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
The SBAR (Situation, Background, Assessment, Recommendation) format is specifically designed for critical communication, particularly when reporting a change in a client’s condition to the healthcare provider. This structured communication tool ensures that essential information is conveyed clearly and concisely, reducing the risk of miscommunication and enhancing patient safety.
Choice B rationale
Completing discharge teaching to a client and family members typically involves providing comprehensive instructions and education, which may not fit the concise and focused nature of the SBAR format. Discharge teaching requires a more detailed and interactive approach to ensure understanding and compliance.
Choice C rationale
Obtaining clarification from a client’s healthcare power-of-attorney involves a more conversational and detailed exchange of information, which may not align with the structured and concise nature of the SBAR format. This interaction often requires a thorough discussion to ensure all aspects are understood.
Choice D rationale
Offering therapeutic support and comfort to a grieving family is a sensitive and empathetic interaction that requires a compassionate and patient-centered approach. The SBAR format is not suitable for this type of communication, as it is designed for conveying critical information quickly and efficiently.
Correct Answer is A
Explanation
Choice A rationale
Ensuring the bevel of the needle is pointing up is crucial for intradermal injections as it allows the medication to be deposited just below the epidermis, forming a small bleb or wheal.
Choice B rationale
The upper arm is not the preferred site for intradermal injections. The inner forearm and upper back are more commonly used as they allow for better visualization of the reaction.
Choice C rationale
Holding the syringe perpendicular to the skin is incorrect for intradermal injections. The correct angle is 5 to 15 degrees to ensure the medication is deposited in the dermis.
Choice D rationale
Massaging the site gently after injection is not recommended for intradermal injections as it can disperse the medication and affect the test results.