The nurse is caring for a client who is having difficulty sleeping in the hospital environment. How can the nurse intervene? (SELECT ALL THAT APPLY)
Offer the client a few pieces of chocolate before bedtime.
Monitor the temperature in the client's room.
Make certain bed linens are clean and dry.
Assess the client for any issues with discomfort.
Move the client closer to the nursing station.
Correct Answer : B,C,D
B. Temperature can significantly affect sleep quality. Ensuring the room is kept at a comfortable temperature (not too hot or cold) can promote better sleep. This intervention is appropriate.
C. Clean and dry bed linens contribute to comfort, which is essential for promoting sleep. This intervention is appropriate.
D. Discomfort can be a major barrier to sleep. Addressing any discomfort, such as pain, anxiety, or positioning issues, can help improve the client's ability to fall and stay asleep. This intervention is appropriate.
A. Offering chocolate, which contains caffeine, close to bedtime is not recommended as caffeine can interfere with sleep. Therefore, this option is not appropriate.
E. Moving the client closer to the nursing station may increase noise and disrupt sleep, especially if there are frequent activities or conversations near the nursing station. Therefore, this option is not typically recommended unless the client requires closer monitoring due to medical reasons.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Confusion can be an early sign of hypoxia, especially when oxygen delivery to the brain is compromised. Inadequate oxygenation can affect cognitive function and mental status, leading to confusion. This occurs because the brain is highly sensitive to changes in oxygen levels.
B. Apnea refers to the absence of breathing. While severe hypoxia can lead to respiratory arrest and apnea, it is not typically an early manifestation of hypoxia. Early hypoxia is characterized by attempts to increase ventilation to compensate for decreased oxygen levels, rather than complete cessation of breathing.
C. Cyanosis occurs when there is a bluish discoloration of the skin and mucous membranes due to deoxygenated hemoglobin in the blood. Cyanosis is a late sign of hypoxia and usually indicates significant oxygen deprivation. It is not typically seen in early hypoxia stages.
DDysrhythmias (irregular heart rhythms) can occur as a result of hypoxia, especially if the heart muscle is not receiving enough oxygen. However, dysrhythmias are generally considered a later manifestation of hypoxia, as the heart attempts to compensate for decreased oxygen delivery.
Correct Answer is ["A","B","E"]
Explanation
A. This is located on the lateral side of the thigh. It is a commonly used site for infants, toddlers, and young children, as well as adults who require large-volume injections.
B. This site is located on the hip or gluteal region. It is considered one of the safest and least painful sites for intramuscular injections in adults. It is also used when the volume of medication is larger or when the dorsogluteal site is contraindicated.
E. This site is located on the upper arm, specifically the lateral aspect. It is commonly used for vaccines and medications that require smaller volumes in adults and older children.
C. There is no specific muscle called the "rectus lateralis." It seems to be a combination of the rectus femoris (a muscle in the quadriceps group of the thigh) and the vastus lateralis. However, neither "rectus lateralis" nor "rectus femoris" is commonly used as a distinct injection site in clinical practice.
D. This site is located on the buttocks. Historically, it was a commonly used site for intramuscular injections, but it has fallen out of favor due to the potential risk of injury to the sciatic nerve and superior gluteal artery.
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