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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. After each instruction, ask if the client understands:

While checking for understanding after each instruction is important, it may not accurately assess the client's ability to perform wound care independently. Verbal confirmation does not ensure competency in wound care techniques.

B. Have an interpreter repeat the wound care instructions:

Having an interpreter repeat the wound care instructions may help ensure accurate communication, but it does not assess the client's ability to perform the wound care independently.

C. Provide written instructions in the client's native language:

Providing written instructions in the client's native language can be helpful for reference, but it may not effectively assess the client's understanding or ability to perform the wound care.

D. Have the client demonstrate prescribed wound care:

This is the most appropriate method for evaluating the client's understanding of self-care at home. Having the client demonstrate wound care techniques allows the nurse to directly observe the client's competency in performing the necessary tasks. It provides a practical assessment of the client's ability to independently manage wound care post-discharge. If the client is unable to demonstrate the procedure correctly, the nurse can provide additional education and support as needed.

A. Encourage Increased fluid intake and measure urinary output every 8 hours. B. Assist the client to ambulate as much as possible during waking hours. C. Determine client's subjective measure of pain using a numerical pain scale. D. Provide comfort measures such as topical warm application and tactile massage. E. Implement a 24 hour schedule of routine administration of prescribed analgesic.

Correct Answer is ["B","C","D","E"]

Explanation

A. Encourage increased fluid intake and measure urinary output every 8 hours:

While hydration and monitoring urinary output are important aspects of overall health care, they are not specifically related to managing chronic pain. Therefore, this intervention may not be directly relevant to addressing the client's pain.

B. Assist the client to ambulate as much as possible during waking hours:

Ambulation helps maintain mobility, prevent complications like muscle atrophy and deep vein thrombosis, and can improve overall well-being. For clients with chronic pain, assisting with ambulation can be beneficial in managing pain and improving quality of life. The goal is to balance activity with the client's pain tolerance and capabilities.

C. Determine client's subjective measure of pain using a numerical pain scale:

Using a numerical pain scale helps assess the intensity of pain and monitor changes over time. It provides valuable information for tailoring pain management strategies to the client's needs and allows for evaluating the effectiveness of interventions.

D. Provide comfort measures such as topical warm application and tactile massage:

Comfort measures such as warm applications and massage can help alleviate pain and promote relaxation. These interventions address the client's comfort and well-being, making them appropriate for inclusion in the plan of care for managing chronic pain.

E. Implement a 24-hour schedule of routine administration of prescribed analgesic:

Establishing a regular schedule of analgesic administration helps maintain consistent pain control and prevents breakthrough pain. This intervention is essential for managing chronic pain effectively and promoting the client's comfort and quality of life.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self care at home?

Correct Answer is D

Explanation

The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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