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?"

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While Lactated Ringer's is often used for fluid resuscitation, it doesn't contain the necessary nutrients to replace TPN. It can lead to electrolyte imbalances and other complications if used for extended periods.
B. While Dextrose 10% provides calories, it lacks essential amino acids, electrolytes, and other nutrients found in TPN. Prolonged use can lead to imbalances and nutritional deficiencies.
C. Dextrose 5% in water is a commonly used IV fluid that can be administered temporarily while waiting for the next TPN container. It provides hydration and some calories, but it's important to monitor the client's glucose levels closely.
D. While 0.9% sodium chloride (normal saline) is used for fluid replacement, it can lead to hypernatremia (excess sodium) if used for extended periods, especially in clients receiving TPN.

A. Relief of gastrointestinal pain B. Alleviate Helicobacter pylori C. Prevention of opportunistic infections D. Improvement of impaired vision

Correct Answer is A

Explanation

A. Sucralfate acts locally on the gastrointestinal mucosa by forming a protective barrier that adheres to ulcers and erosions. This barrier helps protect the tissue from stomach acid and promotes healing. As a result, the therapeutic effect of sucralfate often includes relief from gastrointestinal pain associated with ulcers and erosions.
B. Sucralfate does not directly treat Helicobacter pylori, a bacterium often associated with peptic ulcers. The treatment for H. pylori usually involves a combination of antibiotics and acid-reducing medications such as proton pump inhibitors (PPIs) or H2-receptor antagonists.
C. Sucralfate does not have a role in preventing opportunistic infections. It is specifically used to protect and heal the gastrointestinal lining, not to influence immune function or infection risk.
D. Sucralfate does not affect vision. It is used to treat gastrointestinal issues, not ocular conditions. Improvement of impaired vision is not related to the therapeutic effect of sucralfate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client's next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives?

Correct Answer is C

Explanation

A nurse is caring for a client who is taking sucralfate. Which of the following outcomes indicates a therapeutic effect of the medication?

Correct Answer is A

Explanation

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