A nurse is reinforcing teaching for with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instructions?

“I don’t take naps throughout the day.”

“I go to bed and get up at the same times each day.”

“I have a small snack and take a bath before going to bed each day.”

“I watch television until I fall asleep at night.”

Answer and Explanation

The Correct Answer is D

A. “I don’t take naps throughout the day.”

This statement suggests that the client avoids daytime napping, which is generally a positive sleep habit. Excessive daytime napping can interfere with nighttime sleep.

B. “I go to bed and get up at the same times each day.”

Maintaining a consistent sleep schedule is a key component of good sleep hygiene. Going to bed and waking up at the same times helps regulate the body's internal clock.

C. “I have a small snack and take a bath before going to bed each day.”

Having a light snack and engaging in a relaxing activity like a bath before bedtime can contribute to a more conducive sleep environment. However, the type and timing of the snack should be considered.

D. “I watch television until I fall asleep at night.”

This statement may indicate a need for further instruction. Watching television right before bedtime, especially until falling asleep, can be counterproductive to good sleep hygiene due to the stimulating effects of the screen's blue light.

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Correct Answer is D

Explanation

A. Provide an antiemetic.

While providing an antiemetic can help alleviate the client's nausea and vomiting, it is not the priority action. Assessment should come first to determine the underlying cause.

B. Make the client NPO.

Making the client NPO might be necessary if there is concern about bowel obstruction or other gastrointestinal issues, but this decision should be based on an initial assessment, such as auscultating bowel sounds.

C. Administer a stimulant laxative.

Administering a stimulant laxative is not appropriate at this stage without first assessing bowel sounds. It could potentially worsen the situation if there is a bowel obstruction.

D. Auscultate bowel sounds.

The priority in this situation is to assess for possible complications such as bowel obstruction or paralytic ileus, which can occur postoperatively and can be exacerbated by opioid use. Auscultating bowel sounds helps determine the presence of normal, hypoactive, or absent bowel sounds, guiding further management.

A. “I will keep my baby’s head slightly elevated during the feeding.” B. “I will hold my baby close to me while feeding.” C. “Each feeding should last about 15 minutes.” D. “Propping a bottle can cause otitis media.”

Correct Answer is C

Explanation

A. “I will keep my baby’s head slightly elevated during the feeding.”

This statement is correct. Keeping the baby's head slightly elevated during feeding can help prevent ear infections (otitis media) and is a recommended practice.

B. “I will hold my baby close to me while feeding.”

Holding the baby close during feeding promotes bonding and is generally considered a good practice for both bottle-feeding and breastfeeding.

C. “Each feeding should last about 15 minutes.”

This statement indicates a need for further teaching. The duration of a feeding can vary among infants, and it's not advisable to put a strict time limit on each feeding. It's important to follow the baby's cues and allow for individual variations in feeding patterns.

D. “Propping a bottle can cause otitis media.”

This statement is correct. Propping a bottle can lead to ear infections (otitis media) and is not a safe or recommended practice. The baby should be held during feedings to prevent these issues.

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A nurse is reinforcing teaching for with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instructions?

Nursing Test Bank

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