1: Tachycardia is a symptom of post-traumatic stress disorder.
Rationale 2: Extreme nervousness or panic attacks are symptoms of post-traumatic stress disorder.
Rationale 3: A fear of crowds is typical in social anxiety disorder.
Rationale 4: A fear of exposure to germs is typical of obsessive-compulsive disorder.
Rationale 5: In post-traumatic stress disorder, the person reexperiences traumatic events, which can take the form of nightmares, hallucinations, or flashbacks.
Global Rationale: Tachycardia and extreme nervousness or panic attacks are symptoms of post-traumatic stress disorder. In post-traumatic stress disorder, the person reexperiences traumatic events, which can take the form of nightmares, hallucinations, or flashbacks. A fear of crowds is typical in social anxiety disorder. A fear of exposure to germs is typical of obsessive-compulsive disorder.

[B]

Gracias!

[tranoy]

Excellent