A nurse is assessing a client who has chronic insomnia. Which question would address the highest safety priority for the client?

When did you begin to have trouble sleeping?

Are there any specific factors that you think are affecting your ability to sleep?

Do you have difficulty staying awake when you are driving?

Can you describe your bedtime routine to me?

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Asking “When did you begin to have trouble sleeping?” is important for understanding the onset and duration of the client’s insomnia. However, it does not directly address immediate safety concerns. Chronic insomnia can lead to significant daytime impairment, but the question about the onset of sleep troubles does not identify specific safety risks.

Choice B Reason:

Inquiring about specific factors affecting the client’s ability to sleep can help identify potential causes of insomnia, such as stress, environmental factors, or medical conditions. While this information is valuable for treatment planning, it does not directly address immediate safety concerns.

Choice C Reason:

Asking “Do you have difficulty staying awake when you are driving?” addresses the highest safety priority. Chronic insomnia can lead to excessive daytime sleepiness, which significantly increases the risk of accidents, especially while driving. Identifying whether the client is at risk of falling asleep during potentially dangerous activities is crucial for immediate safety.

Choice D Reason:

Understanding the client’s bedtime routine can provide insights into their sleep hygiene and habits, which are important for managing insomnia. However, this question does not directly address immediate safety concerns related to daytime functioning and the risk of accidents.

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

Explanation

Choice A Reason:

Cured fat foods, such as bacon, sausages, and other processed meats, are high in saturated fats and sodium. Consuming these foods in excess can lead to increased cholesterol levels and a higher risk of heart disease. Limiting these foods is essential for maintaining a healthy diet and reducing the risk of chronic diseases.

Choice B Reason:

Vegetables are generally low in calories and high in essential nutrients, including vitamins, minerals, and fiber. They are an important part of a balanced diet and should not be limited. Instead, increasing vegetable intake is often recommended for better health outcomes.

Choice C Reason:

Canned soups often contain high levels of sodium, which can contribute to high blood pressure and other cardiovascular issues. Limiting the intake of canned soups can help manage sodium consumption and promote better heart health.

Choice D Reason:

Processed snacks, such as chips, crackers, and packaged baked goods, are typically high in unhealthy fats, sugars, and sodium. These foods can contribute to weight gain, high blood pressure, and other health problems. Reducing the intake of processed snacks is beneficial for overall health.

Choice E Reason:

Sugary drinks, including sodas, fruit juices with added sugars, and energy drinks, are high in calories and can lead to weight gain and increased risk of type 2 diabetes. Limiting sugary drinks is crucial for maintaining a healthy weight and preventing chronic diseases.

A. 380 mL B. 550 mL C. 600 mL D. 720 mL

Correct Answer is A

Explanation

Choice A Reason:

A 24-hour urinary output of 380 mL indicates oliguria. Oliguria is defined as a urine output of less than 400-500 mL per day in adults. This condition can be caused by various factors, including dehydration, kidney dysfunction, or postoperative complications. Monitoring urine output is crucial for assessing kidney function and overall fluid balance, especially after major surgeries like a colon resection.

Choice B Reason:

A 24-hour urinary output of 550 mL is slightly above the threshold for oliguria. While it is still relatively low, it does not meet the strict criteria for oliguria, which is typically defined as less than 400-500 mL per day. This output suggests that the client is producing an adequate amount of urine, though it may still warrant close monitoring to ensure it does not decrease further.

Choice C Reason:

A 24-hour urinary output of 600 mL is within the normal range and does not indicate oliguria. Normal urine output for adults is generally considered to be around 800-2000 mL per day, depending on fluid intake and other factors. This output suggests that the client’s kidneys are functioning properly and that there is no immediate concern for oliguria.

Choice D Reason:

A 24-hour urinary output of 720 mL is also within the normal range and does not indicate oliguria. This output is closer to the lower end of the normal range but still suggests adequate kidney function. It is important to continue monitoring the client’s urine output to ensure it remains within a healthy range, especially after surgery.

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A nurse is assessing a client who has chronic insomnia. Which question would address the highest safety priority for the client?

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