A nurse is assessing a client's sleep-wake patterns during an initial clinic visit. Which of the following findings should the nurse report to the provider?

The client reports frequently having a headache in the morning.

The client reports having vivid dreams about their childhood.

The client reports taking 30 min to fall asleep on average.

The client reports sleeping about 7 hr on average.

Answer and Explanation

The Correct Answer is A

A. The client reports frequently having a headache in the morning: Frequent morning headaches can indicate sleep-related issues such as sleep apnea or bruxism (teeth grinding), both of which can significantly affect sleep quality and overall health.

B. The client reports having vivid dreams about their childhood: Vivid dreams can occur naturally, especially during rapid eye movement (REM) sleep. Although they may be unusual, they are not typically a cause for concern.

C. The client reports taking 30 min to fall asleep on average: Taking up to 30 minutes to fall asleep is within normal limits for most people. This is not a concerning finding and does not necessarily require reporting unless the client is experiencing other sleep disturbances.

D. The client reports sleeping about 7 hr on average: Sleeping around 7 hours per night is considered within the normal range for most adults. This is generally adequate sleep, and there is no indication of a significant issue that would require reporting to the provider.

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Correct Answer is A

Explanation

A. "Would you like to discuss other treatment options with your provider?": This response invites the client to express concerns and explore alternative treatments. It shows respect for their preferences and promotes a collaborative decision-making process.

B. "Regular monitoring is not difficult and will ensure that you remain healthy.": This response downplays the client’s concerns and could be seen as dismissive. It focuses more on the ease of monitoring than addressing the client’s discomfort.

C. "Your provider wants you to take this medication.": Using authority to justify medication may cause the client to feel coerced rather than involved in their treatment. This doesn’t address their concerns and may erode trust.

D. "Why don't you want to undergo monitoring?": Asking why could put the client on the defensive and may make them feel judged. It doesn’t foster open communication or understanding of the client’s concerns.

A. Slowly pull the catheter out of urethral canal. B. Don clean gloves. C. Withdraw the solution from the balloon. D. Dry the perineal area. E. Attach the syringe to the balloon injection port.

Correct Answer is B,E,C,A,D

Explanation

B. Don clean gloves: The nurse should first don clean gloves to ensure proper hygiene and to reduce the risk of infection during the procedure. This protects both the client and the nurse from any potential contamination.

E. Attach the syringe to the balloon injection port: After gloves are on, the next step is to attach the syringe to the balloon injection port of the catheter. This is the part where sterile fluid (usually saline) was used to inflate the balloon that keeps the catheter in place.

C. Withdraw the solution from the balloon: Once the syringe is attached, the nurse slowly withdraws the fluid from the balloon. This is necessary to deflate the balloon, which allows the catheter to be removed easily and without causing injury to the urethral canal.

A. Slowly pull the catheter out of urethral canal: After the balloon is deflated, the nurse gently and slowly pulls the catheter out of the urethral canal. This should be done carefully to avoid causing trauma to the urethra and surrounding tissues. The catheter should be removed in a smooth, controlled motion.

D. Dry the perineal area: After the catheter is removed, the nurse should clean and dry the perineal area to ensure hygiene. This step helps prevent skin irritation and infection after the catheter removal, ensuring that the area is properly cared for and free of moisture.

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A nurse is assessing a client's sleep-wake patterns during an initial clinic visit. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for warfarin. The client states, "I don't want to take that medication because I don't want to have to undergo any kind of monitoring." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is B,E,C,A,D

Explanation

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