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 D

Explanation

A. Chicken broth is a clear liquid and would be appropriate for a clear liquid diet. However, it is not suitable for a full liquid diet because it is a clear liquid and does not represent the expanded options available on a full liquid diet.
B. Cranberry juice is a clear liquid and is appropriate for a clear liquid diet but is not typically included in the full liquid diet. While it is acceptable for hydration, it does not provide the more substantial nutrition options available in a full liquid diet.
C. Flavored gelatin is part of the clear liquid diet but is also compatible with the full liquid diet. It is liquid at room temperature and does not contain solid particles, making it an acceptable option for a full liquid diet.
D. Skim milk is considered a full liquid as it is liquid at room temperature and provides additional nutrients like protein and calcium that are beneficial for recovery. It is a suitable addition when progressing from a clear liquid diet to a full liquid diet.

A. "I should drink about 2 liters of fluid each day." B. "I should not drink alcoholic beverages during my pregnancy." C. "I can have a moderate amount of caffeine daily." D. "I should increase my calcium intake to 1,500 milligrams per day"

Correct Answer is D

Explanation

A. Drinking adequate fluids is essential during pregnancy to support overall health and amniotic fluid levels. A general recommendation is to drink about 2 to 3 liters (8-12 cups) of fluids per day. This includes water, and sometimes other beverages and soups.
B. It is well-established that alcohol consumption during pregnancy is harmful and can lead to serious conditions such as fetal alcohol syndrome. The advice to avoid alcohol entirely during pregnancy is accurate and reflects current medical guidelines.
C. Moderate caffeine consumption is generally considered acceptable during pregnancy. Most guidelines suggest limiting caffeine intake to about 200-300 milligrams per day (equivalent to about 1-2 cups of coffee). This advice is consistent with current recommendations.
D. The recommended daily calcium intake during pregnancy is typically around 1,000 milligrams per day for most pregnant women. An intake of 1,500 milligrams per day is higher than the usual recommendation and may not be necessary unless specifically advised by a healthcare provider for individual circumstances.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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