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 ["A","B","D"]

Explanation

A) Calcium gluconate 1.5 grams IV now: Calcium gluconate is administered to counteract the effects of hyperkalemia by stabilizing the myocardial cell membrane. It does not lower potassium levels but helps protect the heart from potential dysrhythmias associated with high potassium levels.

B) Dextrose 50% injection (50ml) IV push now: Dextrose 50% injection, also known as D50W, is administered to temporarily shift potassium from the extracellular space into the intracellular space, thereby lowering serum potassium levels. It is commonly used in combination with insulin to facilitate the movement of potassium into cells.

C) Colace 100 mg PO now: Colace is a stool softener and does not affect serum potassium levels. It is not indicated for the treatment of hyperkalemia.

D) Regular insulin 10 units IV now: Regular insulin is administered with dextrose to facilitate the movement of potassium from the extracellular space into the intracellular space. Insulin stimulates the cellular uptake of glucose, which in turn drives potassium into cells along with glucose.

E) Potassium chloride 20 mEq orally now: Potassium chloride is contraindicated in the treatment of hyperkalemia as it would further increase serum potassium levels. It is typically used to supplement potassium in clients with hypokalemia, not hyperkalemia.

A. Raise the bed to a comfortable height. B. Stand on the left side of the bed C. Raise the side rat on the working side of the bed. D. Use the non-dominant hand to insert the catheter.

Correct Answer is A

Explanation

A. Raise the bed to a comfortable height:
Raising the bed to a comfortable height is essential for proper body mechanics and preventing back strain. It ensures the nurse can perform the procedure efficiently and safely.

B. Stand on the left side of the bed:
While a left-handed nurse might prefer to stand on the left side for better access, this choice depends on the room layout and client position. Standing on the side where the nurse is most comfortable is essential, but it is not the primary action compared to ensuring proper bed height.

C. Raise the side rail on the working side of the bed:
Raising the side rail on the working side of the bed could obstruct the nurse's access to the client and is not generally recommended during procedures requiring close access to the client.

D. Use the non-dominant hand to insert the catheter:
The dominant hand, in this case, the left hand, should be used to insert the catheter for better control and precision. The non-dominant hand is typically used to hold the genitalia and provide stability.

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

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Naxlex Comprehensive Predictor Exams

The nurse is caring for the client with cardiac and renal disease. The client now has a serum potassium level of 6.0 mEq/L. Which medications, if prescribed, should the nurse administer? Select all that apply.

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

Explanation

A nurse who is left-handed is preparing to perform a straight catheterization for a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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