In implementing the plan of care, which data should the practical nurse (PN) obtain first for a client with a sleep pattern disturbance?
The client's current and previous sleep habits and cycles.
The client's evening meal and snacking habits at bedtime.
Symptoms that occur as the result of sleep disturbance.
Sleep routines that the client has thought about practicing.
The Correct Answer is A
A. Understanding the client’s current and previous sleep habits and cycles is the most foundational step for assessing sleep disturbances. This information provides a baseline from which the PN can identify patterns and deviations in the client’s sleep behavior.
B. While evening meal and snacking habits can affect sleep, they are secondary to understanding the client’s overall sleep habits and cycles. These habits are part of a broader assessment but not the initial focus.
C. Identifying symptoms resulting from sleep disturbances is important but follows after understanding the client’s sleep history. Symptoms are a result of disturbances, and their identification is based on a foundational understanding of sleep patterns.
D. Exploring new sleep routines the client is considering is part of the intervention phase but comes after understanding current sleep patterns and disturbances. The initial focus should be on gathering comprehensive sleep history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Instructing the UAP to lower the bed for safety is the correct action. The bed should be in a low position to prevent falls and ensure safety during client care activities.
B. Determining if the UAP would like assistance is not the most effective immediate action. The priority is to address the safety concern of the bed position rather than offering assistance.
C. Remaining in the room to supervise the UAP is less effective than directly addressing the safety issue. The bed should be in the proper position for safe client care.
D. Assuming care of the client immediately is not necessary unless there are additional concerns about the client's well-being. The primary action should be to correct the unsafe practice of the bed position.
Correct Answer is A, F, E
Explanation
A. Take the child's pulse
Assessing the pulse is crucial to determine if the child has a heartbeat and to evaluate the effectiveness of CPR. This helps to determine the current cardiovascular status of the child and the urgency of further resuscitation efforts.
F. Determine if the child's airway is clear
Ensuring a clear airway is a priority in any emergency situation. A blocked airway can prevent effective ventilation and oxygenation, which is critical for a child who has experienced a near-drowning incident.
D. Start a peripheral IV line
Starting a peripheral IV line is important for administering fluids and medications that may be necessary for resuscitation and stabilization. It allows for rapid access to the child's circulatory system for necessary interventions.
E. Look for any open wounds
Checking for open wounds is necessary to identify any immediate sources of bleeding or potential infections that need to be addressed. It is part of a thorough initial assessment to ensure comprehensive care for the child.
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