N126: Exam #3

The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat? A. 60° to 64° F B. 65° to 75° F C. 15° to 17° C D. 25° to 28° C

ANS: B A person's comfort zone is usually between 18.3° and 23.9° C (65° and 75° F). The other ranges are too low or too high and do not reflect the average person's comfort zone.

Clients undergoing stress may have periods of regression. The nurse assesses this regressive behavior in the situation where: A. An adult client exercises to the point of fatigue B. An 8 year old child sucks his thumb and wets the bed C. An adult client avoids speaking about health concerns D. An 11 year old child experiences stomach cramps and headaches

ANS: B Regression is coping with a stressor through actions and behaviors associated with an earlier developmental period, such as an 8 year child sucking his thumb and wetting the bed.

The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing? a. Young infant b. Toddler c. Preschooler d. Adolescent

ANS: B The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouths. Young infant is too young. A preschooler and an adolescent are too old.

A nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? A. "I feel refreshed when I wake up in the morning." B. "I use soft music at night to help me relax." C. "It takes me about 45 to 60 minutes to fall asleep." D. "I take the pain medication for my leg pain about 30 minutes before I go to bed."

ANS: C Good sleep-hygiene practices indicate that individuals should fall asleep within 30 minutes of going to bed. Taking 45 to 60 minutes to fall asleep indicates a potential sleep problem and requires follow-up on sleep-hygiene practices. If an individual does not fall asleep within 30 minutes, encourage him or her to get out of bed and do a quiet activity until he or she feels sleepy

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, what is the first assessment the nurse conducts? A. The amount of family support B. A 3-day diet recall C. A thorough physical assessment D. Threats to safety in her home

ANS: C Stress often causes symptoms similar to physical illnesses. Physical causes for problems need to be investigated and treated before treatment for stress-related symptoms can be initiated.

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel? A. Determining the need for restraints B. Assessing the patient's orientation C. Obtaining an order for a restraint D. Applying the restraint

ANS: D The application and routine checking of a restraint can be delegated to nursing assistive personnel. The skill of assessing a patient's behavior, orientation to the environment, need for restraints, and appropriate use cannot be delegated. A nurse must obtain an order from a health care provider.

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which statement would be the nurse's best response? A. "Are you thinking of suicide?" B. "You've been doing a good job raising your children. You can do it!" C. "Is there someone who can help you during the evenings and weekends?" D. "Tell me what you mean when you say you can't go on any longer."

ANS: D You need to get information about what the gentleman means when he says he can't go on any longer. He might be thinking of turning his children over to a grandparent or seeking other child-care arrangements. Asking about suicide initially might be premature. Asking "Are you thinking of suicide?" prematurely might shut the patient down entirely. If the patient talks about suicide, for safety reasons it is very important to further discuss his suicidal thoughts and refer to the appropriate health care professional. Asking the open-ended question provides an opportunity to understand what the person is thinking and open lines of communication.

For a lifestyle stress indicator and reduction in the incidence of heart disease a recommended intervention would be: A. Regular physical exercise B. Attendance at a support group C. Self-awareness skill development D. Effective time management techniques

ANS: A A regular exercise program reduces tension, promotes relaxation, increases one's resistance to stress, and reduces the risk of cardiovascular disease.

Which activity will cause the nurse to monitor for equipment-related accidents? A. Uses a patient-controlled analgesic pump B. Uses a computer-based documentation record C. Uses a measuring device that measures urine D. Uses a manual medication-dispensing device

ANS: A Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient-controlled analgesic pumps need to have free-flow protection devices. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient and are considered procedure-related accidents.

Which of the following client behaviors best reflects Neuman Systems Model of tertiary prevention? The client who: A. Swims daily to strengthen muscles weakened as a result of hip surgery B. Follows a low-fat diet in order to bring her HDLs to under 200 mg/dL C. Walks 1 mile daily to keep her blood pressure from rising higher than 130/70 mmHg D. Attends a survivor support group after the loss of a spouse in an automobile accident

ANS: A At the tertiary level of prevention, the nurse supports rehabilitation processes involved in healing, moving the client back to wellness and the primary level of disease prevention.

