What would be the primary focus of interventions for a client who sleepwalks?

Administer and teach about medications to suppress stage III sleep.

Encourage the child to verbalize feelings regarding sleep pattern.

Provide a quiet environment for nighttime sleep.

Maintain patient safety during episodes of somnambulism.

Answer and Explanation

The Correct Answer is D

A) Administer and teach about medications to suppress stage III sleep:
Suppressing stage III sleep is not a primary intervention for sleepwalking and could potentially disrupt the client’s overall sleep quality.

B) Encourage the child to verbalize feelings regarding sleep pattern:
While understanding feelings about sleep patterns may be helpful, it is not the immediate priority in managing sleepwalking.

C) Provide a quiet environment for nighttime sleep:
A quiet environment is generally beneficial for good sleep hygiene but does not directly address the safety concerns associated with sleepwalking.

D) Maintain patient safety during episodes of somnambulism:
Ensuring the client’s safety is the primary focus. Sleepwalking can lead to accidents or injuries; therefore, implementing safety measures to prevent harm during episodes of somnambulism is crucial. This may include securing the environment, using safety gates, and ensuring the client’s immediate surroundings are safe.

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Correct Answer is C

Explanation

A. You should advance your weak leg forward to the cane, then move your strong leg:
Advancing the weak leg first and then the strong leg is not the proper technique for using a cane. The correct method is to hold the cane on the stronger side and move the cane and the weaker leg forward together, followed by the stronger leg.

B. You should advance the cane 12 to 14 inches before taking a step:
Advancing the cane 12 to 14 inches is too far. The cane should be advanced approximately 6 to 10 inches to maintain balance and support.

C. The cane’s height should be the same as the distance from the floor to the crest of your hip bone:
The correct height for a cane is when the handle is at the level of the wrist when the user is standing with the arm hanging naturally at their side. This typically corresponds to the distance from the floor to the greater trochanter (hip bone). This ensures the cane provides the right amount of support and reduces the risk of strain or imbalance.

D. You should hold the cane in your weak hand when ambulating:
The cane should be held in the stronger hand, not the weak hand. This allows the cane to provide support to the weaker side of the body and helps to balance the weight distribution more effectively.

A. Apply a warm compress to the IV site. B. Remove the IV saline lock. C. Inject the solution more slowly while flushing the IV saline lock. D. Apply firm pressure to the plunger of the syringe during the NV flush to improve patency.

Correct Answer is B

Explanation

A. Apply a warm compress to the IV site: While warm compresses can sometimes help alleviate discomfort associated with certain IV complications, such as phlebitis or infiltration, they should not be applied until the cause of the pain is identified. In this case, removing the IV saline lock is the priority action to assess the site properly.

B. Remove the IV saline lock: Pain above the catheter site during flushing may indicate infiltration or phlebitis, both of which require intervention. Removing the IV saline lock allows the nurse to assess the site for signs of complications such as swelling, redness, or coolness to the touch. Once removed, the nurse can then determine the appropriate course of action, such as reinserting the IV at a different site, applying warm compresses, or notifying the healthcare provider if further evaluation or treatment is necessary.

C. Inject the solution more slowly while flushing the IV saline lock: Injecting the solution more slowly may reduce discomfort during flushing, but it does not address the underlying cause of the pain. If there is infiltration or another issue with the IV site, continuing to flush slowly could exacerbate the problem.

D. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency: Applying firm pressure to the plunger of the syringe during flushing is not appropriate when the client reports pain above the catheter site. This action could potentially force fluid into surrounding tissues, worsening infiltration or causing additional discomfort. It is essential to address the pain and assess the IV site before attempting to flush the saline lock again.

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What would be the primary focus of interventions for a client who sleepwalks?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the lowing client statements indicates an understanding of the teaching?

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.)

A home health nurse is teaching about endotracheal suctioning. Which of the following information should the nurse include in the teaching?

A nurse is teaching a client about the sleep-wake cycle. The nurse should include that which of the following factors can interfere with the sleep-wake cycle? (Select All that Apply)

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority?

A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take?