A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following actions should the nurse take first?

Determine the source of the client's stress.

Instruct the client to turn off their TV just before they go to bed.

Encourage the client to listen to soft music at the onset of stress.

Advise the client to exercise daily in the morning.

Answer and Explanation

The Correct Answer is A

A. Determine the source of the client's stress: The first step in managing insomnia related to stress is assessing and identifying the underlying cause. Understanding the source allows the nurse to tailor interventions effectively and ensures that care addresses the root of the problem rather than just the symptoms.

B. Instruct the client to turn off their TV just before they go to bed: Reducing screen time before sleep is helpful in promoting rest, but this is a specific behavioral strategy. It should follow an assessment of the client’s stressors and sleep patterns to be applied appropriately.

C. Encourage the client to listen to soft music at the onset of stress: Relaxation techniques such as music therapy can aid stress reduction, but they are supportive measures. Without assessing the client’s unique stressors first, these interventions may not fully address the insomnia.

D. Advise the client to exercise daily in the morning: Morning exercise can improve sleep quality and reduce stress, but it is a long-term strategy. The nurse must first explore the client’s stress triggers to ensure that interventions are individualized and effective.

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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

A. Only use restraints if the client becomes violent: Restraints should be used as a last resort when the client poses a danger to themselves or others. They are not meant for convenience or managing disorientation alone.

B. Use seclusion to manage the client's behavior: Seclusion is typically reserved for managing severe aggression or self-harm in psychiatric settings. It is not an appropriate first-line intervention for a disoriented client attempting to get out of bed.

C. Attempt the use of less restrictive methods before using restraints: The nurse should first implement interventions such as frequent monitoring, bed alarms, or sitter assistance. This approach prioritizes client safety while respecting autonomy and minimizing harm.

D. Use restraints for the minimum amount of time necessary: If restraints are applied, they must be removed as soon as it is safe to do so to prevent physical and psychological complications, adhering to best practice and regulatory guidelines.

E. Ensure the restraint limits the client's movement as little as possible: Proper application of restraints focuses on safety while allowing maximum mobility and comfort. Overly restrictive restraints can cause injury, skin breakdown, and additional stress.

A. "I will regulate the oxygen flow rate as needed." B. "I will store oxygen tanks in an upright position." C. "I should check the oxygen equipment once per week." D. "I should place the oxygen equipment 4 feet from a heat source."

Correct Answer is B

Explanation

A. "I will regulate the oxygen flow rate as needed.": Clients should never change their prescribed oxygen flow rate independently. Altering the rate without guidance can lead to hypoxemia if too low or oxygen toxicity if too high.

B. "I will store oxygen tanks in an upright position.": Oxygen cylinders should always be stored upright and secured to prevent tipping, which could cause the cylinder to become a dangerous projectile. This demonstrates safe handling of compressed oxygen.

C. "I should check the oxygen equipment once per week.": Oxygen equipment should be checked daily for function, cleanliness, and safety. Weekly checks are insufficient and could allow unnoticed malfunctions to compromise oxygen delivery.

D. "I should place the oxygen equipment 4 feet from a heat source.": Oxygen equipment should be kept at least 8 feet away from open flames, heaters, or other heat sources. Four feet is too close and increases the risk of fire hazards.

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A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is disoriented and is continuously getting out of bed. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy using a compressed oxygen system. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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