The nurse is discussing lack of sleep with a middle-aged adult. Which area should the nurse most likely assess to determine a possible cause of the lack of sleep? A. Anxiety B. Loud teenagers C. Caring for pets D. Late night television

ANS: A During middle adulthood, the total time spent sleeping at night begins to decline. Anxiety, depression, and certain physical illnesses can affect sleep, and women can experience menopausal symptoms. Insomnia is common because of the changes and stresses associated with middle age. Teenagers, caring for pets, and late night television can influence the amount of sleep; however, these are not the most common causes of insomnia in this age group.

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs? A. The electricity was turned off 3 days ago. B. The water comes from the county water supply. C. A son and family recently moved into the home. D. This home is not furnished with a microwave oven.

ANS: A Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting, and diarrhea due to food poisoning. This discussion about the patient's electrical needs can be referred to social services. Foods that are inadequately prepared or stored or subject to unsanitary conditions increase the patient's risk for infections and food poisoning, and an assessment should include storage practices. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient.

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next? A. Remove the restraint. B. Place a blanket over the feet. C. Immediately do a complete head-to-toe neurologic assessment. D. Take the patient's blood pressure, pulse, temperature, and respiratory rate.

ANS: A If the patient has altered neurovascular status of an extremity such as cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness, remove the restraint immediately and notify the health care provider. Light blue is cyanosis, indicating the restraints are too tight, not that the patient is cold and needs a blanket. A complete head-to-toe neurological assessment is not needed at this time. The nurse can take vital signs after the restraint is removed.

The nurse is caring for a patient on the medical-surgical unit who is experiencing an exacerbation of asthma. Which intervention will be most appropriate to help this patient sleep? A. Place bed in semi-Fowler's position. B. Offer iron-rich foods for meals. C. Provide a snack before bedtime. D. Encourage the patient to read.

ANS: A Placing the patient in a semi-Fowler's position eases the work of breathing. Respiratory disease often interferes with sleep. Patients with chronic lung disease such as emphysema or asthma are short of breath and frequently cannot sleep without two or three pillows to raise their heads. Iron-rich food may help a patient with restless legs syndrome. Providing a snack and encouraging the patient to read may be good interventions for patients, but the most appropriate would be raising the head of the bed.

A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident? A. Pathogenic asepsis B. Medical asepsis C. Surgical asepsis D. Clean asepsis

ANS: C The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Pathogenic and clean asepsis are not types of asepsis. Medical asepsis is not sterile.

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? (Select all that apply.) A. Loss of autonomy caused by health problems B. Physical appearance and body image C. Accepting one's personal identity D. Separation from family E. Taking tests in school

B, C, D, E As adolescents search for identity with peer groups and separate from their families, they also experience stress. In addition, they face stressful questions about sex, jobs, school, career choices, and using mind-altering substances. During this stage of development, stress can occur because of a preoccupation with appearance and body image. A loss of autonomy caused by health problems usually applies to older adults.

Which nursing intervention(s) best promote(s) effective sleep in an older adult? (Select all that apply.) A. Limit fluids 2 to 4 hours before sleep. B. Ensure that the room is completely dark. C. Ensure that the room temperature is comfortably cool. D. Provide warm covers. E. Encourage walking an hour before going to bed.

ANS: A, C, D Limiting fluids reduces incidence of nocturia. For safety reasons complete darkness should be avoided. A soft nightlight lessens the chance of a fall should the patient require ambulation to the bathroom during the night. Older adults sometimes require extra blankets or covers to achieve a comfortable sleeping temperature. Keeping the bedroom temperature at a cooler, comfortable temperature is conducive to sleep

A client who has experienced massive soft tissue trauma is handling both the physical and emotional stressors via the GAS. The major benefit of this defense mechanism is through the: A. Identification of foreign antigens on invading bacteria B. Production of endorphins that decrease awareness of pain C. Increased epinephrine, resulting in improved cardiac output D. Increased norepinephrine directed towards sustaining blood pressure

ANS: B Endorphins, hormones that act on the mind like morphine and opiates, produce a sense of well-being and reduce pain. It is the body's immune system that recognizes antigens on the surface of the bacterial cells and thus identifies bacteria as invaders. During the alarm reaction stage of the GAS process, rising epinephrine and norepinephrine levels result in increased heart rate and blood flow.

