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 B

Explanation

Choice A rationale:

The administration of Rh(D) immune globulin (RhoGAM) is typically indicated for Rh-negative mothers who are carrying Rh-positive fetuses to prevent sensitization to Rh antigens. It is not directly related to the amniocentesis procedure. Therefore, this information is not necessary for the client undergoing an amniocentesis.

Choice B rationale:

This is the correct answer. Having an empty bladder is crucial during an amniocentesis procedure because a full bladder can obscure visualization of the fetus and the needle placement. It is essential for a successful and safe procedure. The nurse should instruct the client to empty their bladder before the test.

Choice C rationale:

The position during an amniocentesis is typically dorsal recumbent or semi-Fowler's position to allow for proper visualization of the fetus and needle placement. Lying on the left side is not a standard position for this procedure, so this information is incorrect and not necessary for the client.

Choice D rationale:

Drinking 50 grams of oral glucose is not a requirement for an amniocentesis procedure. This information is unrelated to the amniocentesis and can be confusing for the client. Therefore, it is not necessary to include this in the instructions.

A. Elevated amylase. B. Decreased bilirubin. C. Elevated lipase. D. Elevated ammonia.

Correct Answer is D

Explanation

Choice A rationale:

Elevated amylase is not typically associated with cirrhosis. Amylase is an enzyme produced by the pancreas and salivary glands, and elevated levels are more commonly associated with pancreatic disorders or acute pancreatitis.

Choice B rationale:

Decreased bilirubin is not an expected laboratory finding in cirrhosis. Cirrhosis often leads to impaired liver function, which can result in elevated bilirubin levels, causing jaundice.

Choice C rationale:

Elevated lipase is not a characteristic laboratory finding in cirrhosis. Lipase is an enzyme produced by the pancreas, and elevated levels are more often seen in pancreatic disorders or acute pancreatitis.

Choice D rationale:

The correct choice is D. Elevated ammonia levels are commonly associated with cirrhosis. In cirrhosis, the damaged liver is unable to effectively metabolize ammonia, leading to its accumulation in the blood. Elevated ammonia levels can result in hepatic encephalopathy, a neurological complication often seen in cirrhotic patients.

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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?

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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?