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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.

A.

Drink a mixture of warm water, whiskey, and honey at bedtime.

B.

Establish a regular time for going to bed and getting up.

C.

Ask the healthcare provider for a mild sedative for bedtime.

D.

Take an afternoon nap to make up for missed sleep.

E.

Avoid drinking caffeinated beverages late in the day.

Question Solution

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 D

Explanation

Choice A rationale

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

Choice B rationale

Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.

Choice C rationale

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

Choice D rationale

Asking the client what is causing the grimacing is the correct intervention to implement first. Nonverbal cues, such as grimacing, can indicate the presence of pain, even if the client denies it verbally. By closely monitoring the client’s nonverbal behavior, the nurse can gather additional information about the client’s pain experience and make appropriate interventions based on a comprehensive assessment.

Correct Answer is A

Explanation

Choice A rationale

Smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease. Smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction. Quitting smoking has a more direct effect on improving the function and structure of the blood vessels and heart, significantly reducing the risk of cardiovascular events and mortality.

Choice B rationale

A low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While it helps in lowering cholesterol levels and reducing inflammation, smoking cessation has a stronger influence on overall cardiovascular health.

Choice C rationale

Stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Although managing stress can improve heart health, smoking cessation has a more immediate and significant impact on reducing cardiovascular risks.

Choice D rationale

Regular exercise is beneficial for preventing and managing cardiac disease, but it is not the most important lifestyle modification. Exercise helps in maintaining a healthy weight, lowering blood pressure, and improving overall cardiovascular health, but smoking cessation has a greater impact on reducing the risk of cardiovascular events.

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