A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

"Perform muscle relaxation before bedtime.”

"Exercise vigorously 1 hour prior to going to bed.”

"Drink a cup of hot chocolate at bedtime.”

"Change the time you go to sleep each day.”

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: "Perform muscle relaxation before bedtime."

Choice A rationale:

Suggesting to the client to "Perform muscle relaxation before bedtime" is a helpful recommendation. Muscle relaxation techniques, such as progressive muscle relaxation or deep breathing exercises, can help calm the body and mind, making it easier to fall asleep.

Choice B rationale:

Advising the client to "Exercise vigorously 1 hour prior to going to bed" is not recommended. Vigorous exercise close to bedtime can actually stimulate the body and make it harder to fall asleep. Gentle, non-strenuous activities are more suitable before bedtime.

Choice C rationale:

Recommending the client to "Drink a cup of hot chocolate at bedtime" is not ideal. Hot chocolate contains caffeine, which is a stimulant that can interfere with sleep. It's better to avoid caffeine-containing beverages close to bedtime.

Choice D rationale:

Suggesting the client to "Change the time you go to sleep each day" disrupts the body's internal clock and sleep-wake cycle. Maintaining a consistent sleep schedule, even on weekends, helps regulate the body's natural sleep patterns.

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Correct Answer is B

Explanation

The correct answer is choice B. Removing the client's dentures.

Choice A rationale:

Gathering the client's personal belongings is an appropriate action in the postmortem care process. This step allows the family to receive their loved one's belongings, contributing to a compassionate and respectful care process.

Choice B rationale:

Removing the client's dentures requires intervention by the nurse. In postmortem care, dentures should be left in place to maintain the natural appearance of the deceased's face and to ensure that the mouth and lips maintain their proper form.

Choice C rationale:

Placing absorbent pads under the client's buttocks is a common practice to manage any potential leakage of bodily fluids after death. This action helps maintain the cleanliness and dignity of the deceased individual.

Choice D rationale:

Closing the client's eyes is an appropriate action during postmortem care. It provides a peaceful appearance and shows respect for the deceased person.

A. "What types of foods have you been eating?” B. "Are you using stool softeners or laxatives?” C. "Have you been passing gas?” D. "Have you had small liquid stools?”

Correct Answer is D

Explanation

The correct answer is choice d. “Have you had small liquid stools?”

Choice A rationale:

While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.

Choice B rationale:

Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.

Choice C rationale:

Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.

Choice D rationale:

Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.

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A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is B

Explanation

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

Correct Answer is D

Explanation

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via a simple face mask. Which of the following actions should the nurse take to ensure client safety?

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences?

A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent healthcare-associated infections for these clients? (Select all that apply.)