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.
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Related Questions
Correct Answer is B
Explanation
A. Sliding hands under the lumbar area and knees can cause strain on the PN’s back and is not the safest method for turning a dependent client.
B. Using a turning sheet to turn the client away from the PN is the safest method for moving a dependent client, as it uses a proper technique that minimizes injury risk for both the client and the PN.
C. Raising bed rails on the opposite side may increase the risk of injury or falls, and is not directly related to the safe turning of the client.
D. Grasping the client's hand to pull them is unsafe and could cause injury or discomfort to both the client and the PN, especially when turning a dependent client.
Correct Answer is A
Explanation
A. Hoarseness in the voice following a thyroidectomy can be a sign of vocal cord damage or laryngeal nerve injury, which are potentially serious complications. The appropriate action is to notify the unit charge nurse to escalate the finding for further assessment by a physician or advanced practice provider.
B. Administering humidified oxygen does not specifically address the issue of hoarseness. While humidified oxygen might be beneficial for general respiratory comfort, it is not a targeted intervention for potential vocal cord damage.
C. Ensuring that the drainage device is compressed is important for managing surgical wounds but does not address or diagnose vocal cord issues. Hoarseness after thyroid surgery is more indicative of a potential complication rather than a drainage issue.
D. Obtaining ice chips does not address the underlying cause of the hoarseness and may not provide significant relief. The priority is to identify potential complications rather than offering symptomatic relief.
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