When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding? A. The patient is allergic to certain medications or foods. B. The patient has do not resuscitate preferences. C. The patient has a high risk for falls. D. The patient is at risk for seizures.

ANS: B In 2008 the American Hospital Association issued an advisory recommending that hospitals standardize wristband colors: red for patient allergies, yellow for fall risk, and purple for do not resuscitate preferences. Purple does not indicate seizures.

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority? A. Monitor for specific symptoms. B. Manage all patients using standard precautions. C. Transport patients quickly and efficiently through the elevators. D. Prepare for post-traumatic stress associated with this bioterrorism attack.

ANS: B Manage all patients with suspected or confirmed bioterrorism-related illnesses using standard precautions. For certain diseases, additional precautions may be necessary. The early signs of a bioterrorism-related illness often include nonspecific symptoms (e.g., nausea, vomiting, diarrhea, skin rash, fever, confusion) that may persist for several days before the onset of more severe disease. Limit the transport and movement of patients to movement that is essential for treatment and care. Psychosocial concerns (post-traumatic stress) are important but are not the first priority at this moment.

During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls? A. The patient is oriented. B. The patient takes a hypnotic. C. The patient walks 2 miles a day. D. The patient recently became widowed.

ANS: B Numerous factors increase the risk of falls, including a history of falling and the effects of various medications such as anticonvulsants, hypnotics, sedatives, and certain analgesics. Being oriented will decrease risk for falls while disorientation will increase the risk of falling. Walking has many benefits, including increasing strength, which would be beneficial in decreasing risk. Becoming widowed would increase stress and may affect concentration but is not a great risk.

A 72-year-old patient asks the nurse about using an over-the counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? A. "Antihistamines are better than prescription medications because prescription medications can cause a lot of problems." B. "Antihistamines should not be used because they can cause confusion and increase your risk of falls." C. "Antihistamines are effective sleep aids because they do not have many side effects." D. "Over-the-counter medications when combined with sleep hygiene measures are a good plan for sleep."

ANS: B Older adults should avoid the use of over-the-counter antihistamines. These medications have a long duration of action in older adults and can cause confusion,constipation, urinary retention, and an increased risk of falls.

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint? A. The patient refuses to call for help to go to the bathroom. B. The patient continues to remove the nasogastric tube. C. The patient gets confused regarding the time at night. D. The patient does not sleep and continues to ask for items

ANS: B Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy such as traction, IV infusions, NG tube feeding, or Foley catheterization. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

Clients experiencing PTSD following the World Trade Tower bombing work with nurses in the medical center. An approach that is appropriate and should be incorporated into the plan of care is: A. Suppression of anxiety-producing memories B. Reinforcement that the PTSD is short term C. Promotion of relaxation strategies D. Focus on physical needs

ANS: C Teaching the client relaxation strategies can help reduce the stress of anxiety-provoking thoughts and events, as seen in PTSD, and reinforces an adaptive coping strategy.

When assessing a young woman who was a victim of a home invasion 3 months earlier, the nurse learns that the woman has vivid images of the event whenever she hears loud yelling or a sudden noise. The nurse recognizes this as ____________.

Post-Traumatic Stress Disorder PTSD originates with a person's experiencing or witnessing a traumatic event and responding with intense fear or helplessness. The home break-in is the traumatic event that is causing intense fear a

A mother and her child sit in a playroom on the pediatric unit. The boy wants to play with a toy that another child has but the mother says no. The child cries, throws a block, and runs over to kick the door. This child is using a mechanism known as: A. Displacement B. Compensation C. Conversion D. Denial

ANS: A Displacement is transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute.

