Hygiene/sleep/elimination HESI prep adult care
The nurse is performing an assessment on an older client who is having difficulty
sleeping at night. Which statement by the client indicates the need for further
teaching regarding measures to improve sleep?
a) "I swim three times a week."
b) "I have stopped smoking cigars."
c) "I drink hot chocolate before bedtime."
d) "I read for 40 minutes before bedtime."
c) "I drink hot chocolate before bedtime."
Rationale: Many nonpharmacological sleep aids can be used to influence sleep.
However, the client should avoid caffeinated beverages and stimulants such as tea,
cola, and chocolate. The client should exercise regularly, because exercise promotes
sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk,
swim, or bicycle ride three times a week is helpful. The client should sleep on a bed with
a firm mattress. Smoking and alcohol should be avoided. The client should avoid large
meals; peanuts, beans, fruit, raw vegetables, and other foods that produce gas; and
snacks that are high in fat because they are difficult to digest.
The nurse has administered approximately half of an enema solution to a
preoperative client when the client complains of pain and cramping. Which
nursing action is most appropriate at this time?
a) Reassure the client and continue the flow.
b) Raise the enema bag so that the solution can be instilled quickly.
c) Discontinue the enema and notify the health care provider (HCP).
d) Clamp the tubing for 30 seconds and restart the flow at a slower rate.
d) Clamp the tubing for 30 seconds and restart the flow at a slower rate.
Rationale: The enema fluid should be administered slowly. If the client complains of
fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate.
Although client reassurance is important, continuing the flow is inappropriate. Slow
enema administration and stopping the flow temporarily, if necessary, decrease the
likelihood of intestinal spasm and premature ejection of the solution. The higher the
solution container is held above the rectum, the faster the flow and the greater the force
in the rectum; this could increase cramping. There is no need to discontinue the enema
and notify the HCP at this time.
A female client states to the home health nurse that she has not had a bowel
movement since coming home from the hospital after surgery 4 days ago. The
nurse instructs the client to follow which diet at this time?
a) High-fiber diet
The nurse is performing an assessment on an older client who is having difficulty
sleeping at night. Which statement by the client indicates the need for further
teaching regarding measures to improve sleep?
a) "I swim three times a week."
b) "I have stopped smoking cigars."
c) "I drink hot chocolate before bedtime."
d) "I read for 40 minutes before bedtime."
c) "I drink hot chocolate before bedtime."
Rationale: Many nonpharmacological sleep aids can be used to influence sleep.
However, the client should avoid caffeinated beverages and stimulants such as tea,
cola, and chocolate. The client should exercise regularly, because exercise promotes
sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk,
swim, or bicycle ride three times a week is helpful. The client should sleep on a bed with
a firm mattress. Smoking and alcohol should be avoided. The client should avoid large
meals; peanuts, beans, fruit, raw vegetables, and other foods that produce gas; and
snacks that are high in fat because they are difficult to digest.
The nurse has administered approximately half of an enema solution to a
preoperative client when the client complains of pain and cramping. Which
nursing action is most appropriate at this time?
a) Reassure the client and continue the flow.
b) Raise the enema bag so that the solution can be instilled quickly.
c) Discontinue the enema and notify the health care provider (HCP).
d) Clamp the tubing for 30 seconds and restart the flow at a slower rate.
d) Clamp the tubing for 30 seconds and restart the flow at a slower rate.
Rationale: The enema fluid should be administered slowly. If the client complains of
fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate.
Although client reassurance is important, continuing the flow is inappropriate. Slow
enema administration and stopping the flow temporarily, if necessary, decrease the
likelihood of intestinal spasm and premature ejection of the solution. The higher the
solution container is held above the rectum, the faster the flow and the greater the force
in the rectum; this could increase cramping. There is no need to discontinue the enema
and notify the HCP at this time.
A female client states to the home health nurse that she has not had a bowel
movement since coming home from the hospital after surgery 4 days ago. The
nurse instructs the client to follow which diet at this time?
a) High-fiber diet
