Author Question: The nurse and the client are discussing possible behaviours that might be interfering with the ... (Read 32 times)

geodog55 · **on:** Jul 22, 2018

The nurse and the client are discussing possible behaviours that might be interfering with the client's ability to fall asleep.

Which of the following assessment questions is most likely to iden-tify possible problems with the client's sleep routine? a. When do you usually retire for the night?
b. What do you do to help yourself fall asleep?
c. How much time does it usually take for you to fall asleep?
d. Have you changed anything about your presleep ritual lately?

Question 2

A 49-year-old client is experiencing problems with depression. She has come to the clinic showing signs of malnutrition and fatigue. Which of the following is the best initial response for the nurse to give in the assessment phase?

a. Your depression is somewhat uncommoncan you tell me what has happened recently to cause it?
b. Have you recently been experiencing menopausal symptoms?
c. Depression is something to expect at your age, and with assistance you will get better.
d. How much weight have you lost over the past month?

nyrave · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the reticular activating system (RAS) decline. If the room is dark and quiet, activation of the RAS further declines. At some point the bulbar synchronizing region (BSR) takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem.
Although the question, When do you usually retire for the night? is not inappropriate, it is not directed toward the cause of the problem.
Although the question, How much time does it usually take for you to fall asleep? is not inap-propriate, it is not directed toward the cause of the problem.
Although the question, Have you changed anything about your presleep ritual lately? is not inappropriate, it is not directed toward the cause of the problem.

Answer to Question 2

B
Hot flashes and insomnia may be severe enough to interfere with activities of daily living, and this client is in the expected age range to be experiencing menopause. The history of fatigue could be related to insomnia.
Depression is not uncommon during menopause.
Depression is not something to expect, although it can occur.
Asking the client about weight loss may be a means to verify depression; however, it is not the best initial response.