The nurse is caring for a hospitalized patient who states, "I cannot sleep at night in this hospital and it's making me crazy." Which of the following should the nurse ask first?

"I can tell your family not to visit you close to bedtime."

"Would you like me to provide you with earplugs?"

"I can get you a mental health consult if you think that would help."

"Tell me why you think you may not be sleeping at night."

Answer and Explanation

The Correct Answer is D

A. "I can tell your family not to visit you close to bedtime." While this could be a consideration, it does not address the patient's immediate concerns and the possible causes of their sleep issues.

B. "Would you like me to provide you with earplugs?" This is a possible solution but does not investigate the underlying cause of the sleep issue.

C. "I can get you a mental health consult if you think that would help." A mental health consult may be helpful, but it is not the first step in understanding and addressing the immediate concern.

D. "Tell me why you think you may not be sleeping at night." This is the best initial response as it allows the nurse to understand the root cause of the patient's sleep disturbances and address specific issues, such as noise, light, or discomfort.

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Correct Answer is B

Explanation

A. Acute pain: This diagnosis might be relevant if the patient has pain, but it does not address the main concern of mobility and risk related to recent falls.

B. Risk for injury: This is the most appropriate diagnosis as the patient’s inability to bear weight and recent falls increase their risk of further injury.

C. Activity Intolerance: While the patient may have activity intolerance, the more pressing concern related to their recent falls and inability to bear weight is the risk for injury.

D. Toileting self-care deficit: This diagnosis might be relevant if there were specific issues with toileting, but it is not the most appropriate for the general risk of injury due to recent falls.

A. "How would you describe your sleep problem?" B. "What types of sleep treatments have you tried?" C. "What do you think is the cause of the sleep problem?" D. "How does the sleep problem affect your everyday living?" E. "Don't you think when you get tired enough, you'll sleep well?"

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

Explanation

A. "How would you describe your sleep problem?" Understanding how the patient describes their sleep problem provides insight into the nature of the disturbance and its potential causes.

B. "What types of sleep treatments have you tried?" Knowing what treatments have been tried helps identify what has or hasn’t worked and can guide further management.

C. "What do you think is the cause of the sleep problem?" Understanding the patient’s perspective on the cause can help in assessing their awareness and any possible underlying issues.

D. "How does the sleep problem affect your everyday living?" This question assesses the impact of sleep disturbances on daily life and overall well-being, providing context for the severity of the problem.

E. "Don't you think when you get tired enough, you'll sleep well?" This statement does not address the underlying problem and might dismiss the patient’s concerns. It is not useful in assessing or managing sleep disturbances.

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The nurse is caring for a hospitalized patient who states, "I cannot sleep at night in this hospital and it's making me crazy." Which of the following should the nurse ask first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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