A nurse is collecting data from a client who has insomnia. The nurse should identify that which of the following is likely to disrupt sleep?

Exercise three times a week in the mornings.

Go to bed at the same time every evening.

Have two glasses of wine every night before bedtime.

Get out of bed when unable to sleep.

Answer and Explanation

The Correct Answer is C

Choice A reason: Regular morning exercise can actually promote better sleep. It helps to regulate the body's clock and can lead to deeper, more restful sleep. However, exercising too close to bedtime may have the opposite effect.

Choice B reason: Going to bed at the same time every evening can help establish a consistent sleep-wake cycle, which is beneficial for people who have insomnia. This regularity can make it easier to fall asleep and wake up naturally.

Choice C reason: Alcohol consumption before bedtime can disrupt sleep patterns. While it may initially help someone fall asleep, it often leads to poorer quality of sleep and can cause awakenings throughout the night.

Choice D reason: If unable to sleep, getting out of bed can be a good strategy. It's part of stimulus control therapy for insomnia, which advises leaving the bed if you can't sleep, so you don't associate the bed with wakefulness

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Correct Answer is C

Explanation

Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.

Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.

Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.

Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.

Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.

A. Pulse 82/min, client sitting in a chair B. Temperature 36.9°C (98.4°F) C. Respirations auscultated, even at 22/min, client supine D. Blood pressure 108/68 mm Hg

Correct Answer is A

Explanation

Choice A reason: Documenting the pulse as "82/min, client sitting in a chair" is correct and shows an understanding of the teaching. The pulse rate is within the normal range for a resting adult, which is typically between 60 to 100 beats per minute. Additionally, noting the client's position is important as body position can affect pulse rate; sitting can slightly increase the pulse compared to lying down.

Choice B reason: The temperature of "36.9°C (98.4°F)" is within the normal range for body temperature, which is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F). Documenting the temperature in both Celsius and Fahrenheit is a good practice, as it provides clarity and prevents confusion in clinical settings where different systems may be used.

Choice C reason: The documentation of respirations as "auscultated, even at 22/min, client supine" is appropriate. The normal respiratory rate for a healthy adult at rest is between 12 to 20 breaths per minute. Noting that the respirations are even and the client's position is supine is important, as different positions can affect breathing patterns and rates.

Choice D reason: A blood pressure reading of "108/68 mm Hg" falls within the normal range, which is generally considered to be between 90/60 mm Hg and 120/80 mm Hg for adults. Proper documentation of blood pressure includes both systolic and diastolic values, as seen here, which is essential for accurate monitoring and treatment decisions.

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A nurse is collecting data from a client who has insomnia. The nurse should identify that which of the following is likely to disrupt sleep?

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Naxlex Comprehensive Predictor Exams

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