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 C

Explanation

The correct answer is: c. The AP pulls the pinna up and back.

Choice A reason: The AP inserting the probe with a straight, forward motion is not the correct technique for tympanic temperature measurement. The ear canal does not run straight forward into the head; instead, it curves slightly. Inserting the probe straight forward could potentially damage the ear canal or eardrum and would not provide an accurate temperature reading.

Choice B reason: Pointing the probe posteriorly is also incorrect. The tympanic membrane is located at the end of the ear canal, and the probe should be directed towards it. However, the probe should be angled slightly downward and toward the jawline, not straight back, to align with the ear canal and ensure an accurate reading.

Choice C reason: Pulling the pinna up and back is the correct method for adults and children over one year old. This action straightens the ear canal, allowing the thermometer’s sensor to get a clear path to the tympanic membrane, which is necessary for an accurate temperature reading. For infants, the correct method is to pull the earlobe straight back.

Choice D reason: The AP positioning the client facing her does not directly relate to the technique of measuring tympanic temperature. While it may be necessary for the AP to see the client’s ear, it is not an indication of understanding the correct procedure for tympanic temperature measurement.

A. Establish learning outcomes. B. Create handouts for participants. C. Determine the literacy level of participants. D. Schedule a time to implement the program.

Correct Answer is C

Explanation

Choice A rationale:

Establish learning outcomes. Establishing learning outcomes is an important step in developing an education program, but it should not be the first step. Before setting learning outcomes, the nurse should assess the participants' needs and abilities, which includes determining their literacy level. Without this information, it is difficult to create meaningful and relevant learning outcomes.

Choice B rationale:

Create handouts for participants. Creating handouts is an essential part of the education program, but it should come after determining the literacy level of participants. Handouts should be tailored to the participants' literacy levels to ensure that they can understand and benefit from the materials provided.

Choice D rationale:

Schedule a time to implement the program. Scheduling a time to implement the program is also an important step, but it should not be the first action taken. Before scheduling, the nurse needs to gather information about the participants' needs and abilities to ensure that the program is appropriately designed and timed for their convenience.

Choice C rationale:

Determine the literacy level of participants. Determining the literacy level of participants should be the first action taken when developing an education program for older adults. This step is crucial because it helps the nurse understand the participants' reading and comprehension abilities. It allows the nurse to tailor the program materials and teaching methods to match the literacy level of the group. Older adults may have varying levels of literacy, and customizing the program to their needs will improve its effectiveness and ensure that participants can fully engage and benefit from the educational content.

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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 observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Correct Answer is C

Explanation

A nurse is assisting with the development of an education program for a group of older adults.Which of the following actions should the nurse take first?

Correct Answer is C

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?