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 A
Explanation
Choice A reason: Guided meditation and other nonpharmacological pain interventions can help reduce the perception of pain, which may allow for lower doses of pain management medications. This is beneficial as it can reduce the risk of side effects and dependency associated with higher doses of pain medications1. Studies have shown that integrating nonpharmacological methods like guided meditation can enhance overall pain management and improve the quality of life for patients2.
Choice B reason: Guided meditation is a complementary therapy and is not intended to replace pain medications entirely. While it can significantly aid in pain management, it is typically used alongside pharmacological treatments to provide a holistic approach to pain relief3. Relying solely on guided meditation without appropriate medical supervision and medication can lead to inadequate pain control.
Choice C reason: Guided meditation is not limited to hospital settings or licensed therapists. Many guided meditation resources are available online, through apps, or in community centers, making it accessible to a broader audience4. Patients can practice guided meditation at home, which provides flexibility and convenience in managing chronic pain.
Choice D reason: Pain medications are often prescribed on a regular schedule to maintain consistent pain control, especially in chronic pain conditions. While nonpharmacological interventions can reduce the need for frequent dosing, they do not eliminate the necessity for scheduled pain medications5. It is essential to follow a healthcare provider’s recommendations for medication administration to ensure effective pain management.
Correct Answer is ["260"]
Explanation
-
Calculation
- Enteral nutrition: 200 mL
- Water flush before feed: 30 mL
- Water flush after feed: 30 mL
Total intake = 200 mL + 30 mL + 30 mL = 260 mL
The nurse should document 260 mL as intake in the I&O.
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