A nurse is caring for a hospitalized pre-operative client experiencing insomnia in the hospital at 3:00 am (0300).
Which nursing intervention is the most appropriate for this client?
Encourage a warm shower.
Offer a glass of warm milk.
Notify the health care provider.
Encourage the client to watch television.
The Correct Answer is D
Offer a glass of warm milk. According to some studies, warm milk may have a relaxing effect on the body and help induce sleep. It also contains tryptophan, an amino acid that is converted to serotonin and melatonin, which are neurotransmitters that regulate sleep cycles.
Choice A is wrong because a warm shower may increase the body temperature and make it harder to fall asleep.
Choice C is wrong because notifying the healthcare provider is not necessary for a client with insomnia unless there are other signs of distress or complications.
Choice D is wrong because watching television may stimulate the brain and interfere with the production of melatonin, a hormone that promotes sleep.
Some other nursing interventions for insomnia are:
- Educate the patient on the proper food and fluid intake such as avoiding heavy meals, alcohol, caffeine, or smoking before bedtime.
- Evaluate the patient’s sleep hygiene such as having a regular bedtime and wake-up time, avoiding naps during the day, and limiting exposure to light at night.
- Provide a conducive environment for sleep such as reducing noise, adjusting temperature and lighting, and using comfortable bedding.
- Help the patient develop a sleeping plan such as engaging in relaxing activities before bed, avoiding checking the clock, and getting out of bed if unable to sleep after 20 minutes.
- Understand the proper use of sleep aids or other medications such as following the prescription, avoiding over-the-counter drugs without consulting the provider, and being aware of the side effects and interactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
One drop left eye daily.
This is because it uses the correct abbreviation for left eye (os) and the correct frequency (daily).
The other choices are wrong because:
Choice A uses od which means right eye, not once daily.
Choice B uses ou which means both eyes, not each eye.
Choice C uses right ear which is not an eye drop medication. Some common eye drop prescription abbreviations are:
- gt or gtt for drop or drops
- od for right eye
- os for left eye
- ou for both eyes
- bid for twice a day
- tid for three times a day
- qid for four times a day
- prn for as needed
Correct Answer is C
Explanation
The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.
Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.
Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.
Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.
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