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?
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
The gastrocnemius muscle, located in the calf, is not a recommended site for intramuscular injections in newborns. This muscle is not typically used due to its small size and the difficulty in accessing it safely for an injection.
Choice B Reason:
The dorsogluteal muscle, located in the buttocks, is also not recommended for newborns. This site is avoided because of the risk of damaging the sciatic nerve and the relatively thick layer of subcutaneous fat, which can interfere with the absorption of the medication.
Choice C Reason:
The vastus lateralis muscle, located in the thigh, is the preferred site for intramuscular injections in newborns. This muscle is well-developed at birth and provides a large, easily accessible area for injections. It is also away from major blood vessels and nerves, making it a safe and effective site for administering medications like vitamin K.
Choice D Reason:
The ventrogluteal muscle, located on the side of the hip, is another site used for intramuscular injections, but it is not typically recommended for newborns. This site is more commonly used in older children and adults due to its deeper location and the need for precise anatomical knowledge to avoid complications.
Correct Answer is C
Explanation
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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