A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

Advise the client that lifestyle changes often take several weeks to be effective.

Determine the amount of weight the client has lost since increasing activity.

Ask the client to describe the exercise schedule that he has been following.

Encourage the client to exercise every day to eliminate bedtime wakefulness.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct action because the nurse should provide realistic expectations and positive reinforcement to the client. Lifestyle changes such as exercise can improve sleep quality and duration, but they may not have immediate effects. The nurse should encourage the client to continue the workout program and follow good sleep hygiene practices.

Choice B reason: This is not the best action because the nurse should focus on the client's sleep problem rather than the weight loss goal. While weight loss can be a benefit of exercise, it is not the primary reason why the client started the workout program. The nurse should not make the client feel that weight loss is the only measure of success.

Choice C reason: This is also not the best action because the nurse should not interrogate the client about the details of the exercise schedule. The nurse should respect the client's autonomy and preferences regarding physical activity. The nurse can offer suggestions or resources to help the client optimize the exercise schedule, but should not imply that the client is doing something wrong.

Choice D reason: This is another incorrect action because the nurse should not encourage the client to exercise every day or close to bedtime. Exercising too frequently or too late can interfere with the body's circadian rhythm and cause sleep problems. The nurse should advise the client to exercise at least three times a week and avoid exercising within three hours of bedtime.

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Correct Answer is B

Explanation

Choice A reason: Requesting a family member to remain with the client is not the best intervention to implement first. It may provide some emotional support, but it does not address the communication barrier. The family member may not be able to translate accurately or objectively, and may have their own biases or emotions.

Choice B reason: Obtaining a staff member who is a bilingual interpreter is the best intervention to implement first. It ensures effective communication and understanding between the nurse and the client. It also respects the client's cultural and linguistic preferences and needs.

Choice C reason: Using drawings that are universal for all cultures is not the most effective intervention to implement first. It may be helpful for some simple concepts, but it may not convey the full meaning or context of the assessment. It may also be misinterpreted or misunderstood by the client.

Choice D reason: Asking for the support of one of the client's friends is not the most appropriate intervention to implement first. It may violate the client's privacy and confidentiality, and may not ensure accurate or unbiased translation. The friend may not be familiar with the medical terminology or the client's condition.

A. Encourage the client to focus on taking deep breaths. B. Tell the client the medication needs more time to work. C. Ask the UAP to offer a backrub to the client. D. Reassess the client and the level of pain.

Correct Answer is D

Explanation

Choice A reason: This is not the best intervention as it does not address the cause of the pain or provide adequate relief. Deep breathing may help the client to relax and cope with the pain, but it is not enough to manage severe pain.

Choice B reason: This is not a true or helpful statement as it may imply that the nurse is dismissing the client's pain or delaying further action. Oxycodone is a fast-acting opioid analgesic that reaches its peak effect within 30 to 60 minutes. If the client is still in severe pain after one hour, the nurse should reassess the pain and notify the healthcare provider.

Choice C reason: This is not the priority intervention as it does not address the cause of the pain or provide adequate relief. A backrub may help the client to relax and distract from the pain, but it is not enough to manage severe pain.

Choice D reason: This is the best intervention as it helps the nurse to evaluate the effectiveness of the medication and the need for further intervention. The nurse should use a valid and reliable pain assessment tool and ask the client about the location, intensity, quality, and duration of the pain. The nurse should also check the client's vital signs and observe for any signs of adverse effects from the medication.

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A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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