a nursing care plan for a client with sleep problems has been implemented all of the following should be expected outcomes except

NCLEX-PN

NCLEX PN Test Bank

1. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:

A. the client reports no episodes of awakening during the night.
B. the client falls asleep within 1 hour of going to bed.
C. the client reports satisfaction with their amount of sleep.
D. the client rates sleep as an 8 or more on the visual analog scale.

Correct answer: B

Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.

2. What does it mean to be a nursing advocate?

A. makes decisions for others.
B. encourages persons to make decisions for themselves and acts with or on behalf of the person to support those decisions.
C. manages the care of others.
D. is the legal representative for a person.

Correct answer: B

Rationale: A nursing advocate does not make decisions for others but instead empowers individuals to make decisions for themselves. By encouraging individuals to make their own decisions and supporting them in this process, nursing advocates uphold the principle of self-determination. This approach respects the autonomy and independence of individuals in managing their care. Therefore, the correct answer is to 'encourage persons to make decisions for themselves and act with or on behalf of the person to support those decisions.' Choices A, C, and D are incorrect as they do not align with the role of a nursing advocate in promoting patient autonomy and self-determination.

3. When removing a client's gown with an intravenous line, what should the nurse do?

A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown
B. cut the gown with scissors
C. thread the bag and tubing through the gown sleeve, keeping the line intact
D. temporarily disconnect the tubing from the intravenous container and thread it through the gown

Correct answer: C

Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line. Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.

4. Which of the following statements describes the purpose of client restraint?

A. Restraints are a nursing measure used to maintain client control.
B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Correct answer: B

Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others. Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.

5. The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?

A. Add this issue to the nursing care plan and include daily gait/balance training as an intervention.
B. Do nothing as this is unrelated to the client's hospitalization.
C. Speak with the attending physician about the concerns and request a referral for the client to go to physical therapy.
D. Speak with the attending physician about the concerns and request a referral to physical therapy.

Correct answer: D

Rationale: Nurses should address any concerns regarding a client's health, even if they are not directly related to the reason for hospitalization. In this case, the nurse noticing the client's poor gait and balance should communicate these concerns to the attending physician. The correct course of action is to request a referral to physical therapy, as this specialized intervention can help address the client's issues effectively. Adding gait/balance training to the care plan without professional assessment and intervention may not be appropriate. Doing nothing is not in line with providing comprehensive care, and referring the client to the hospital gym is not as effective as a referral to physical therapy for addressing gait and balance issues.