In implementing the plan of care, which data should the practical nurse (PN) obtain first for a client with a sleep pattern disturbance?

The client's current and previous sleep habits and cycles.

The client's evening meal and snacking habits at bedtime.

Symptoms that occur as the result of sleep disturbance.

Sleep routines that the client has thought about practicing.

Answer and Explanation

The Correct Answer is A

A. Understanding the client’s current and previous sleep habits and cycles is the most foundational step for assessing sleep disturbances. This information provides a baseline from which the PN can identify patterns and deviations in the client’s sleep behavior.
B. While evening meal and snacking habits can affect sleep, they are secondary to understanding the client’s overall sleep habits and cycles. These habits are part of a broader assessment but not the initial focus.
C. Identifying symptoms resulting from sleep disturbances is important but follows after understanding the client’s sleep history. Symptoms are a result of disturbances, and their identification is based on a foundational understanding of sleep patterns.
D. Exploring new sleep routines the client is considering is part of the intervention phase but comes after understanding current sleep patterns and disturbances. The initial focus should be on gathering comprehensive sleep history.

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Correct Answer is D

Explanation

A. Assigning the UAP to more stable clients does not address the immediate issue of the protocol omission and does not ensure that the protocol is followed correctly in the future.
B. Completing an unusual occurrence report is not necessary if the omission was corrected and the situation does not involve a significant error or safety issue.
C. Reporting to the charge nurse may be appropriate, but the priority is to ensure the UAP understands and follows the protocol, which is best achieved through direct supervision.
D. Supervising the UAP and reviewing the protocol ensures that the UAP understands and adheres to the fall prevention protocol moving forward, addressing both the immediate issue and future adherence.

A. Describe the procedure to the client using a step-by-step approach. B. Ask the client to describe the intensity of the pain being experienced. C. Encourage the client to reminisce about a favorite past family event. D. Explain the benefits of various alternative strategies in managing pain.

Correct Answer is C

Explanation

A. Describing the procedure in detail can increase anxiety or focus the client on the pain rather than distracting them from it.
B. Asking the client to describe the pain could heighten their awareness of it, which is counterproductive to the goal of distraction.
C. Encouraging the client to reminisce about a favorite past family event is a distraction technique that shifts the client's focus away from the pain, helping to manage discomfort during the procedure.
D. Explaining alternative pain management strategies is useful but not a distraction technique; it does not provide immediate relief or shift the client's focus during the procedure.

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In implementing the plan of care, which data should the practical nurse (PN) obtain first for a client with a sleep pattern disturbance?

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Correct Answer is D

Explanation

The practical nurse (PN) plans to use distraction techniques while a client undergoes a brief painful procedure. Which action should the PN implement during the procedure?

Correct Answer is C

Explanation

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