A nurse is assessing a client who has chronic insomnia. Which question would address the highest safety priority for the client?

When did you begin to have trouble sleeping?

Are there any specific factors that you think are affecting your ability to sleep?

Do you have difficulty staying awake when you are driving?

Can you describe your bedtime routine to me?

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Asking “When did you begin to have trouble sleeping?” is important for understanding the onset and duration of the client’s insomnia. However, it does not directly address immediate safety concerns. Chronic insomnia can lead to significant daytime impairment, but the question about the onset of sleep troubles does not identify specific safety risks.

Choice B Reason:

Inquiring about specific factors affecting the client’s ability to sleep can help identify potential causes of insomnia, such as stress, environmental factors, or medical conditions. While this information is valuable for treatment planning, it does not directly address immediate safety concerns.

Choice C Reason:

Asking “Do you have difficulty staying awake when you are driving?” addresses the highest safety priority. Chronic insomnia can lead to excessive daytime sleepiness, which significantly increases the risk of accidents, especially while driving. Identifying whether the client is at risk of falling asleep during potentially dangerous activities is crucial for immediate safety.

Choice D Reason:

Understanding the client’s bedtime routine can provide insights into their sleep hygiene and habits, which are important for managing insomnia. However, this question does not directly address immediate safety concerns related to daytime functioning and the risk of accidents.

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Correct Answer is C

Explanation

Choice A reason: While lift pads can help reduce the risk of workplace injuries for staff, such as pulled muscles, this is not their primary purpose. The main goal of using lift pads is to protect the client from injury during repositioning. Lift pads distribute the client’s weight more evenly, making it easier for staff to move them without straining themselves.

Choice B reason: Lift pads are not designed to absorb urinary incontinence or contain stool. There are specific products like incontinence pads and briefs for managing urinary and fecal incontinence. Lift pads are primarily used to assist with the safe repositioning of immobile clients.

Choice C reason: The primary purpose of lift pads is to help prevent friction and shearing when repositioning the client. Friction and shearing can cause skin damage and pressure ulcers, especially in immobile clients. Lift pads reduce the risk of these injuries by allowing smoother and safer movements.

Choice D reason: Lift pads do not prevent clients from being diaphoretic (sweating excessively). Diaphoresis can be managed through other means, such as adjusting room temperature, using fans, or providing appropriate clothing and bedding. Lift pads are not intended for this purpose.

A. Urinary tract infection B. Deep vein thrombosis C. Constipation D. Atelectasis

Correct Answer is D

Explanation

Choice A Reason:

Urinary tract infections (UTIs) are typically caused by bacteria entering the urinary tract. While strict bed rest can increase the risk of UTIs due to factors like catheter use and reduced mobility, the use of an incentive spirometer does not directly prevent UTIs. Instead, preventing UTIs involves maintaining good hygiene, ensuring adequate fluid intake, and, if necessary, using catheters properly.

Choice B Reason:

Deep vein thrombosis (DVT) is a condition where blood clots form in the deep veins, usually in the legs. This can occur due to prolonged immobility, such as strict bed rest after surgery. Preventing DVT involves measures like using compression stockings, administering anticoagulant medications, and encouraging leg exercises. An incentive spirometer, which is used to improve lung function, does not directly prevent DVT.

Choice C Reason:

Constipation is a common issue for patients on bed rest due to reduced physical activity and changes in diet. Preventing constipation involves ensuring adequate hydration, providing a high-fiber diet, and encouraging as much physical activity as possible. The use of an incentive spirometer, which focuses on respiratory function, does not directly address constipation.

Choice D Reason:

Atelectasis is a condition where the alveoli in the lungs collapse, leading to reduced or absent breath sounds in the affected areas. This is a common postoperative complication, especially in patients on strict bed rest, due to shallow breathing and reduced lung expansion. The use of an incentive spirometer encourages deep breathing and helps to keep the alveoli open, thereby preventing atelectasis. This is why the incentive spirometer is an essential tool for postoperative respiratory care.

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A nurse is assessing a client who has chronic insomnia. Which question would address the highest safety priority for the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?

Correct Answer is C

Explanation

A nurse is caring for a client who will be placed on strict bed rest after surgery. The nurse should educate the client on the use of an incentive spirometer. The use of an incentive spirometer would prevent which postoperative complication?

Correct Answer is D

Explanation

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A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?