An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.
Drink a mixture of warm water, whiskey, and honey at bedtime.
Establish a regular time for going to bed and getting up.
Ask the healthcare provider for a mild sedative for bedtime.
Take an afternoon nap to make up for missed sleep.
Avoid drinking caffeinated beverages late in the day.
Correct Answer : B,E
Choice A rationale
Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.
Choice B rationale
Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.
Choice C rationale
Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep
.
Choice D rationale
Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.
Choice E rationale
Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.
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Correct Answer is A
Explanation
Choice A rationale
Knowing when the client voided following catheter removal is crucial because it indicates the return of the client’s ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.
Choice B rationale
The time of the last dose of IV antibiotic administration is important for managing the client’s urinary tract infection, but it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.
Choice C rationale
Intake and output reports for the previous shift are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.
Choice D rationale
The color of the urine during catheter removal may provide some insight into the client’s urinary condition, but it is not as critical as knowing when the client voided after catheter removal to assess urinary function.
Correct Answer is D
Explanation
Choice A rationale
Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.
Choice B rationale
Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.
Choice C rationale
Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.
Choice D rationale
Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.