A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

"Can you describe your bedtime routine to me?"

"Do you have difficulty staying awake when you are driving?"

"Are there any specific factors that you think are affecting your ability to sleep?"

"When did you begin to have trouble sleeping?"

Answer and Explanation

The Correct Answer is B

A.   Understanding the client’s bedtime routine can provide insights into habits that might affect sleep quality, such as engaging in stimulating activities before bed or the absence of a calming pre-sleep routine. However, while useful for identifying lifestyle factors that could impact sleep, this question
B.   This question is highly important because difficulty staying awake while driving can indicate severe sleep disturbances that may pose safety risks. It helps identify whether the client is experiencing excessive daytime sleepiness, which can be a symptom of serious underlying conditions such as sleep apnea or other sleep disorders.
C.   This question aims to identify potential triggers or contributing factors to the client’s insomnia, such as stress, medications, or environmental issues. While this information is valuable for understanding and managing insomnia, it may not immediately address urgent concerns related to the client’s safety or overall well-being.
D.   Understanding the onset of sleep difficulties is important for diagnosing potential causes and determining the duration and pattern of insomnia. This information helps in identifying whether the problem is acute or chronic, but it may not be as immediately critical as addressing potential safety issues related to the client’s sleep disturbances.

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Correct Answer is B

Explanation

A. Measuring gastric residuals is not intended to remove gastric acid or address dyspepsia (indigestion). Instead, residuals help assess the function of the stomach and the effectiveness of the feeding process.
B. Measuring gastric residuals helps determine if the stomach is emptying properly. If residuals are high, it can indicate delayed gastric emptying, which means the stomach is not processing the enteral feedings effectively. This could signal potential issues like gastroparesis or obstruction and may necessitate adjusting the feeding rate or formula, or evaluating the client for other complications.
C. While electrolyte balance is important in overall nutritional care, measuring gastric residuals is not used to assess electrolytes. Instead, it focuses on stomach function and gastric emptying.
D. Confirming the placement of the NG tube is done through other methods, such as aspirating gastric contents and checking pH, or by using imaging techniques. Measuring residuals does not provide information on tube placement but rather on stomach function and feeding tolerance.

A. "Support your body weight on the underarm crutch pads." B. "Look down at your feet before moving the crutches." C. "Place one crutch forward with the opposite foot and then place the second crutch forward followed by the second foot." D. "Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches."

Correct Answer is D

Explanation

A. Crutches should not be used to support body weight under the arms, as this can cause nerve damage or discomfort. Instead, weight should be supported on the hands and arms, with the crutches positioned to support the client’s weight. Proper use involves placing the crutches slightly in front of the feet, with weight supported on the hands, not the underarms.
B. While it's important to be aware of your surroundings, looking down at your feet can be counterproductive as it may affect balance and coordination. The client should maintain an upright posture and look ahead to ensure proper gait and balance while moving. This helps in coordinating the movement of crutches and feet more effectively.
C. In a four-point gait, each crutch and foot move alternately, which is different from the three-point gait. The three-point gait involves moving both crutches and the affected leg forward simultaneously, followed by the unaffected leg.
D. In the three-point gait, the client moves both crutches forward at the same time while keeping the affected leg off the ground or in a non-weight-bearing position. Then, the client swings the unaffected leg forward to step past the crutches. This method ensures that weight is only placed on the unaffected leg while moving.

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A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is B

Explanation

A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching?

Correct Answer is D

Explanation

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