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 D

Explanation

A) Administer 200 mL of formula during the initial infusion:
The initial infusion rate for continuous enteral feeding is typically started at a slower rate, often lower than 200 mL, to assess the client's tolerance and prevent complications such as aspiration or dumping syndrome.

B) Give the initial feeding over 15 min:
Continuous enteral feeding is administered slowly over an extended period, usually 24 hours, to ensure gradual delivery of nutrients and minimize the risk of complications such as aspiration or gastrointestinal intolerance. Giving the initial feeding over 15 minutes is too rapid and can lead to adverse events.

C) Reconstitute the formula with tap water:
Reconstituting enteral formula with tap water is not recommended due to the potential risk of contamination with bacteria or other pathogens. It's essential to use sterile water or water that has been specifically purified for enteral feeding to minimize the risk of infection.

D) Discard unused formula after 8 hr:
Unused formula should be discarded after 4 hours, not 8 hours, to reduce the risk of bacterial contamination and ensure the integrity of the enteral nutrition. This practice aligns with guidelines for safe enteral feeding administration.

A. Severity B. Precipitating cause C. Region D. Quality

Correct Answer is A

Explanation

A) Severity: When the nurse asks the client to rate the pain on a scale of 0 to 10, they are assessing the severity of the pain. This component of the PQRST mnemonic focuses on understanding the intensity or severity of the pain experienced by the client. By asking the client to quantify their pain on a scale, the nurse gains insight into how much the pain is affecting the client's well-being and can use this information to guide pain management interventions.
B) Precipitating cause: This component of the PQRST mnemonic involves identifying factors that trigger or worsen the pain. Asking about activities or events that preceded the onset of pain helps the nurse understand the precipitating cause.
C) Region: This component involves identifying the specific location or region of the body where the pain is experienced. It helps the nurse localize the pain and identify potential underlying causes.
D) Quality: This component involves asking the client to describe the characteristics or quality of the pain, such as sharp, dull, stabbing, or burning. Understanding the quality of the pain provides additional information about its nature and possible underlying mechanis

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

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who reports back pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is using which of the following components of the PQRST mnemonic?

Correct Answer is A

Explanation

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

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