The nurse is educating a client with insomnia how to promote better sleep. Which interventions should she include for this client? (Select all that apply).

The nurse should complete an incident report when he or she contaminates and discards two indwelling catheters during the insertion procedure. This is because an incident report is a tool for documenting any event that is not consistent with the routine operation of a health care unit or the routine care of a client. An incident report helps to identify potential risks and improve quality and safety.

Choice A is wrong because not completing the care plan for a newly admitted client before leaving the unit is not an incident that requires reporting.

It is a matter of time management and prioritization.

Choice B is wrong because recording a client’s refusal to take prescribed medication on the chart is not an incident that requires reporting.

It is a part of the nursing documentation and communication.

Choice D is wrong because experiencing back pain after moving a client up in the bed is not an incident that requires reporting.

It is a personal injury that may be related to improper body mechanics or ergonomics.

A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.

The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.

Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.

Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.

The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.

Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.

Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.

The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.