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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. This option is not the most effective strategy for a bowel training program. While regular trips to the toilet can help establish a routine, taking the client to the toilet every 2 hours may be excessive and not tailored to the individual’s natural bowel patterns. This approach does not align with the client’s specific needs or natural urges and may lead to unnecessary discomfort or disruption.
B. Abdominal cramping can be a sign that the client’s bowels are ready to move. Taking the client to the
toilet after they feel abdominal cramping aligns with their natural physiological signals and can be an effective way to manage bowel movements. It helps ensure that the client responds to their body’s cues, which can promote regular bowel habits.
C. For some individuals, having a bowel movement before a meal can be part of a routine if it aligns with their digestive patterns. However, this strategy might not be effective for all clients, as bowel movements are not necessarily influenced by meal times for everyone. The timing might be more
relevant if it fits the individual’s routine or helps establish a regular pattern.
D. Responding to the client’s natural urge to defecate is the most effective way to manage bowel movements. Encouraging the client to use the toilet when they feel the urge helps to establish a natural and responsive routine, which can be more effective in promoting regular bowel habits and preventing constipation.

A. To remove gastric acid that might cause dyspepsia B. To identify delayed gastric emptying C. To determine the client's electrolyte balance D. To confirm the placement of the NG tube

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

Correct Answer is D

Explanation

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 developing a program about strategies to prevent foodborne illnesses for a community group. The nurse should plan to include which of the following recommendations? (Select all that apply)."

A patient presents with urinary incontinence. Which of the following expected findings would the nurse most likely assess?

A nurse at a health fair is assessing the weight status of four clients. Which of the following clients are classified as overweight?

A nurse is reviewing the medication list for a client who has a new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medications?

A nurse is providing dietary teaching to the parents of a newborn who is being breastfed. The nurse should instruct that the transition to whole milk can occur at which of the following ages?

A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion?

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?