To promote adequate sleep for a patient who suffers from a sleep pattern disturbance, what are the most appropriate nursing interventions? (Select all that apply).
Provide personal hygiene before bedtime.
Synchronize the schedule for medications and vital signs.
Administer sleep aids every night at the same time.
Assist the patient to use the toilet before bed.
Straighten and change any soiled bed linens.
Correct Answer : A,B,D,E
Choice A reason: This is a correct choice because providing personal hygiene before bedtime is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to feel more comfortable, relaxed, and refreshed, and to reduce the risk of infection or skin breakdown.
Choice B reason: This is a correct choice because synchronizing the schedule for medications and vital signs is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to have uninterrupted sleep cycles, and to avoid unnecessary disturbances or discomforts from frequent assessments or treatments.
Choice C reason: This is an incorrect choice because administering sleep aids every night at the same time is not an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can cause dependence, tolerance, or adverse effects from the sleep aids, and may not address the underlying cause of the sleep problem. The nurse should use non-pharmacological methods to promote sleep, and administer sleep aids only as prescribed and indicated.
Choice D reason: This is a correct choice because assisting the patient to use the toilet before bed is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to avoid nocturia, which is the need to urinate at night, and to prevent urinary tract infections or incontinence.
Choice E reason: This is a correct choice because straightening and changing any soiled bed linens is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to maintain a clean, dry, and comfortable sleeping environment, and to prevent skin irritation or infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because asking the patient about his usual blood pressure results is not a priority action. The patient's blood pressure is elevated, but not dangerously high. The nurse should monitor the blood pressure and report any significant changes to the physician, but this is not an urgent intervention.
Choice B reason: This is an incorrect choice because applying a cool washcloth to the patient's forehead is not a priority action. The patient's temperature is normal, and there is no indication of fever or heat stroke. The nurse should ensure the patient is comfortable and hydrated, but this is not an urgent intervention.
Choice C reason: This is the correct choice because administering oxygen at 2 L/minute via nasal cannula is a priority action. The patient's pulse oximetry is low, indicating hypoxia or inadequate oxygenation of the tissues. The nurse should provide supplemental oxygen to improve the patient's oxygen saturation and prevent further complications.
Choice D reason: This is an incorrect choice because documenting the findings in the patient's medical record is not a priority action. The nurse should document the patient's vital signs and any interventions performed, but this is not an urgent intervention. The nurse should prioritize the patient's safety and well-being over documentation.
Correct Answer is A
Explanation
Choice A reason: This is correct. Teaching the patient to wear low-heeled, comfortable, supportive footwear at all times is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet. This can prevent foot injuries, ulcers, and infections that can lead to amputation.
Choice B reason: This is incorrect. Encouraging the patient to participate in tai chi exercises to promote balance is a beneficial intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Tai chi can improve muscle strength, coordination, and flexibility, but it does not protect the feet from injury.
Choice C reason: This is incorrect. Evaluating the patient's blood pressure for orthostatic hypotension is an important intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Orthostatic hypotension is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting. It can be caused by autonomic neuropathy, which affects the nerves that control blood pressure and heart rate.
Choice D reason: This is incorrect. Instructing the patient to wear a medical alert bracelet that identifies risk for falls is a helpful intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. A medical alert bracelet can alert emergency personnel of the patient's condition and medications, but it does not prevent falls or foot injuries.
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