A client presents to the clinic reporting high stress at work, constant headache, and having difficulty falling asleep at night. Over the counter and herbal sleep medications have not worked. The client requests medication to help promote sleep. Which intervention should the nurse implement to initiate a plan of care?

Recommend taking a nap for 15 minutes after lunch.

Encourage the client to eliminate stressful situations.

Determine the client's sleep and activity pattern.

Obtain a PRN prescription to be taken for stress.

Answer and Explanation

The Correct Answer is C

A.   While napping can be beneficial for some people, a nap of 15 minutes may not address the root causes of the client’s sleep difficulties, such as stress and chronic headaches. Additionally, napping during the day can sometimes interfere with nighttime sleep.
B.   Reducing or eliminating stressful situations is a valuable goal for improving overall well-being and sleep quality. However, this recommendation is often not immediately actionable or practical, as stressors in life can be difficult to eliminate completely. It’s more effective to focus on identifying and managing stress through practical and immediate interventions.
C.   Assessing the client's sleep and activity patterns is a critical step in identifying potential causes of sleep disturbances. Understanding the client’s current sleep habits, daily routines, and factors affecting their sleep can help in developing an effective plan of care.
D.   While medication might be necessary for some clients, it should not be the first line of intervention without a thorough assessment. PRN (as needed) medications for stress might not address the root causes of sleep issues and could potentially lead to dependence or other side effects.

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Correct Answer is ["A","B","C"]

Explanation

A. Escorting the client back to their room is a direct and immediate intervention that ensures the client is safely returned to a controlled environment. This action helps prevent further wandering and reduces the risk of falls or accidents.
B. Securing a bed alarm is a preventive measure that helps alert staff if the client attempts to get out of bed. This can be particularly useful for clients who are confused or at risk of wandering. The alarm provides an early warning to intervene before the client leaves the bed, thereby enhancing their safety and reducing the risk of falls.
C. Orienting the client helps them become more aware of their environment and can reduce confusion. Providing verbal cues and reassuring the client about their location and time can be beneficial in calming them and helping them to recognize where they are.
D. Raising all four side rails can be considered a form of restraint and is generally not recommended unless absolutely necessary and with appropriate justification. It can lead to increased risk of injury if the client tries to climb over the rails or if there is an emergency.
E. Closing the client’s room door can be a safety measure to prevent them from wandering out into other areas of the facility. However, it is crucial to ensure that the client is not left feeling isolated or trapped.

A. Over the cheeks. B. Around the nostrils. C. Across the forehead. D. Bridge of the nose. E. Tops of the ears.

Correct Answer is ["A","B","D","E"]

Explanation

A. The cheeks can be affected by the nasal cannula, especially if it is not positioned properly or if it causes irritation over time.
B. The area around the nostrils is one of the most common sites for skin damage related to nasal cannulas. Continuous contact with the cannula can cause irritation, redness, or even sores in this area.
C. The nasal cannula itself does not typically make contact with the forehead. Therefore, skin damage across the forehead is not generally a concern related to the use of a nasal cannula.
D. The bridge of the nose is a key area to inspect for skin damage. The nasal cannula’s prongs often rest on or near the bridge of the nose, which can lead to pressure sores, redness, or irritation in this area. Regular assessment is important to prevent and address any damage.
E. The tops of the ears can be affected if the nasal cannula’s tubing or securing mechanism (such as behind-the-ear supports or loops) causes friction or pressure. Skin breakdown can occur in this area if the cannula is not properly adjusted or if it causes irritation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

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The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?