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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While Lactated Ringer's is often used for fluid resuscitation, it doesn't contain the necessary nutrients to replace TPN. It can lead to electrolyte imbalances and other complications if used for extended periods.
B. While Dextrose 10% provides calories, it lacks essential amino acids, electrolytes, and other nutrients found in TPN. Prolonged use can lead to imbalances and nutritional deficiencies.
C. Dextrose 5% in water is a commonly used IV fluid that can be administered temporarily while waiting for the next TPN container. It provides hydration and some calories, but it's important to monitor the client's glucose levels closely.
D. While 0.9% sodium chloride (normal saline) is used for fluid replacement, it can lead to hypernatremia (excess sodium) if used for extended periods, especially in clients receiving TPN.
Correct Answer is D
Explanation
A. A jacket harness is typically used for clients who need more significant support, such as those who are unable to bear weight on their legs. It's not the most appropriate choice for a client who occasionally loses their balance.
B. A four-wheel walker provides more stability than a cane, but it can be difficult for some clients to use, especially those with limited upper body strength.
C. A cane can be helpful for clients who need some support while walking, but it may not provide enough stability for a client who frequently loses their balance.
D. A Galt belt is a wide, padded belt that can be used to assist clients with ambulation. It provides a secure grip without restricting the client's movement and is ideal for clients who occasionally lose their balance.
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