Which statement, if made by a client diagnosed with sleep disturbance, should a nurse evaluate as correct understanding of the plan of care to improve sleep patterns?
“I am allowing myself to sleep in most mornings.”.
“I’m getting more work done on my computer before going to bed.”.
“I have limited my alcohol intake before bedtime.”.
“I watch television for 1 hour before sleeping.”.
The Correct Answer is C
“I have limited my alcohol intake before bedtime.”. This statement shows that the client understands that alcohol can interfere with sleep quality and quantity. Alcohol can disrupt the normal sleep cycle and cause frequent awakenings, nightmares, or insomnia.
Choice A is wrong because sleeping in most mornings can disrupt the regular sleep schedule and make it harder to fall asleep at night. It is better to keep a consistent bedtime and wake time, even on weekends.
Choice B is wrong because working on the computer before going to bed can expose the client to blue light, which can suppress the production of melatonin, a hormone that regulates sleep. It is better to avoid screens and other stimulating activities at least an hour before bedtime.
Choice D is wrong because watching television for 1 hour before sleeping can also expose the client to blue light and interfere with sleep onset. It is better to engage in relaxing activities such as reading, listening to soothing music, or meditating before sleeping.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should ask this question to support safe medication administration because the client is to receive medications that are highly teratogenic. Teratogens are substances that can cause congenital disorders and fetal abnormalities.
The nurse should avoid giving teratogenic medications to pregnant clients or clients who may become pregnant.
Choice A is wrong because the family history of cancer is not relevant to the teratogenic effects of the medications.
Choice C is wrong because the previous experience of severe side effects from a drug is not related to the risk of fetal harm.
Choice D is wrong because the allergy to any prescription or non-prescription drugs is not specific to the teratogenic potential of the medications.
Correct Answer is A
Explanation
The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.
This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.
Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.
The surgeon may order interventions based on the assessment findings.
Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.
The nurse should encourage fluid intake only after ensuring adequate urinary output.
Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.
Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.
Normal urine output is about 30 mL per hour or 240 mL in eight hours.
The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.
Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.
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