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 A

Explanation

A. The supine position increases the risk of aspiration, where food or liquid could enter the airway and potentially cause aspiration pneumonia. To minimize this risk, the client should be positioned in a semi- Fowler’s position (head of the bed elevated at 30-45 degrees) during feedings.
B. Aspirating gastric residual volumes is a standard practice to check for proper digestion and tolerance of the feeding. Generally, a residual of up to 250-500 mL can be acceptable depending on institutional policy and client condition. This action does not necessarily require intervention unless specific guidelines indicate otherwise.
C. Irrigating the NG tube with tap water is a common practice to ensure the tube remains patent and to help clear any residual feeding material from the tube. Tap water is generally considered acceptable for this purpose, though some facilities may use sterile or distilled water to avoid any potential infections.
D. Administering the feeding through a syringe barrel by gravity is a standard method for intermittent tube feedings. This technique allows the feeding to flow slowly into the stomach without excessive pressure, which can help prevent complications such as nausea or cramping.

A. "I will have a cup of hot cocoa immediately before bedtime." B. I will no longer have a glass of wine before bedtime." C. "I will walk briskly for 30 minutes before bedtime." D. "I will do my muscle relaxation techniques each afternoon."

Correct Answer is B

Explanation

A. Consuming hot cocoa, especially if it contains caffeine or sugar, is generally not advisable before bedtime. Caffeine is a stimulant that can interfere with the ability to fall asleep, and sugar can lead to disruptions in sleep. Even if the hot cocoa is caffeine-free, having a liquid right before bed can cause frequent awakenings during the night.
B. Alcohol can initially make a person feel drowsy, but it often disrupts sleep patterns later in the night, leading to poorer quality sleep. Reducing or eliminating alcohol consumption before bedtime can improve sleep quality and promote better rest.
C. While regular physical activity is beneficial for sleep, exercising too close to bedtime can actually be stimulating and make it harder to fall asleep. It is generally recommended to complete vigorous exercise at least 2-3 hours before going to bed to avoid interfering with sleep.
D. Muscle relaxation techniques, such as progressive muscle relaxation, are effective for reducing stress and improving sleep quality. However, performing these techniques in the afternoon is less beneficial compared to doing them closer to bedtime.

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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 charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

Correct Answer is A

Explanation

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

Correct Answer is B

Explanation

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