A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

Encourage the client to ambulate in the hallway 1 hr before bedtime.

Tell the client to avoid drinking fluids 1 hr before bedtime.

Schedule routine care tasks during hours when the client is awake.

Advise the client to leave the television in the room on when trying to fall asleep.

Answer and Explanation

The Correct Answer is C

A. Encourage the client to ambulate in the hallway 1 hr before bedtime: Physical activity too close to bedtime can increase heart rate and body temperature, making it more difficult for the client to fall asleep. While ambulation is beneficial for overall health, it should be scheduled earlier in the day to promote sleep rather than interfere with it.

B. Tell the client to avoid drinking fluids 1 hr before bedtime: Limiting fluids before bed may reduce nighttime awakenings due to urination, but it does not directly address the client’s difficulty falling asleep. This intervention can support sleep quality but is secondary to scheduling care and reducing disturbances.

C. Schedule routine care tasks during hours when the client is awake: Performing nursing care while the client is awake minimizes nighttime interruptions and allows for uninterrupted rest. Prioritizing sleep hygiene by aligning care with the client’s natural sleep-wake cycle is an effective strategy to improve sleep onset and overall sleep quality.

D. Advise the client to leave the television in the room on when trying to fall asleep: Leaving the television on provides light and auditory stimulation, which can interfere with melatonin release and delay sleep onset. This practice is counterproductive and can worsen difficulty falling asleep.

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Correct Answer is B

Explanation

A. Encourage the client to talk about their feelings: During a panic attack, clients are often overwhelmed and unable to process or articulate feelings. Encouraging discussion is helpful later but is not the first priority during acute panic.

B. Assure the client that they are in a safe place: Ensuring the client feels safe addresses immediate anxiety and establishes a calming environment. Safety and emotional stabilization are the first priorities according to the nursing process when managing acute panic attacks.

C. Promote problem-solving with the client: Problem-solving requires cognitive processing, which is impaired during a panic attack. This intervention is appropriate after the client has calmed and is able to think clearly.

D. Explore behaviors that have worked to relieve anxiety in the past: Reviewing coping strategies is useful once the client’s acute panic symptoms are under control. It is not the immediate priority compared with ensuring safety and reducing immediate fear.

A. Collecting a urine specimen B. Measuring a client's pain level C. Monitoring blood glucose levels D. Adjusting the flow rate of a client's oxygen tank

Correct Answer is A

Explanation

A. Collecting a urine specimen: This task is routine, noninvasive, and does not require nursing judgment, making it appropriate for delegation to assistive personnel. APs are trained to obtain clean-catch or routine urine specimens while following proper technique. Delegating this task allows the nurse to focus on interventions requiring professional judgment.

B. Measuring a client's pain level: Pain assessment requires clinical judgment and involves interpreting verbal and nonverbal cues. Determining the severity, characteristics, and impact of pain is a nursing responsibility. Because it directly influences clinical decisions and interventions, it cannot be delegated to assistive personnel.

C. Monitoring blood glucose levels: Although APs in some settings may perform point-of-care glucose checks, this task generally requires specific training and competency validation. Interpretation of results and subsequent actions rely on nursing assessment, making it less appropriate for routine delegation unless the facility has clear protocols allowing it.

D. Adjusting the flow rate of a client's oxygen tank: Oxygen therapy adjustment involves evaluating the client’s respiratory status and making changes that can affect ventilation and oxygenation. Altering flow rates requires nursing judgment to ensure safety and prevent complications such as hypoxia or CO₂ retention.

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A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

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