Which statement made by the patient indicates an understanding of sleep-hygiene practices? A. "I usually drink a cup of warm milk in the evening to help me sleep." B. "If I exercise right before bedtime, I will be tired and fall asleep faster." C. "I know it does not matter what time I go to bed as long as I am tired." D. "If I use hypnotics for a long time, my insomnia will be cured."

ANS: A Drinking a warm beverage such as milk in the evening can help promote sleep. Milk contains l-tryptophan, which helps promote sleep. Other snacks that contain l-tryptophan, such as cereal and cheese and crackers, may also promote sleep. Exercising right before bedtime may prevent sleep. Good sleep hygiene includes going to bed and getting up at the same time

Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep? A. Eyes closed, lying quietly, respirations 12, heart rate 60 B. Eyes closed, tossing in bed, respirations 18, heart rate 80 C. Eyes closed, mumbling to self, respirations 16, heart rate 68 D. Eyes closed, lying supine in bed, respirations 22, heart rate 66

ANS: A During NREM sleep, biological functions slow. During sleep, the heart rate decreases to 60 beats/min or less. The patient experiences decreased respirations, blood pressure, and muscle tone. Heart rates above 60 are too high and respirations of 22 are too high to indicate comfortable NREM sleep.

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take? A. Assess the patient. B. Gather restraint supplies. C. Try alternatives to restraint. D. Call the health care provider for a restraint order.

ANS: A When a patient becomes suddenly confused, the priority is to assess the patient, to identify the reason for change in behavior, and to try to eliminate the cause. If interventions and alternatives are exhausted, the nurse working with the health care provider may determine the need for restraints.

The patient and the nurse discuss the need for sleep. After the discussion, the patient is able to state the factors that hinder sleep. Which statements indicate the patient has a good understanding of the teaching? (Select all that apply.) A. "Drinking coffee at 7 PM could interrupt my sleep." B. "Staying up late for a party can interrupt sleep patterns." C. "Exercising 2 hours before bedtime can decrease relaxation." D. "Changing the time of day that I eat dinner can disrupt sleep." E. "Worrying about work can disrupt my sleep." F. "Taking an antacid can decrease sleep."

ANS: A, B, D, E Caffeine, alcohol, and nicotine consumed late in the evening produce insomnia. Worry over personal problems or situations frequently disrupts sleep. Alterations in routines, including changing mealtimes and staying up late at night for social activities, can disrupt sleep. Exercising 2 hours before bedtime actually increases a sense of fatigue and promotes relaxation. Taking an antacid does not decrease sleep.

The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching? A. "I can't wait to get the baby home to play with the brothers and sisters." B. "I will ask my mom to come after the first week, when the baby is more alert." C. "I can get the baby on a sleeping schedule the first week while my mom is here." D. "I won't be able to nap during the day because the baby will be awake."

ANS: B The patient indicates an understanding when asking the mother to come after the first week. The neonate up to the age of 3 months averages about 16 hours of sleep a day, sleeping almost constantly during the first week. The baby will sleep rather than play. The baby will not be on a sleeping schedule the first week home. The mother will be able to nap since the baby sleeps 16 hours a day.

Which of the following client behaviors best reflect Neuman Systems Model of primary prevention? The client who: A. Swims daily to strengthen muscles weakened as a result of shoulder surgery B. Follows a low-fat diet in order to bring her HDLs to under 200 mg/dL C. Walks 1 mile daily to keep her blood pressure from rising higher than 130/70 mmHg D. Attends a survivor support group after the loss of a spouse in an automobile accident

ANS: C According to Neuman's theory, the goal of primary prevention is to promote client wellness by stress prevention and reduction of risk factors. Secondary prevention occurs after symptoms appear. At the tertiary level of prevention, the nurse supports rehabilitation processes involved in healing, moving the client back to wellness and the primary level of disease prevention.

