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.

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

Explanation

A. The cheeks can be affected by the nasal cannula, especially if it is not positioned properly or if it causes irritation over time.
B. The area around the nostrils is one of the most common sites for skin damage related to nasal cannulas. Continuous contact with the cannula can cause irritation, redness, or even sores in this area.
C. The nasal cannula itself does not typically make contact with the forehead. Therefore, skin damage across the forehead is not generally a concern related to the use of a nasal cannula.
D. The bridge of the nose is a key area to inspect for skin damage. The nasal cannula’s prongs often rest on or near the bridge of the nose, which can lead to pressure sores, redness, or irritation in this area. Regular assessment is important to prevent and address any damage.
E. The tops of the ears can be affected if the nasal cannula’s tubing or securing mechanism (such as behind-the-ear supports or loops) causes friction or pressure. Skin breakdown can occur in this area if the cannula is not properly adjusted or if it causes irritation.

A. Offer to adjust the height of the walker. B. Explain the need to remove the wheels from the walker. C. Demonstrate more coordinated movement of the legs and walker. D. Encourage the client to continue using the walker as observed.

Correct Answer is A

Explanation

A. The walker should be adjusted to the client's height so that their elbows are slightly flexed when grasping the hand bars. This allows for proper weight-bearing and reduces strain on the shoulders and arms. Using a walker that is the correct height can help to prevent falls by providing better stability and support.
B. Removing the wheels from the walker would make it difficult for the client to use. The wheels are an important feature of a walker, as they allow the client to move more easily.
C. While demonstrating more coordinated movement may be helpful, it's not the most immediate action needed. Adjusting the height of the walker is a more important step to ensure the client's safety and comfort.
D. Encouraging the client to continue using the walker as observed may not be appropriate if the walker is not adjusted to the correct height. A properly adjusted walker is essential for safe and effective mobility.

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Naxlex Comprehensive Predictor Exams

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

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

Explanation

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

Correct Answer is A

Explanation

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The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.

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