What would be the primary focus of interventions for a client who sleepwalks?

Administer and teach about medications to suppress stage III sleep.

Encourage the child to verbalize feelings regarding sleep pattern.

Provide a quiet environment for nighttime sleep.

Maintain patient safety during episodes of somnambulism.

Answer and Explanation

The Correct Answer is D

A) Administer and teach about medications to suppress stage III sleep:
Suppressing stage III sleep is not a primary intervention for sleepwalking and could potentially disrupt the client’s overall sleep quality.

B) Encourage the child to verbalize feelings regarding sleep pattern:
While understanding feelings about sleep patterns may be helpful, it is not the immediate priority in managing sleepwalking.

C) Provide a quiet environment for nighttime sleep:
A quiet environment is generally beneficial for good sleep hygiene but does not directly address the safety concerns associated with sleepwalking.

D) Maintain patient safety during episodes of somnambulism:
Ensuring the client’s safety is the primary focus. Sleepwalking can lead to accidents or injuries; therefore, implementing safety measures to prevent harm during episodes of somnambulism is crucial. This may include securing the environment, using safety gates, and ensuring the client’s immediate surroundings are safe.

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Correct Answer is C

Explanation

A. Contact the provider for further orders:
Contacting the provider for further orders might delay the administration of blood, which is crucial in situations where there is an urgent need, such as severe bleeding or anemia. Given that the unit of blood available is type O negative, which is universally compatible with most recipients in emergency situations, waiting for further orders could jeopardize the client's health.
B. Complete an incident report:
There is no incident or error that occurred in this situation. Using type O negative blood for a recipient with type A positive blood is an accepted practice in emergencies, and therefore, does not warrant the completion of an incident report.
C. Administer the blood as ordered:
Type O negative blood can be safely administered to recipients with any blood type in emergency situations. Since the client requires blood, and the unit available is type O negative, which is universally compatible, administering the blood as ordered is the appropriate action to ensure timely treatment.
D. Notify the blood bank:
Notifying the blood bank is unnecessary in this situation. The nurse has a unit of type O negative blood on hand, which is appropriate for immediate administration to the client with type A positive blood. There's no need to inform the blood bank as the blood is compatible and can be safely administered.

A. Localized edema B. An increase in RBCS C. Bradycardia D. An increase in platelets E. An increase in neutrophils

Correct Answer is ["A","E"]

Explanation

A. Localized edema:
Localized edema, especially when accompanied by erythema (redness), warmth, and tenderness, can be indicative of an infection in a client with diabetes mellitus. Infections in diabetic patients, particularly those affecting the feet, can lead to localized inflammation and swelling.

B. An increase in RBCs:
An increase in red blood cells (RBCs), known as erythrocytosis, is not typically associated with an infection. Erythrocytosis may occur in conditions such as polycythemia vera or chronic hypoxemia but is not a typical marker of infection.

C. Bradycardia:
Bradycardia, a heart rate slower than the normal range, is not typically associated with infections. Infections often cause tachycardia (an increased heart rate) as part of the body's systemic inflammatory response.

D. An increase in platelets:
An increase in platelets, known as thrombocytosis, is not typically associated with infections. Thrombocytosis can occur in response to various factors, including inflammation, but it is not a specific marker of infection in diabetic clients with foot pain.

E. An increase in neutrophils:
An increase in neutrophils, known as neutrophilia, is a common response to infection. Neutrophils are a type of white blood cell involved in the body's immune response to bacterial infections. In diabetic clients with foot pain, an elevated neutrophil count may suggest the presence of an infection, as the body mobilizes these cells to combat the invading pathogens.

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What would be the primary focus of interventions for a client who sleepwalks?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer blood to a client. The unit of blood on hand is type O negative, and the client has type A positive blood. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as Indications that the client has an infection? (Select all that apply)

Correct Answer is ["A","E"]

Explanation

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