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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

Hyperglycemia is not typically associated with tranylcypromine, a monoamine oxidase inhibitor (MAOI) MAOIs can affect blood pressure regulation, but hyperglycemia is not a common adverse effect of this medication.

Choice B rationale:

Hematuria (blood in the urine) is not a known adverse effect of tranylcypromine. This symptom is not directly related to the use of MAOIs.

Choice C rationale:

Tinnitus (ringing in the ears) is not a common adverse effect of tranylcypromine. MAOIs can affect the cardiovascular system, but tinnitus is not a typical manifestation.

Choice D rationale:

Tranylcypromine, an MAOI, can cause hypertension (high blood pressure) as an adverse effect due to its ability to inhibit the breakdown of tyramine in the body. When tyramine-rich foods are ingested, there can be a sudden release of norepinephrine, leading to a hypertensive crisis. Therefore, monitoring for hypertension is essential when a client is taking tranylcypromine and has ingested tyramine-rich foods.

A. Place a padded tongue blade in the child's mouth. B. Place a pillow under the child's head. C. Turn the child onto their back. D. Restrain the child's upper extremities.

Correct Answer is B

Explanation

Choice A rationale:

Placing a padded tongue blade in the child's mouth is not recommended during a tonic-clonic seizure. This action can cause injury to the child's mouth or teeth and does not help manage the seizure itself.

Choice C rationale:

Turning the child onto their back is generally the correct action to take during a seizure to ensure an open airway. However, this should be done gently and after ensuring the child's safety. Placing a pillow under the head is also important to prevent head injury during the seizure.

Choice D rationale:

Restraining the child's upper extremities is not recommended during a tonic-clonic seizure. It can lead to injury for both the child and the healthcare provider and is not an effective way to manage the seizure. The priority is to ensure the child's safety and protect them from harm.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods.The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

Correct Answer is D

Explanation

A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse is caring for a client who has bulimia nervosa.Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception.Which of the following statements by the client indicates an understanding of the teaching?

A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath.Which of the following actions should the nurse take first?

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough.Which type of isolation precautions should the nurse initiate for the client?

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?