An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.
Drink a mixture of warm water, whiskey, and honey at bedtime.
Ask the healthcare provider for a mild sedative for bedtime.
Avoid drinking caffeinated beverages late in the day.
Take an afternoon nap to make up for missed sleep.
Establish a regular time for going to bed and getting up.
Correct Answer : C,E
A. Drink a mixture of warm water, whiskey, and honey at bedtime:
This suggestion is not appropriate as alcohol consumption close to bedtime can disrupt sleep patterns and exacerbate sleep problems. Additionally, alcohol can interact with medications and pose risks to health.
B. Ask the healthcare provider for a mild sedative for bedtime:
While medication may be prescribed for sleep disturbances in some cases, it should not be the first line of treatment, especially in older adults. Sedatives can have adverse effects and may lead to dependency if used long-term. Non-pharmacological interventions should be tried first.
C. Avoid drinking caffeinated beverages late in the day:
This is an appropriate suggestion. Caffeine is a stimulant that can interfere with sleep, so avoiding caffeinated beverages late in the day can help improve sleep quality.
D. Take an afternoon nap to make up for missed sleep:
While napping may be beneficial for some individuals, particularly if they are sleep deprived, it can worsen sleep difficulties in others, especially if taken late in the day. For individuals with insomnia or frequent nighttime awakenings, avoiding naps or limiting them to earlier in the day may be helpful.
E. Establish a regular time for going to bed and getting up:
This is an appropriate suggestion. Establishing a consistent sleep schedule helps regulate the body's internal clock and promotes better sleep quality. Going to bed and waking up at the same time each day, even on weekends, can help synchronize sleep-wake cycles and improve overall sleep patterns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Switch to a non-rebreather mask:
A non-rebreather mask delivers a higher concentration of oxygen (typically 10-15 L/min) compared to a nasal cannula. However, switching to a non-rebreather mask is a more drastic step that might not be necessary immediately. Other, simpler interventions should be considered first.
B. Verify placement of pulse oximeter:
Before making any changes, it's crucial to verify the accuracy of the oxygen saturation reading. The pulse oximeter might be misplaced or malfunctioning, leading to an inaccurate reading. This is an appropriate first action to ensure the reading is correct before deciding on further interventions.
C. Remove nasal cannula:
Removing the nasal cannula would decrease the client’s oxygenation further, worsening the situation. This is not an appropriate action when oxygen saturation is already low.
D. Increase the oxygen to 3 L/minute:
Increasing the oxygen flow rate is a reasonable intervention to improve oxygen saturation. However, this should typically be done after verifying the accuracy of the oxygen saturation reading. If the reading is correct, this is a valid next step to improve the client’s oxygenation.
Correct Answer is A
Explanation
A. A well approximated incision site:
A properly healing surgical incision typically appears well approximated, meaning the wound edges are closely aligned and held together with sutures or staples. This indicates that the wound is healing as expected and that the risk of infection and complications is minimized.
B. Erythema and serosanguineous exudate:
Erythema (redness) and serosanguineous exudate (pinkish fluid composed of serum and blood) can be normal findings in the early stages of wound healing, but they may also indicate inflammation or infection if they persist or worsen over time.
C. Eschar and slough in the wound:
Eschar (dead tissue) and slough (yellow or white necrotic tissue) are signs of tissue necrosis or delayed wound healing. They indicate that the wound is not healing properly and may require intervention such as debridement to remove dead tissue and promote healing.
D. Beefy red granulation tissue:
Beefy red granulation tissue is a sign of the proliferative phase of wound healing and indicates that the wound is healing from the bottom up. While granulation tissue is a positive sign of healing, it typically appears later in the healing process rather than one week post-surgery.
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