A nurse is caring for a hospitalized pre-operative client experiencing insomnia in the hospital at 3:00 am (0300).
Which nursing intervention is the most appropriate for this client?
Encourage a warm shower.
Offer a glass of warm milk.
Notify the health care provider.
Encourage the client to watch television.
The Correct Answer is D
Offer a glass of warm milk. According to some studies, warm milk may have a relaxing effect on the body and help induce sleep. It also contains tryptophan, an amino acid that is converted to serotonin and melatonin, which are neurotransmitters that regulate sleep cycles.
Choice A is wrong because a warm shower may increase the body temperature and make it harder to fall asleep.
Choice C is wrong because notifying the healthcare provider is not necessary for a client with insomnia unless there are other signs of distress or complications.
Choice D is wrong because watching television may stimulate the brain and interfere with the production of melatonin, a hormone that promotes sleep.
Some other nursing interventions for insomnia are:
- Educate the patient on the proper food and fluid intake such as avoiding heavy meals, alcohol, caffeine, or smoking before bedtime.
- Evaluate the patient’s sleep hygiene such as having a regular bedtime and wake-up time, avoiding naps during the day, and limiting exposure to light at night.
- Provide a conducive environment for sleep such as reducing noise, adjusting temperature and lighting, and using comfortable bedding.
- Help the patient develop a sleeping plan such as engaging in relaxing activities before bed, avoiding checking the clock, and getting out of bed if unable to sleep after 20 minutes.
- Understand the proper use of sleep aids or other medications such as following the prescription, avoiding over-the-counter drugs without consulting the provider, and being aware of the side effects and interactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Are you taking the medication as prescribed? This is because warfarin is a blood-thinning medication that affects the prothrombin time (PT) and the international normalized ratio (INR).
The PT measures how long it takes for blood to clot, and the INR is a calculation based on the PT that standardizes the results across different laboratories. A normal INR range is 0.8 to 1.1 for people who are not taking warfarin. People who take warfarin usually have a target INR range of 2 to 3, depending on their condition.
An INR of 0.8 means that the blood clots faster than normal, which increases the risk of blood clots and strokes.
This could indicate that the client is not taking enough warfarin or is taking other medications or foods that interfere with warfarin’s effect.
Choice A is wrong because bleeding gums are a sign of excessive bleeding, which could happen if the INR is too high, not too low.
Choice C is wrong because blood in stools is also a sign of excessive bleeding, which could happen if the INR is too high, not too low.
Choice D is wrong because unusual bruising is another sign of excessive bleeding, which could happen if the INR is too high, not too low.
Correct Answer is C
Explanation
This is because spinach and salads contain a lot of vitamin K, which can make warfarin less effective at preventing blood clots.
Vitamin K helps the blood to clot, so eating foods high in vitamin K can counteract the effect of warfarin.
Choice A is wrong because wheat bread and butter do not contain a lot of vitamin K and do not affect warfarin.
Choice B is wrong because mangoes and tomatoes do not contain a lot of vitamin K and do not affect warfarin.
Choice D is wrong because aged cheeses and wine do not contain a lot of vitamin K and do not affect warfarin.
It is important to keep a stable diet while taking warfarin and avoid sudden changes in the amount of vitamin K intake. Foods that are high in vitamin K include green leafy vegetables, chickpeas, liver, egg yolks, avocado, and olive oil.
These foods should be limited but not eliminated from the diet. Do not drink cranberry or grapefruit juice while taking warfarin as they can increase the risk of bleeding.
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