While assessing an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which questions provide information about the impact of this crisis? (Select all that apply.) A. With whom do you talk on a routine basis? B. What do you do when you feel lonely? C. Tell me what your husband was like. D. I know this must be hard for you. Let me tell you what might help. E. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?

A, B, E A developmental crisis occurs as a person moves through the stages of life, including widowhood. It is important to gather information about how this crisis affects the woman's interactions, how she is currently coping with loneliness and any changes in her lifestyle habits. Although losing her husband is a source of stress, discussing him now does not focus on her current situation. Saying "I know this must be hard for you. Let me tell you what might help" is unacceptable because the purpose of assessment is to gather data and let the patient tell his or her story

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1c, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1c is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? A. Denial B. Conversion C. Dissociation D. Displacement

ANS: A Denial is avoiding emotional stress by refusing to consciously acknowledge anything that causes intolerable anxiety. This patient's statements reflect denial about poorly controlled blood sugars.

A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session? A. Proper fit of a bicycle helmet B. Proper fit of soccer shin guards C. Proper fit of swimming goggles D. Proper fit of baseball sliding shorts

ANS: A Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries. Proper fit of the helmet helps to decrease head injuries resulting from these bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death.

The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session? A. Increased aggressiveness and blood spots on clothing may indicate substance abuse. B. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing. C. Adolescents need information about the effects of uncoordination on accidents. D. Adolescents need to be reminded to use seat belts primarily on long trips.

ANS: A Increased aggressiveness (psychosocial clue) and blood spots on clothing (environmental clue) may indicate substance abuse. School-age children are often uncoordinated. Seat belts should be used all the time. In fact, teens have the lowest rate of seat belt use.

The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic? A. "Smoking even at parties is not good for my body." B. "Our campus is safe; we leave our dorms unlocked all the time." C. "As long as I have only two drinks, I can still be the designated driver." D. "I am young, so I can work nights and go to school with 2 hours' sleep."

ANS: A Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning.

The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient? A. Depression B. Mild fatigue C. Hypertension D. Hypothyroidism

ANS: A Older adults and other individuals who experience depressive mood problems experience delays in falling asleep, earlier appearance of REM sleep, frequent awakening, feelings of sleeping poorly, and daytime sleepiness. A person who is moderately fatigued usually achieves restful sleep, especially if the fatigue is the result of enjoyable work or exercise. Hypertension often causes early-morning awakening and fatigue. Alcohol speeds the onset of sleep. Hypothyroidism decreases stage 4 sleep.

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens? A. Wash hands B. Wash wound C. Wear gloves D. Wear eye protection

ANS: A One of the most effective methods for limiting the transmission of pathogens is the medically aseptic practice of hand hygiene. The most common means of transmission of pathogens is by the hands. While washing the wound is needed, the best method to prevent transmission is hand hygiene. Wearing gloves and possibly eye protection help protect the nurse, but handwashing is best for limiting the transmission of pathogens.

The nurse is preparing an older-adult patient's evening medications. Which treatment will the nurse recognize as relatively safe for difficulty sleeping in older adults? A. Ramelteon (Rozerem) B. Benzodiazepine C. Antihistamine D. Kava

ANS: A Ramelteon (Rozerem), a melatonin receptor agonist, is well tolerated and appears to be effective in improving sleep by improving the circadian rhythm and shortening time to sleep onset. It is safe for long- and short-term use particularly in older adults. The use of benzodiazepines in older adults is potentially dangerous because of the tendency of the drugs to remain active in the body for a longer time. As a result, they also cause respiratory depression, next-day sedation, amnesia, rebound insomnia, and impaired motor functioning and coordination, which leads to increased risk of falls. Caution older adults about using over-the-counter antihistamines because their long duration of action can cause confusion, constipation, and urinary retention. Kava promotes sleep in patients with anxiety; it should be used cautiously because of its potential toxic effects on the liver.

