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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A reason: Reviewing the advanced directive document is not the priority action. The nurse should first intervene to clear the airway and prevent aspiration of vomitus.
Choice B reason: Elevating the head of the bed 45 degrees is a good practice, but it is not sufficient to relieve the choking. The nurse should also perform suctioning to remove the vomitus from the mouth and throat.
Choice C reason: Performing oropharyngeal suctioning is the best action as it helps to clear the airway and prevent aspiration of vomitus. The nurse should use a Yankauer suction catheter and apply intermittent suction while moving the catheter around the mouth and throat.
Choice D reason: Irrigating the nasogastric tube with water is not appropriate as it may worsen the vomiting and choking. The nurse should stop the enteral feeding and clamp the tube until the client's condition is stabilized.
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