A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.
Which of the following interventions is the nurse's priority?
Inquire about the client's bedtime routine.
Recommend that the client go for a walk every morning.
Instruct the client to turn off the television before bedtime.
Encourage the client to listen to soft music at the onset of stress.
The Correct Answer is A
Choice A rationale:
Inquiring about the client's bedtime routine is the nurse's priority because it directly addresses the client's reported problem of insomnia due to increased stress. Understanding the client's routine can help identify factors contributing to sleep difficulties and guide the development of an appropriate plan of care.
Choice B rationale:
Recommending that the client go for a walk every morning may be a helpful intervention, but it does not directly address the client's immediate concern of insomnia. It's important to first assess the client's current situation and then provide tailored interventions.
Choice C rationale:
Instructing the client to turn off the television before bedtime is a good sleep hygiene practice, but it may not be the priority when the client is experiencing acute insomnia due to increased stress. The nurse should first gather information about the client's specific situation.
Choice D rationale:
Encouraging the client to listen to soft music at the onset of stress is a useful relaxation technique, but it may not be the priority in this case. The nurse should focus on addressing the client's insomnia by identifying contributing factors and implementing appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Clamp chest tube when client ambulates.Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition.The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider.Indicated.
Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue.The provider should be notified of any changes in the client’s pain or discomfort.
Reinforce dressing around the tube as needed if it loosens.Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection.If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape.
Strip the tubing twice daily to ensure patency.Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange.The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed.
Maintain chest tube below the chest.Indicated.The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.
Correct Answer is B
Explanation
Answer is B: Write the information at an 8th-grade reading level.
This is the best action for the nurse to take because it ensures that the information is accessible and understandable to a wide audience, which is suitable for the general population¹². The other options are not as effective for the following reasons:
- Use a 12-point font size: This is important for readability, but not enough for comprehension. The font size should also match the layout and design of the brochure.
- Explain medical terminology using basic, one-syllable words: This is a good approach, but it does not address the reading level of the content. The nurse should also use simple sentences and avoid jargon.
- Present information from complex to simple: This might be helpful, but it is not the most effective way to educate the public. The nurse should start with the simpler concepts and gradually build on them to explain the more complex aspects of hypertension.
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