The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which statement by the nurses will best indicate that the teaching is effective? A. "If the patient has a disease process in the central nervous system, it can influence the functions of sleep." B. "If the patient has a disease process in the cranial nerves, it can influence the functions of sleep." C. "If the patient has an interruption in the urinary pathways, it can influence the functions of sleep." D. "If the patient has an interruption in the spinal reflexes, it can influence the functions of sleep."

ANS: A Sleep involves a sequence of physiological states maintained by the central nervous system. It is associated with changes in the peripheral nervous, endocrine, cardiovascular, respiratory, and muscular systems. A disease process associated with the cranial nerves, urinary pathway, or spinal reflexes may influence a person's ability to sleep, but the best answer is the central nervous system.

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group? A. "Are you able to hear the tornado sirens in your area?" B. "Are you able to read your favorite book?" C. "Are you able to taste spices like before?" D. "Are you able to open a jar of pickles?"

ANS: A The ability to hear safety alerts and seek shelter is imperative to life safety. Decreased hearing acuity alters the ability to hear emergency vehicle sirens. Natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are major causes of death and injury. Although age-related changes may cause a decrease in sight that affects reading, and although tasting is impaired and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the most important.

The nurse is caring for a patient who has been in holding in the emergency department for 24 hours. The nurse is concerned about the patient's experiencing sleep deprivation. Which action will be best for the nurse to take? A. Expedite the process of obtaining a medical-surgical room for the patient. B. Pull the curtains shut, dim the lights, and decrease the number of visitors. C. Obtain an order for a hypnotic medication to help the patient sleep. D. Ask everyone in the unit to try to be quiet so the patient can sleep.

ANS: A The most effective treatment for sleep deprivation is elimination or correction of factors that disrupt the sleep pattern. Obtaining a private room in the medical-surgical unit for the patient will help with decreasing stimuli and promoting more rest than an individual can obtain in an emergency department even with the interventions mentioned.

The nurse is completing a sleep assessment on a patient. Which tool will the nurse use to complete the assessment? A. Visual analog scale B. Cataplexy scale C. Polysomnogram D. RAS scale

ANS: A The visual analog scale is utilized for assessing sleep quality. Cataplexy, or sudden muscle weakness during intense emotions such as anger, sadness, or laughter, occurs at any time during the day; there is no cataplexy scale for sleep assessment. A polysomnogram involves the use of EEG, EMG, and EOG to monitor stages of sleep and wakefulness during nighttime sleep; this is used in a sleep laboratory study. Researchers believe that the ascending reticular activating system (RAS) located in the upper brainstem contains special cells that maintain alertness and wakefulness; however, there is no assessment tool called the RAS scale.

An adolescent child who is having behavioral problems has had added responsibilities put upon her because the father has just lost his job and is experiencing periods of depression and the mother has a chronic debilitation illness. The nurse is involved in crises intervention and intervenes to specifically focus the family on their feelings by: A. Pointing out the connection between the situation and their responses B. Encouraging the use of the family's usual coping skills C. Working on time management skills D. Discussing past experiences

ANS: A When using a crisis intervention approach, pointing out the connections between situation and responses, the nurse helps the client make the mental connection between the stressful event and the client's reaction to it. Because an individual's or family's usual coping strategies are ineffective in managing the stress of the precipitating event in a crisis situation, the use of new coping mechanisms are required.

The nurse is evaluating outcomes for the patient with insomnia. Which key principle will the nurse consider during this process? A. The patient is the best evaluator of sleep. B. The nurse is the best evaluator of sleep. C. Effective interventions are the best evaluators of sleep. D. Observations of the patient are the best evaluators of sleep.

ANS: A With regard to problems with sleep, the patient is the source for evaluating outcomes. The patient is the only one who knows whether sleep problems have improved and what has been successful. Interventions are not the best indicator; achievement of goals according to the patient is the best. Observations do provide needed data, but in the case of insomnia, the patient is the source for evaluating the restfulness of sleep.

