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:
“I will keep spare crutch tips handy.” This statement is correct and indicates good practice. Keeping spare crutch tips handy ensures that the client can replace worn or damaged tips promptly, maintaining the safety and effectiveness of the crutches.
Choice B Reason:
“I will inspect my crutches every day for signs of wear.” This statement is also correct. Regular inspection of crutches for signs of wear and tear helps prevent accidents and ensures that the crutches remain in good working condition.
Choice C Reason:
“I will bear the weight of my body on my axillas.” This statement is incorrect and indicates that the client needs additional education. Bearing weight on the axillas (armpits) can cause nerve damage and discomfort. The correct technique is to support the body’s weight with the hands and arms, not the axillas.
Choice D Reason:
“I will support most of the weight of my body with my arms.” This statement is correct. Supporting the body’s weight with the arms and hands is the proper technique for using crutches, as it prevents nerve damage and ensures better control and stability.
Correct Answer is A
Explanation
Choice A reason: Thrombophlebitis is characterized by inflammation of the vein with the formation of a blood clot. The signs and symptoms include erythema, warmth, edema, and a red line traveling up the vessel, which indicates the presence of inflammation and possible clot formation. This condition requires prompt intervention to prevent further complications such as the spread of infection or the clot traveling to other parts of the body.
Choice B reason: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue. Signs of infiltration include swelling, discomfort, and coolness at the IV site, but it does not typically present with erythema, warmth, or a red line traveling up the vessel. Infiltration is less likely to cause the systemic signs seen in this case.
Choice C reason: Infection at the IV site can cause erythema, warmth, and edema, but it usually does not present with a red line traveling up the vessel. The red line is more indicative of thrombophlebitis, where the inflammation follows the path of the vein. Infection would also likely present with additional systemic signs such as fever.
Choice D reason: Extravasation involves the leakage of vesicant drugs into the surrounding tissue, causing severe local tissue damage. Signs include pain, burning, and blistering at the site, but it does not typically present with a red line traveling up the vessel. Extravasation is more localized and does not follow the vein’s path like thrombophlebitis.
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