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 A
Explanation
This is because the nurse should first ensure that help is on the way before performing any other actions on an unconscious and unresponsive client. Calling for assistance may also alert someone who can bring an automated external defibrillator (AED) if needed.
Choice B is wrong because giving 2 rescue breaths is part of CPR, which should only be done after checking for a pulse and finding none or a weak one.
Giving rescue breaths to a client who has a pulse may cause harm.
Choice C is wrong because checking for apical pulse is not the most reliable way to assess circulation in an emergency situation. The nurse should check for a carotid pulse instead, which is easier to locate and more indicative of blood flow to the brain.
Choice D is wrong because beginning chest compressions is also part of CPR, which should only be done after calling for assistance and checking for a pulse and finding none or a weak one.
Chest compressions may cause harm to a client who has a pulse.
Correct Answer is D
Explanation
The client with a labored respiratory rate of 28 should be seen first because this indicates respiratory distress, which is a life-threatening condition that requires immediate intervention. Respiratory rate is one of the vital signs that are used to assess the severity of a patient’s condition and to triage them accordingly. A normal respiratory rate for an adult is 12 to 20 breaths per minute.
Choice A is wrong because a large laceration on the left scapula is not as urgent as respiratory distress.
A laceration is a wound that involves a cut or tear in the skin, which may cause bleeding, pain, and infection. However, it can be managed with wound care and suturing in the urgent care center.
Choice B is wrong because a compound fracture of the right tibia is not as urgent as respiratory distress.
A compound fracture is a fracture that breaks through the skin, which may cause bleeding, pain, infection, and nerve or blood vessel damage. However, it can be stabilized with splinting and dressing in the urgent care center before transferring to a hospital for further treatment.
Choice C is wrong because being unable to breastfeed a 4 week old is not as urgent as respiratory distress.
Breastfeeding difficulties may be caused by various factors, such as poor latch, low milk supply, sore nipples, or mastitis. However, they can be managed with education, support, and medication in the urgent care center.
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