A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

Encourage the client to ambulate in the hallway 1 hr before bedtime.

Tell the client to avoid drinking fluids 1 hr before bedtime.

Schedule routine care tasks during hours when the client is awake.

Advise the client to leave the television in the room on when trying to fall asleep.

Answer and Explanation

The Correct Answer is C

A. Encourage the client to ambulate in the hallway 1 hr before bedtime - While light exercise during the day can promote better sleep, exercising close to bedtime can actually disrupt sleep.

B. Tell the client to avoid drinking fluids 1 hr before bedtime - While limiting fluids close to bedtime can reduce nighttime awakenings to urinate, it may not directly address difficulty falling asleep.

C. Schedule routine care tasks during hours when the client is awake - This action ensures that the client can maximize restful sleep during the night by minimizing disruptions from care

activities.

D. Advise the client to leave the television in the room on when trying to fall asleep - Screen

time before bed can interfere with falling asleep due to the stimulating effect of light and content.

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Correct Answer is A

Explanation

A. Edema is a common early sign of compartment syndrome as increased pressure within the compartment impairs venous outflow, leading to swelling.

B. Shortness of breath is not typically associated with compartment syndrome but may indicate other respiratory or cardiac issues.

C. Petechiae are not typically associated with compartment syndrome but may occur in conditions such as thrombocytopenia or coagulopathy.

D. Change in mental status is not typically associated with compartment syndrome but may indicate other neurological issues.

A. The client tucks his chin while swallowing food. B. The client sits upright in bed during meals. C. The client pockets food on one side of his mouth. D. The client has a cough reflex.

Correct Answer is C

Explanation

A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.

B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.

C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.

D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.

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A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

Nursing Test Bank

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