A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following actions should the nurse take first?

Determine the source of the client's stress.

Instruct the client to turn off their TV just before they go to bed.

Encourage the client to listen to soft music at the onset of stress.

Advise the client to exercise daily in the morning.

Answer and Explanation

The Correct Answer is A

A. Determine the source of the client's stress: The first step in managing insomnia related to stress is assessing and identifying the underlying cause. Understanding the source allows the nurse to tailor interventions effectively and ensures that care addresses the root of the problem rather than just the symptoms.

B. Instruct the client to turn off their TV just before they go to bed: Reducing screen time before sleep is helpful in promoting rest, but this is a specific behavioral strategy. It should follow an assessment of the client’s stressors and sleep patterns to be applied appropriately.

C. Encourage the client to listen to soft music at the onset of stress: Relaxation techniques such as music therapy can aid stress reduction, but they are supportive measures. Without assessing the client’s unique stressors first, these interventions may not fully address the insomnia.

D. Advise the client to exercise daily in the morning: Morning exercise can improve sleep quality and reduce stress, but it is a long-term strategy. The nurse must first explore the client’s stress triggers to ensure that interventions are individualized and effective.

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Correct Answer is B

Explanation

A. Insert an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not recommended solely for immobility. Managing incontinence with skin care and barrier products is safer for preserving skin integrity.

B. Use an alcohol-free barrier product: Alcohol-free barrier products protect the skin from moisture, friction, and irritation without causing dryness. This helps maintain skin integrity, especially in clients who are immobile and at high risk for breakdown.

C. Reposition the client every 4 hr: Immobile clients should be repositioned at least every 2 hours, not every 4. Prolonged pressure over bony areas can rapidly lead to pressure injuries if turning is delayed.

D. Massage the skin over bony prominences: Massaging over bony prominences can damage fragile tissue and worsen the risk of pressure injury. Instead, gentle repositioning and cushioning should be used to protect the skin.

A. Place the client in a side-lying position. B. Clean the client's mouth with foam swabs. C. Position an emesis basin under the client's chin. D. Place a towel under the client's head.

Correct Answer is A

Explanation

A. Place the client in a side-lying position: Positioning the client on their side is the priority because it helps maintain airway safety and prevents aspiration during oral care. This step must be done first before beginning the cleaning process.

B. Clean the client's mouth with foam swabs: Oral cleaning is important to reduce bacterial growth and maintain comfort, but it should only be performed after the client is positioned safely to avoid aspiration.

C. Position an emesis basin under the client's chin: The emesis basin helps catch secretions and cleaning solution, but this is a supportive measure that comes after ensuring the client’s airway protection through proper positioning.

D. Place a towel under the client's head: A towel provides comfort and helps keep linens dry, but it is a secondary measure. Airway protection through positioning always takes priority before comfort and cleanliness.

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A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following actions should the nurse take first?

Nursing Test Bank

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