A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.
Which of the following interventions is the nurse's priority?

Inquire about the client's bedtime routine.

Recommend that the client go for a walk every morning.

Instruct the client to turn off the television before bedtime.

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

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Inquiring about the client's bedtime routine is the nurse's priority because it directly addresses the client's reported problem of insomnia due to increased stress. Understanding the client's routine can help identify factors contributing to sleep difficulties and guide the development of an appropriate plan of care.

Choice B rationale:

Recommending that the client go for a walk every morning may be a helpful intervention, but it does not directly address the client's immediate concern of insomnia. It's important to first assess the client's current situation and then provide tailored interventions.

Choice C rationale:

Instructing the client to turn off the television before bedtime is a good sleep hygiene practice, but it may not be the priority when the client is experiencing acute insomnia due to increased stress. The nurse should first gather information about the client's specific situation.

Choice D rationale:

Encouraging the client to listen to soft music at the onset of stress is a useful relaxation technique, but it may not be the priority in this case. The nurse should focus on addressing the client's insomnia by identifying contributing factors and implementing appropriate interventions.

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Correct Answer is D

Explanation

Choice A rationale:

A laissez-faire leadership style is characterized by a lack of involvement or control, and it is not typically associated with perpetrators of child abuse.

Choice B rationale:

Self-blame for financial problems may lead to stress but is not a characteristic finding of perpetrators of child abuse.

Choice C rationale:

High self-esteem is not typically associated with perpetrators of child abuse. In fact, abusers often have low self-esteem and exert power and control over others to compensate for it.

Choice D rationale:

Perpetrators of child abuse often have rigid expectations of behavior from their children and may employ authoritarian parenting styles. This characteristic can contribute to abusive behaviors.

A. A client who has an infection refused the evening meal. B. A client fell when ambulating to the bathroom alone. C. An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. D. A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. E. A client received an 0900 daily medication at 1000.

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

Explanation

The correct answers are Choices B, C, D, and E.

Choice A rationale: Refusal of meals, especially in an infected client, is not typically incident reportable. Nurses should note this in the client record and monitor the client's nutritional intake and overall condition.

Choice B rationale: Falls are always reportable incidents. When a client falls, an incident report is required to document the event, analyze contributing factors, and implement measures to prevent future falls.

Choice C rationale: Recording an approximate urine output due to leakage from the catheter bag is a reportable incident. Accurate measurement of urine output is essential, and an incident report helps to address the cause of leakage and prevent recurrence.

Choice D rationale: Administering antibiotics before blood culture and sensitivity testing can affect test results and is a reportable incident. The incident report documents the error and helps to implement measures to prevent such occurrences in the future.

Choice E rationale: Administering medication at the wrong time is a medication administration error. An incident report should be filed to document the deviation from the prescribed schedule and address any potential impacts on the client's condition.

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A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing risk factors for child abuse with members of a parenting group.The nurse should identify which of the following findings as characteristic of perpetrators of child abuse?

Correct Answer is D

Explanation

A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

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

Explanation

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A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.
Which of the following interventions is the nurse's priority?