A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?
"Can you describe your bedtime routine to me?"
"Do you have difficulty staying awake when you are driving?"
"Are there any specific factors that you think are affecting your ability to sleep?"
"When did you begin to have trouble sleeping?"
The Correct Answer is B
A. Understanding the client’s bedtime routine can provide insights into habits that might affect sleep quality, such as engaging in stimulating activities before bed or the absence of a calming pre-sleep routine. However, while useful for identifying lifestyle factors that could impact sleep, this question
B. This question is highly important because difficulty staying awake while driving can indicate severe sleep disturbances that may pose safety risks. It helps identify whether the client is experiencing excessive daytime sleepiness, which can be a symptom of serious underlying conditions such as sleep apnea or other sleep disorders.
C. This question aims to identify potential triggers or contributing factors to the client’s insomnia, such as stress, medications, or environmental issues. While this information is valuable for understanding and managing insomnia, it may not immediately address urgent concerns related to the client’s safety or overall well-being.
D. Understanding the onset of sleep difficulties is important for diagnosing potential causes and determining the duration and pattern of insomnia. This information helps in identifying whether the problem is acute or chronic, but it may not be as immediately critical as addressing potential safety issues related to the client’s sleep disturbances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Measuring gastric residuals is not intended to remove gastric acid or address dyspepsia (indigestion). Instead, residuals help assess the function of the stomach and the effectiveness of the feeding process.
B. Measuring gastric residuals helps determine if the stomach is emptying properly. If residuals are high, it can indicate delayed gastric emptying, which means the stomach is not processing the enteral feedings effectively. This could signal potential issues like gastroparesis or obstruction and may necessitate adjusting the feeding rate or formula, or evaluating the client for other complications.
C. While electrolyte balance is important in overall nutritional care, measuring gastric residuals is not used to assess electrolytes. Instead, it focuses on stomach function and gastric emptying.
D. Confirming the placement of the NG tube is done through other methods, such as aspirating gastric contents and checking pH, or by using imaging techniques. Measuring residuals does not provide information on tube placement but rather on stomach function and feeding tolerance.
Correct Answer is ["A","B","C","D"]
Explanation
A. This helps to remove dirt, pesticides, and harmful bacteria that may be present on the surface of the vegetables.
B. This ensures that any bacteria that may have grown on the food are killed.
C. Unpasteurized dairy products may contain harmful bacteria, such as Salmonella and Listeria.
D. This helps to prevent the growth of bacteria.
E. Cooked foods should be kept hot (above 60°C/140°F) or cold (below 4°C/40°F) to prevent bacterial growth.
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