a nurse is caring for a client who is reporting difficulty falling asleep which of the following measures should the nurse recommend
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Nursing Elites

HESI LPN

HESI Fundamentals Practice Questions

1. A client is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?

Correct answer: C

Rationale: The correct answer is to recommend the client to use progressive relaxation techniques at bedtime. Progressive relaxation techniques help reduce stress and muscle tension, which can promote better sleep. Choice A, drinking a cup of hot cocoa before bedtime, contains caffeine which can interfere with falling asleep. Choice B, exercising 1 hour before going to bed, can stimulate the body and mind, making it harder to fall asleep. Choice D, reflecting on the day's activities before going to bed, may lead to increased mental activity and prevent relaxation, making it difficult to fall asleep.

2. During an admission assessment, a nurse is documenting a client's medication. Which of the following actions should the nurse take?

Correct answer: C

Rationale: During an admission assessment, compiling a list of the client's current medications is crucial for accurate documentation and planning. This information helps prevent medication errors, identify potential interactions, and ensure continuity of care. While counseling the client on medication adherence (Choice A) is important, it is not the primary action when documenting medications. Assessing the client for medication reactions (Choice B) is relevant for monitoring side effects but not the immediate focus during documentation. Evaluating the client's understanding of medications (Choice D) is essential for education but does not address the immediate need for compiling a list of current medications.

3. The patient diagnosed with athlete's foot (tinea pedis) states that he is relieved because it is only athlete's foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient?

Correct answer: A

Rationale: Athlete's foot, also known as tinea pedis, is a contagious fungal infection that can easily spread to other body parts, particularly the hands. It often recurs if not properly treated, making choice A the correct answer. Choices B and C are incorrect because while it is beneficial to air-dry feet after bathing to prevent moisture buildup, athlete's foot is commonly treated with antifungal medications, not salicylic acid. Choice D is incorrect because athlete's foot is caused by a fungal infection, not lice.

4. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?

Correct answer: B

Rationale: A fracture near the epiphysis can result in retarded bone growth, so this should be communicated to the parents.

5. When providing oral care to an unconscious patient, what action should the nurse take to protect the patient from injury?

Correct answer: D

Rationale: When caring for an unconscious patient, it is crucial to prevent choking and aspiration. Suctioning the oral cavity helps in removing secretions and preventing potential harm. Moisten the mouth using lemon-glycerin sponges may not effectively clear secretions. Holding the patient's mouth open with gloved fingers can cause discomfort and potential harm. Using foam swabs to remove plaque may not address the immediate risk of aspiration.

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