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 C

Explanation

Choice A rationale:

Tape the tube to the child's cheek. Rationale: Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy enteral tube. It can cause discomfort and skin irritation for the child. Proper securing methods involve using specialized tube holders or dressings designed for this purpose.

Choice B rationale:

Apply water-soluble lubricant to the site. Rationale: Applying a water-soluble lubricant to the site is not a standard practice for gastrostomy tube care. It is essential to keep the site clean and dry to prevent infection. Lubricants are not typically used in this context.

Choice C rationale:

Attach an extension tube to the site's opening prior to use. Rationale: This is the correct action. Before using the gastrostomy tube, it is essential to attach an extension tube to the site's opening to facilitate feeding or medication administration. This extension tube allows for the connection of feeding syringes or other equipment.

Choice D rationale:

Apply a skin barrier protectant to the site. Rationale: Applying a skin barrier protectant is not typically required for gastrostomy tube care. The primary focus should be on maintaining the cleanliness and integrity of the site to prevent complications such as infection or skin irritation.

A. Assign the client to a negative pressure airflow room. B. Administer aspirin if the client develops a fever. C. Have visitors remain at least 0.91 m (3 feet) away from the client. D. Initiate contact precautions for the client.

Correct Answer is D

Explanation

The correct answer is **d. Initiate contact precautions for the client**.

Choice a rationale: Varicella zoster does not require airborne precautions, as it is primarily transmitted through direct contact and respiratory droplets. Assigning the client to a negative pressure airflow room is not necessary for this specific infection.

Choice b rationale: Aspirin should not be administered to clients with varicella zoster, as it has been associated with the development of Reye's syndrome, a rare but serious condition that can cause liver and brain damage. Instead, acetaminophen or ibuprofen may be used to manage fever and discomfort.

Choice c rationale: While maintaining a distance of at least 0.91 m (3 feet) from the client can help reduce the risk of respiratory droplet transmission, it is not sufficient as the sole intervention. Contact precautions, which include the use of PPE and proper hand hygiene, are essential to prevent the spread of varicella zoster.

Choice d rationale: Varicella zoster, also known as chickenpox, is a highly contagious viral infection that spreads through direct contact with the rash, respiratory droplets, or aerosolized particles from the skin lesions. To prevent the transmission of the virus, contact precautions should be implemented for clients with varicella zoster. This includes using personal protective equipment (PPE) such as gowns and gloves when in direct contact with the client or their environment, and ensuring proper hand hygiene before and after contact. Additionally, the client should be placed in a private room or cohorted with other clients with the same infection.

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 providing site care for a child who has a gastrostomy enteral tube.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Correct Answer is D

Explanation

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

A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect?

Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)

A nurse is reinforcing teaching with a client who has a new prescription for ciprofloxacin.Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube.Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops.Which of the following statements indicates an understanding of the teaching?

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

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?