A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?
Offer a wet washcloth for the client to wash their face.
Perform range-of-motion exercises.
Prepare hot cocoa or tea for the client.
Provide a late supper.
The Correct Answer is A
A. Offer a wet washcloth for the client to wash their face: Washing the face with a wet washcloth can promote relaxation and help signal to the body that it’s time to wind down. This calming routine can be soothing and may help improve the client’s ability to fall asleep.
B. Perform range-of-motion exercises: Doing range of motion exercises shortly before bedtime can be overstimulating. Physical activity close to bedtime may increase alertness and make it harder for the client to fall asleep.
C. Prepare hot cocoa or tea for the client: While warm drinks might seem comforting, caffeine in some teas or high sugar in hot cocoa can interfere with sleep. It’s important to avoid stimulants and opt for calming beverages, such as caffeine-free herbal teas, instead.
D. Provide a late supper: A large meal late at night can be disruptive to sleep as it may cause indigestion or discomfort. It’s better to encourage lighter, earlier meals to prevent any disturbances that could affect the client’s ability to fall asleep.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place a vibrating tuning fork against the midline vertex of the client's head: The Weber test is performed by placing a vibrating tuning fork on the midline of the client's forehead or vertex of the head. This tests for lateralization of sound, helping to distinguish between conductive and sensorineural hearing loss based on which ear hears the sound louder.
B. Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden: This action refers to the "speech discrimination test" rather than the Weber test. It is not part of the Weber test, which is specifically used to assess the lateralization of sound.
C. Whisper words for the client to identify: This refers to a different hearing test, called the "whisper test," used to assess hearing ability, not the Weber test. The Weber test specifically uses a tuning fork to assess how sound is heard by the client.
D. Ask the client to occlude one ear with a finger: While blocking one ear can be used in other tests (like Rinne's test), it is not necessary for the Weber test, which involves placing the tuning fork in the center of the head.
Correct Answer is D
Explanation
A. Place the client in a supine position: The position should prioritize the client’s safety and comfort, considering their condition and the risk of aspiration or discomfort. A supine position may not be the most appropriate for this client’s agitation or confusion.
B. Attach the straps to the side rails of the bed frame: Attaching the restraints to the side rails could be dangerous, as it may cause injury or further agitation. Restraints should be attached to a non-movable part of the bed to ensure the client’s safety and prevent injury due to entrapment.
C. Secure the straps with a square knot: Restraints should not be secured with a square knot, as this could make them difficult to release quickly in an emergency. Instead, the restraint should be fastened in a way that allows for quick removal when needed to ensure the client's safety.
D. Remove the restraints every 2 hr: It is essential to remove restraints at least every 2 hours to check for any signs of injury, provide comfort, and ensure circulation. Removing restraints allows for proper skin care and reduces the risk of complications like pressure ulcers.
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