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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Acquiring coping skills is important, but the immediate focus for discharge planning is on practical goals related to managing daily activities and maintaining independence rather than on long-term psychological coping.
B. Conserve energy is the most important goal for a client with rheumatoid arthritis preparing for discharge. Managing energy effectively helps clients cope with fatigue and pain, which are common challenges in daily life with rheumatoid arthritis.
C. Adapting self-care skills is also important but is a broader goal that includes conserving energy as a component. Effective energy management is a key aspect of self-care for clients with rheumatoid arthritis.
D. Improving body image is a valid goal but is not the most urgent concern for discharge planning. The primary focus should be on practical aspects of managing rheumatoid arthritis in daily life.

A. Re-lubricate the tubing and re-insert it. B. Insert the tubing an additional three inches into the rectum. C. Raise the saline container six inches higher. D. Instruct the client to take several slow, deep breaths.

Correct Answer is B

Explanation

A. Re-lubricating the tubing and re-inserting it is unnecessary if the enema solution is not infusing; the primary issue is likely related to the tubing's position or the height of the container.
B. Inserting the tubing an additional three inches into the rectum ensures that it is positioned correctly for the solution to flow. If the tubing is not inserted far enough, the solution may not enter the rectum.
C. Raising the saline container higher is not needed since it is already six inches above the client’s body. The problem is more likely related to the tubing’s depth rather than the height of the container.
D. Instructing the client to take deep breaths does not affect the infusion of the enema solution. The solution's flow is influenced by the mechanics of the enema administration, not by the client’s breathing.

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In implementing the plan of care, which data should the practical nurse (PN) obtain first for a client with a sleep pattern disturbance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assigned to provide care for a client with rheumatoid arthritis who is preparing for discharge. While planning the client's care, the PN should identify which client goal as the most important?

Correct Answer is B

Explanation

When administering a saline enema, the practical nurse (PN) inserts the enema tubing three inches into the client's rectum, and elevates the container six inches above the client's body. When the clamp is opened, the solution does not infuse. Which action should the PN take?

Correct Answer is B

Explanation

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) obtain a client's vital signs. The PN should intervene when observing the UAP performing which technique?

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

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The practical nurse (PN) assesses a child in 90-90 skeletal traction. It is most important for the PN to assess for signs of inflammation at which location? (Select the correct location on the image)

A female client who has been taking oral contraceptives for the past year comes into the clinic for an annual exam. Which finding is most important for the practical nurse (PN) to report to the healthcare provider?

An unlicensed assistive personnel (UAP) is assisting with the care of a client with a peripherally inserted central venous catheter (PICC). Which guidance should the practical nurse (PN) provide to the UAP?

The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?

What foods should the practical nurse (PN) recommend to a client as good sources of vitamin K? Select all that apply.