HESI

How many hours of sleep would a nurse recommend for an 11yr old

9

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. Which response by the nurse is appropriate when the client reports pain and requests medication

Acknowledging that the pain is real and administering medication to relieve it

Which action would the nurse take first for post surgical client who is still intubated but becoming restless with an increased pulse rate and blood pressure when it has been 4 hours since the last dose of pain medication

Administer the prescribed pain medication

When would analgesics be administered after an abdominal cholecystectomy is performed

As prescribed by the health care provider

Which action would the nurse perform first when a home hospice client reports unrelenting pain 1 hour after administration of the maximum dose of a narcotic analgesic

Ask the client to rate the pain according to a pain scale

Which nursing consideration would be made when determining the plan of care for the client who has severe back pain?

Ask the client what the clients tolerable level of pain is Administer the pain meds regularly around the clock

After surgery a 12yr old child is receiving morphine for pain control by way of patient controlled analgesia infusion. A bolus of morphine can be delivered every 6 minutes. Which statement by the parents indicates instructions about the PCA pump have been understood

She needs to press the PCA button whenever she needs pain medication

Which lifestyle factor does the nurse recall that can affect sleep

Change in evening meal time

Which is the most reliable indicator of a 2yr olds pain

Changes in behavior

Which alternative and complementary therapy does the nurse recognize as not being typically used to promote sleep

Chiropractic therapy

Which question would the nurse ask to determine the clients potential for injury because of sleep deprivation

Do you operate heavy machinery Does sleepiness affect your performance at work

Which statement by the nurse indicates a need for better understanding of the difference between the two stages of NREM and REM

Dreams occur during NREM sleep but not during REM sleep

Which would the nurse incorporate into the plan of care for the older adult experiencing chronic pain

Exercise

Which sleep promotion technique would the nurse advise for a client who complains about being unable to sleep well at night and then feeling sleepy throughout the next day

Exercise daily

Which activity would the nurse recommend to a client who expresses concern about insomnia and asks "what can I do to get better sleep"

Follow the same bedtime ritual each night Perform deep breathing exercises

Which discharge teaching is anticipated when the client reports frequent awakening at night, snoring, and excessive daytime sleepiness

Get fitted for an oral appliance that will bring the mandible and tongue forward

Which physiological finding would the nurse determine the client is experiencing from sleep deprivation

Hand tremors Cardiac dysrhythmias

Which response would be the nurses primary consideration when responding to the client in hospice who has severe pain and asks for another dose of oxycodone

Help reduce the clients pain immediately

Which statement about sleep patterns in older adults is correct

Inadequate sleep in older adults may lead to memory and personality changes.

Which instruction would the nurse provide to the client to promote sleep

Include meat in your diet Drink milk before going to sleep Perform moderate exercise 2 hours before bedtime

A client tells a nurse "I have been having trouble sleeping and feel wide awake as soon as I get into bed" which strategy should the nurse teach the client to promote sleep

Leave the bedroom when unable to sleep Exercise in the afternoon rather than in the evening Count backwards from 100 when the clients mind is racing

The client rates pain as an 8 out of 10 before receiving an analgesic and as a 7 after being medicated. Which conclusion would the nurse make regarding the clients response to the pain medication

Medication is not adequately effective

Which action would the nurse take when caring for an Asian client who had laparoscopic cholecystectomy 6 hours ago and denies having pain

Monitoring for nonverbal cues of pain

Which sleep disorder does the nurse conclude that the client is experiencing when the client reports overwhelming, frequent, and uncontrollable urges to sleep

Narcolepsy

Which sleep disorder is being experienced when the client reports overwhelming irresistible attacks of sleep

Narcolepsy

Which finding would the nurse include in the pain assessment of a client with chronic pain in the knee

Pain history including location, intensity, and quality of pain Pain pattern including precipitating and alleviating factors

When interpreting findings from a pain assessment which does a nurse consider the most significant influence on many clients perception of pain

Past experience and cultural values

Which involuntary physiological response would a nurse monitor for in a client experiencing pain

Perspiring

Which method qualifies as an alternative therapy for pain

Prayer Hypnosis Aromatherapy Guided imagery

Which statement about REM sleep requires correction

REM sleep is the deepest stage of sleep

Which nursing intervention would the nurse implement to promote sleep for a client in a health care setting

Reduce lighting Provide activities during the day

Which statement describes phantom limb pain

Sensation of pain that feels like it's coming from the amputated body part

Which sleep hygiene strategy is aimed at obtaining a restful nights sleep

Set a consistent time to go to bed and wake up Maintain a cool temp in the bedroom Avoid excessive alcohol in the evening and before bed Do not eat, read, work, or watch tv in bed Get out of bed and engage in other activities if unable to fall asleep

Which statement about sleep is correct

Sleep is associated with healing It is a state of rest that occurs for a sustained period of time Sleep restores a persons energy and feeling of well being

Which statement made by the nurse demonstrates a need for further understanding about the different stages of NREM sleep

Stage 2 is the initial stage of deep sleep, whereas stage 4 is the deepest stage of sleep

Which pain assessment method would the nurse use for an adult client with Down syndrome and limitations in mental functioning

Using the wong baker faces pain rating scale

A surgical client continues to report pain in the lower abdomen after receiving pain medication. Which intervention would the nurse choose to directly address the need to improve pain management

Utilize distraction technique Notify health care provider of ineffective pain relief from medication

When leaving for a lunch break the primary nurse shares that the client is prescribed morphine PRN. Which action would the covering nurse take first when the client complains of a pain level of 8 on a scale of 1-10

Verify the pain medication prescription in the clinical record

In discharge planning for a client in a long leg cast for a fractured bone, when would the nurse advise the client to take the prescribed as needed oxycodone and acetaminophen

When the discomfort begins

Which technique is not used to manage mild sleep apnea

polysomnography