Nokea
A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?
- A. Avoid beverages containing caffeine
- B. Take a sleep medication regularly at bedtime
- C. Watch television for 30 minutes in bed to relax before falling asleep
- D. Advise the client to take several naps during the day
Correct Answer: A
Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.
You may also like to solve these questions
Which of the following is responsible for the rhythm and quality of breathing?
- A. Medulla oblongata
- B. Pons
- C. Carotid bodies
- D. Aortic bodies
Correct Answer: A
Rationale: The medulla oblongata's respiratory center sets breathing rhythm and depth e.g., 12-20 breaths/min via dorsal and ventral groups. Pons refines, carotid/aortic bodies adjust via chemo input. Nurses assess this e.g., in COPD for foundational respiratory function, per neurophysiology.
A client is receiving discharge teaching after a total hip arthroplasty. Which of the following instructions should be included?
- A. Cross your legs at the ankles while sitting
- B. Avoid bending your hips more than 90 degrees
- C. Sit in a low-seated chair
- D. Twist your body when standing up
Correct Answer: B
Rationale: To prevent dislocation of the hip prosthesis, the client should avoid bending their hips more than 90 degrees. Excessive bending at the hips can increase the risk of hip dislocation, which is a significant concern following total hip arthroplasty. Sitting with crossed legs at the ankles (choice A) can also increase the risk of hip dislocation and should be avoided. Sitting in a low-seated chair (choice C) can make it more challenging for the client to stand up safely. Twisting the body when standing up (choice D) can also strain the hip joint and increase the risk of dislocation. Therefore, the correct instruction to include during discharge teaching is to avoid bending the hips more than 90 degrees.
The nurse is assessing a post operative client who underwent a colostomy, which of the following findings will warrant further nursing interventions?
- A. The stoma appears pale and dry
- B. The stoma appears red
- C. The stoma drains a bloody drainage then progressed to greenish discharge
- D. The stoma drains a greenish discharge
Correct Answer: A
Rationale: A pale, dry stoma e.g., ischemia needs intervention (e.g., notify MD), unlike red (healthy), bloody-to-green (normal), or green (expected). Nurses assess e.g., color for complications, per ostomy care.
A client with ulcerative colitis is receiving dietary management education from a healthcare provider. Which statement by the client indicates an understanding of the teaching?
- A. I should increase my intake of dairy products.
- B. I should decrease my intake of dairy products.
- C. I should increase my intake of high-fiber foods.
- D. I should decrease my intake of high-fat foods.
Correct Answer: B
Rationale: The correct answer is B because reducing dairy product intake can help manage symptoms of ulcerative colitis. Dairy products can exacerbate symptoms in some individuals due to their lactose content and may need to be limited or avoided based on individual tolerance levels. Choice A is incorrect because increasing dairy products can worsen symptoms for some ulcerative colitis patients. Choice C is incorrect as while high-fiber foods are generally beneficial, they may exacerbate symptoms during a flare-up. Choice D is also incorrect as while reducing high-fat foods can be beneficial, dairy products are a more specific concern for ulcerative colitis.
When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?
- A. Complete a fall-risk assessment
- B. Place a fall-risk identification bracelet on the client
- C. Provide the client with nonskid footwear
- D. Set the bed to the lowest position
Correct Answer: A
Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.