A nurse is caring for a client who reports difficulty falling and remaining asleep. Which of the following actions should the nurse take to promote sleep?
Encourage exercise 1 hr prior to sleep.
Provide a warm cup of coffee 30 min before bedtime.
Turn on the client's television at bedtime.
Encourage the client to take a warm bath before bedtime.
The Correct Answer is D
A. Encourage exercise 1 hr prior to sleep: Vigorous exercise immediately before bedtime can increase alertness and delay sleep onset. Exercise is best scheduled earlier in the day to promote better sleep quality.
B. Provide a warm cup of coffee 30 min before bedtime: Caffeine is a stimulant that can interfere with the ability to fall and stay asleep. Offering coffee close to bedtime is counterproductive to promoting sleep.
C. Turn on the client's television at bedtime: Television and other electronic devices emit light and provide stimulation that can disrupt circadian rhythms and inhibit melatonin release, making it harder to fall asleep.
D. Encourage the client to take a warm bath before bedtime: A warm bath helps relax muscles and promotes a decrease in core body temperature afterward, which can facilitate sleep onset. This is an effective, nonpharmacologic intervention to improve sleep quality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client to rate their pain on a scale of 0 to 10: Pain assessment is the first step in managing pain effectively. Using a standardized pain scale helps determine the severity, effectiveness of the previous dose, and guides subsequent interventions or medication adjustments.
B. Request a prescription for an opioid pain medication for the client: While opioids may be appropriate for breakthrough pain, the nurse must first assess the current pain level and response to prior medication before requesting additional prescriptions. Immediate escalation is premature without assessment.
C. Report this client finding to the provider: Reporting is important if pain persists despite interventions, but initial assessment and documentation of pain severity should precede notifying the provider to provide accurate information.
D. Administer an additional dose of ibuprofen to the client: Administering another dose without verifying timing, maximum daily dosage, or assessing pain response could risk overdose or toxicity. Pain assessment must guide safe medication administration.
Correct Answer is A
Explanation
A. "The test will determine if there is leaking amniotic fluid.": The nitrazine test is used to detect the presence of amniotic fluid in the vagina by measuring pH. A positive result indicates a more alkaline pH, suggesting rupture of membranes. This explanation accurately describes the purpose of the test to the client.
B. "Your bladder should be full prior to me performing this test.": A full bladder is not required for a nitrazine test. In fact, urine can interfere with results because it is acidic and may cause a false-negative reading, so the bladder should not influence the test outcome.
C. "I will be taking a blood sample to test for changes in your hormone levels.": The nitrazine test does not involve blood samples and is unrelated to hormone levels. It is performed using vaginal fluid to detect amniotic fluid, so this statement is inaccurate.
D. "If this test is positive you will be required to have a non-stress test.": A positive nitrazine test indicates ruptured membranes, which may require further assessment, but it does not automatically mandate a non-stress test. Additional evaluation and clinical judgment guide next steps rather than an automatic NST.
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