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
Explanation
Choice A rationale:
Reporting a penicillin allergy in the client's history is essential when the client is prescribed cefaclor. Cefaclor is a cephalosporin antibiotic, and individuals with a documented penicillin allergy may have an increased risk of cross-reactivity and allergic reactions to cephalosporin antibiotics. Therefore, it is crucial to report a penicillin allergy to the provider to evaluate the potential risks and consider alternative antibiotics if necessary.
Choice B rationale:
An egg allergy is not directly relevant to the prescription of cefaclor. While allergies to various substances can be important in healthcare, egg allergy is not a contraindication or concern when prescribing cefaclor. Therefore, it does not require specific reporting in this context.
Choice C rationale:
Tendonitis is not directly related to the prescription of cefaclor. Tendonitis is an inflammatory condition affecting tendons and is not typically a contraindication for cefaclor or other cephalosporin antibiotics.
Correct Answer is B
Explanation
Choice A rationale:
Applying a cold compress to the client's calf is not the priority in this situation. The client is reporting pain in the calf, which could be indicative of deep vein thrombosis (DVT), a potentially serious condition. Monitoring the client's oxygen saturation (pulse oximetry) is a more appropriate action to assess for possible DVT complications, such as a pulmonary embolism.
Choice B rationale:
Monitoring the client's pulse oximetry is the correct action in this scenario. Pain in the calf can be a symptom of DVT, which can lead to reduced blood flow and potential oxygenation issues. Monitoring the client's oxygen saturation levels can help identify any oxygenation problems early.
Choice C rationale:
Instructing the client to massage the calf gently is not recommended in this situation, as it may dislodge a clot if DVT is present. Massaging the calf can be harmful and is contraindicated when DVT is suspected.
Choice D rationale:
Maintaining the leg in a dependent position while in bed is not a recommended action in this case. Elevating the leg can help reduce swelling and improve venous return, but it should be done cautiously, especially if DVT is suspected. Monitoring the client's condition and oxygen saturation takes precedence.
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