Which bedtime action by the nurse may make it more difficult for the patient to fall asleep?

Providing a warm cup of hot chocolate

Giving the patient a gentle backrub

Encouraging the patient to use the bathroom

Giving the patient an extra blanket when cold

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct choice because providing a warm cup of hot chocolate may make it more difficult for the patient to fall asleep. Hot chocolate contains caffeine and sugar, which are stimulants that can interfere with the sleep cycle and cause insomnia. The nurse should avoid giving the patient any beverages or foods that contain caffeine or sugar before bedtime.

Choice B reason: This is an incorrect choice because giving the patient a gentle backrub may make it easier for the patient to fall asleep. A backrub is a relaxation technique that can reduce muscle tension, pain, and anxiety, and promote comfort and sleep. The nurse should offer the patient a backrub or other soothing interventions before bedtime.

Choice C reason: This is an incorrect choice because encouraging the patient to use the bathroom may make it easier for the patient to fall asleep. Using the bathroom before bed can prevent nocturia, which is the need to urinate at night, and allow the patient to have uninterrupted sleep. The nurse should assist the patient to use the bathroom or provide a urinal or bedpan if needed.

Choice D reason: This is an incorrect choice because giving the patient an extra blanket when cold may make it easier for the patient to fall asleep. Maintaining a comfortable temperature is important for sleep quality and quantity. The nurse should adjust the room temperature and provide extra blankets or fans as requested by the patient.

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Correct Answer is D

Explanation

Choice A reason: This is an incorrect choice because perceived constipation related to expectation of daily bowel movements is not an appropriate nursing diagnosis for this patient. Perceived constipation is a subjective problem that occurs when the patient's bowel elimination pattern does not meet their personal expectations. The patient may not have any objective signs of constipation, such as hard stools, straining, or abdominal discomfort. This diagnosis is not applicable to this patient, who has objective signs of constipation and a clear cause of the problem.

Choice B reason: This is an incorrect choice because impaired bowel elimination related to abdominal muscle weakness is not an appropriate nursing diagnosis for this patient. Impaired bowel elimination is a problem that occurs when the patient has difficulty in passing stools or has a change in bowel habits. Abdominal muscle weakness is a possible factor that can affect bowel function, but it is not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who has a normal muscle strength and a clear cause of the problem.

Choice C reason: This is an incorrect choice because risk for constipation related to irregular defecation habits is not an appropriate nursing diagnosis for this patient. Risk for constipation is a potential problem that occurs when the patient is vulnerable to developing constipation due to various factors. Irregular defecation habits are a possible factor that can increase the risk of constipation, but they are not the cause of the problem for this patient. This diagnosis is not applicable to this patient, who already has constipation and a clear cause of the problem.

Choice D reason: This is the correct choice because constipation related to side effects of pain medication is an appropriate nursing diagnosis for this patient. Constipation is a problem that occurs when the patient has infrequent, difficult, or incomplete bowel movements. Pain medication, especially opioids, are a common cause of constipation, as they can slow down the gastrointestinal motility and reduce the stool volume and water content. This diagnosis is applicable to this patient, who has objective signs of constipation and a clear cause of the problem..

A. The patient’s lung sounds are diminished bilaterally with expiratory wheezes. B. The patient worries that the insurance company will not pay the hospital bill. C. The patient wonders if supplemental oxygen at home would be beneficial. D. The patient felt less short of breath after receiving a nebulizer treatment.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because the patient’s lung sounds are diminished bilaterally with expiratory wheezes is an example of objective data. Objective data is observable and measurable information that can be verified by the nurse or other health care professionals. The nurse can use a stethoscope to listen to the patient’s lung sounds and document the findings.

Choice B reason: This is an incorrect choice because the patient worries that the insurance company will not pay the hospital bill is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s worry, but can only rely on the patient’s verbal report.

Choice C reason: This is an incorrect choice because the patient wonders if supplemental oxygen at home would be beneficial is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s wonder, but can only rely on the patient’s verbal report.

Choice D reason: This is an incorrect choice because the patient felt less short of breath after receiving a nebulizer treatment is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s feeling, but can only rely on the patient’s verbal report.

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Which bedtime action by the nurse may make it more difficult for the patient to fall asleep?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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