Hygiene/sleep/elimination HESI prep adult care

A client has a problem with sleeping at night. The nurse encourages the client to do which measure to best enhance nighttime sleep? a) Drink a glass of milk. b) Eat a large bedtime snack. c) Eat a snack with spicy ingredients. d) Avoid caffeine products 1 hour before sleep.

a) Drink a glass of milk. Rationale: Milk contains the essential amino acid tryptophan, which can enhance sleep by promoting production of the neurotransmitter serotonin in the brain. The client should avoid spicy foods and a large intake just before bedtime. The client should also avoid caffeine after noon.

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 b) Full liquid diet c) Low-fiber diet d) Low-sodium diet

a) High-fiber diet

The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse should assist the client into which position? a) Left-sided lateral Sims position b) Right-sided lateral Sims position c) Left side-lying, with the head of the bed elevated 45 degrees d) Right side-lying, with the head of the bed elevated 45 degrees

a) Left-sided lateral Sims position

The nurse notes that an older client with dementia is unable to care for self. Which is an appropriate goal for this client? a) The client will function at the highest level of independence possible. b) The client will be admitted to a long-term care facility to have ADL needs met. c) The nursing staff will attend to all the client's ADL needs during the hospital stay. d) The client will complete all activities of daily living (ADL) independently within a 1-hour time frame.

a) The client will function at the highest level of independence possible.

Before enema administration, which position should the nurse assists the client to assume? a) Right Sims position b) Dorsal recumbent position c) Left lateral position, with the right leg acutely flexed d) Right lateral position, with the left leg acutely flexed

c) Left lateral position, with the right leg acutely flexed Rationale: The sigmoid and descending colons are located on the left side. Therefore the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colons. Acute flexion of the right leg allows for adequate exposure of the anus. The remaining options are incorrect positions.

The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action? a) Withdraw the catheter slightly and reinflate the balloon. b) Remove the catheter, and reinsert a new one that is one size smaller. c) Finish inflating the balloon; the discomfort is normal and temporary. d) Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

d) Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

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 client is experiencing chronic insomnia. The nurse interprets this to mean that which areas of the brain are involved? a) Hippocampus and frontal lobe b) Temporal lobe and frontal lobe c) Limbic system and cerebral hemispheres d) Reticular activating system and cerebral hemispheres

d) Reticular activating system and cerebral hemispheres Rationale: The reticular activating system in conjunction with the cerebral hemispheres is responsible for arousal. The temporal lobe, hippocampus, and frontal lobe are responsible for memory. The limbic system is responsible for feelings and affect.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What should the nurse do next? a) Immediately twist the catheter, and then slowly inflate the balloon. b) Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. c) Insert the catheter until resistance is met, and then inflate the balloon. d) Withdraw the catheter approximately 1 inch, and then inflate the balloon.

b) Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon.

Which interventions are appropriate when administering a tepid bath to a child with a fever? Select all that apply. 1. Allow the child's skin to air dry. 2. Apply alcohol-soaked cloths over the child's body. 3. Use a water toy to distract the child during the bath. 4. Place lightweight pajamas on the child after the bath. 5. Squeeze water over the child's body, using the washcloth.

3. Use a water toy to distract the child during the bath. 4. Place lightweight pajamas on the child after the bath. 5. Squeeze water over the child's body, using the washcloth. Rationale: Alcohol should never be used for bathing the child with a fever because it can cause rapid cooling, peripheral vasoconstriction, and chilling, thus elevating the temperature further. Washcloths can be used to squeeze water over the child's body. Towels are used to dry the child. Toys, especially water toys, can be used to provide distraction during the bath. Lightweight clothing should be placed on the child after the child is dried.

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.