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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min. This set of vital signs indicates that the client may have an infection or sepsis, which are potential complications of an open cholecystectomy. The client has a fever, tachycardia, tachypnea, and hypotension, which are signs of systemic inflammatory response syndrome (SIRS).

Choice A is wrong because it shows mild hypothermia, hypotension, and tachycardia, which could be due to dehydration or blood loss, but not necessarily infection.

Choice B is wrong because it shows a slight fever, normal blood pressure, and bradycardia, which could be due to pain or medication, but not infection.

Choice C is wrong because it shows a low-grade fever, normal blood pressure and pulse, and mild tachypnea, which could be due to inflammation or dehydration, but not infection.

A. Increased heart rate. B. Decreased blood pressure. C. Increased temperature. D. Hypoactive muscle responses. E. Alert and oriented.

Correct Answer is ["A","B"]

Explanation

Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.

Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.

Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.

Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.

Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:

Heart rate: 60 to 100 beats per minute for adults
Blood pressure: less than 120/80 mmHg for adults

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Correct Answer is ["A","B"]

Explanation

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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?