A client presents to the clinic reporting high stress at work, constant headache, and having difficulty falling asleep at night. Over the counter and herbal sleep medications have not worked. The client requests medication to help promote sleep. Which intervention should the nurse implement to initiate a plan of care?

Recommend taking a nap for 15 minutes after lunch.

Encourage the client to eliminate stressful situations.

Determine the client's sleep and activity pattern.

Obtain a PRN prescription to be taken for stress.

Answer and Explanation

The Correct Answer is C

A.   While napping can be beneficial for some people, a nap of 15 minutes may not address the root causes of the client’s sleep difficulties, such as stress and chronic headaches. Additionally, napping during the day can sometimes interfere with nighttime sleep.
B.   Reducing or eliminating stressful situations is a valuable goal for improving overall well-being and sleep quality. However, this recommendation is often not immediately actionable or practical, as stressors in life can be difficult to eliminate completely. It’s more effective to focus on identifying and managing stress through practical and immediate interventions.
C.   Assessing the client's sleep and activity patterns is a critical step in identifying potential causes of sleep disturbances. Understanding the client’s current sleep habits, daily routines, and factors affecting their sleep can help in developing an effective plan of care.
D.   While medication might be necessary for some clients, it should not be the first line of intervention without a thorough assessment. PRN (as needed) medications for stress might not address the root causes of sleep issues and could potentially lead to dependence or other side effects.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. This action is appropriate given that the client’s posture is upright and their gait is smooth and steady. If the client demonstrates safe ambulation and is capable of performing ADLs effectively, documenting this observation is crucial for maintaining a record of their functional status.
B. Initiating a fall risk protocol may not be immediately necessary if the client shows a smooth, steady gait and upright posture. However, fall risk assessments are generally based on multiple factors, including history of falls, medication side effects, and environmental hazards.
C. The client’s smooth and steady gait suggests they are ambulating effectively. Teaching the client to shorten their stride is typically advised when there is observed instability or an increased risk of falls.
D. Assessing the client's activity tolerance is a valid consideration, but it may not be the immediate next step if the client’s gait and posture are already observed to be steady and upright.

A. Before changing assignments, determine which staff members have fitted particulate filter masks. B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client. C. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. D. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.

Correct Answer is D

Explanation

A. This action involves assessing which staff members are appropriately equipped to handle the situation. While it is useful to know which staff are fitted with particulate filter masks, this step does not directly address the UAP’s immediate concern or resolve the issue with the current assignment.
B. Pertussis (whooping cough) is a disease that requires droplet precautions, which generally means using a standard surgical mask rather than a particulate filter mask. However, it’s crucial to ensure that the UAP is aware of and follows the correct infection control measures.
C. Pertussis requires droplet precautions, which usually involve wearing a standard surgical mask, not a particulate filter mask (N95). Fitting for an N95 mask is generally reserved for airborne precautions.
D. This action addresses the immediate need by allowing the UAP to perform tasks that do not involve close personal care (such as taking vital signs) with a standard face mask, which is appropriate for droplet precautions. It also ensures that the UAP receives proper fitting for a particulate filter mask if needed for other tasks or future assignments.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vagina tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

A male client tells the nurse that he is taking large doses of a fish oil supplement to lower his triglyceride level. Which action should the nurse take?

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?