Which sleep-hygiene actions at bedtime can the nurse delegate to assistive personnel? (Select all that apply.) A. Giving the patient a back rub B. Turning on quiet music C. Dimming the lights in the patient's room D. Giving a patient a cup of coffee E. Monitoring for the effect of the sleeping medication that was given

ANS: A, B, C Giving the patient a back rub, turning on quiet music, and dimming the lights are all appropriate sleep-hygiene measures. These activities are within the scope of practice for assistive personnel. Coffee, tea, cola, and chocolate act as stimulants, causing a person to stay awake or awaken throughout the night and should not be ingested before bedtime. Monitoring medication effect is a registered nurse activity

The nurse is caring for a patient who has not been able to sleep well while in the hospital, leading to a disrupted sleep-wake cycle. Which assessment findings will the nurse monitor for in this patient? (Select all that apply.) A. Changes in physiological function such as temperature B. Decreased appetite and weight loss C. Anxiety, irritability, and restlessness D Shortness of breath and chest pain E. Nausea, vomiting, and diarrhea F. Impaired judgment

ANS: A, B, C, F The biological rhythm of sleep frequently becomes synchronized with other body functions. Changes in body temperature correlate with sleep pattern. When the sleep-wake cycle becomes disrupted, changes in physiological function such as temperature can occur. Patients can experience decreased appetite, loss of weight, anxiety, restlessness, irritability, and impaired judgment. Gastrointestinal and respiratory/cardiovascular symptoms such as shortness of breath and chest pain are not symptoms of a disrupted sleep cycle.

Which statements from a patient indicate an understanding of behaviors that will promote sleep? (Select all that apply.) A. "I will not watch television in bed." B. "I will not drink caffeine later in the day." C. "A short nap late in the evening will lead to a more restful night of sleep." D. "I am going to start eating dinner closer to my bedtime" E. "I will start to exercise regularly during the day.

ANS: A, B, E To promote sleep, you should not watch television in bed. The noise of television can be disruptive and adds stimulation that is disruptive to sleep. Caffeine should not be consumed late in the day because it can cause wakefulness at bedtime. A regular exercise program completed in the morning is part of sleep hygiene practices and can help promote sleep. Exercise or eating a meal should not be done right before bed because sleep can be disrupted.

The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. Which information will the nurse include in the teaching session? (Select all that apply.) A. NREM sleep contributes to body tissue restoration. B. During NREM sleep, biological functions increase. C. Restful sleep preserves cardiac function. D. Sleep contributes to cognitive restoration. E. REM sleep decreases cortical activity.

ANS: A, C, D Sleep contributes to physiological and psychological restoration. NREM sleep contributes to body tissue restoration. It allows the body to rest and conserve energy. This benefits the cardiac system by allowing the heart to beat fewer times each minute. During stage 4, the body releases growth hormone for renewal and repair of specialized cells such as the brain. During NREM sleep, biological functions slow. REM sleep is necessary for brain tissue restoration and cognitive restoration and is associated with a change in cerebral blood flow and increased cortical activity.

A crisis intervention nurse is working with a mother whose child with Down syndrome has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in her classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) A. Referral to social service process reestablishing the child's disability payment B. Sending the child home in 72 hours and having the child return to school C. Coordinating hospital-based and home-based schooling with the child's teacher D. Teaching the mother signs and symptoms of a respiratory tract infection E. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

ANS: A, C, E The stressors for this parent are her child's illness, missing school, and loss of disability payments. Obtaining resources to resolve these stressors will reduce the mother's stress load and allow her to focus on helping her child improve and on preventing another respiratory tract infection. Discharging the child in 72 hours with a return to school may not be best for the child's physical condition and may make the situation worse. Giving the mother a 6-week time frame is unrealistic because everyone's time frame is different. The mother may also need to adjust.

A nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply.) A. Take brief, 20-minute naps no more than twice a day. B. Drink a glass of wine with dinner. C. Eat a large meal at lunch rather than dinner. D. Establish a regular exercise program. E. Teach the patient about the side effects of modafinil.

ANS: A, D, E Taking short naps, no longer than 20 minutes, during the day, and regular exercise are management strategies that help reduce the feeling of sleepiness. Modafinil is a stimulant used to treat narcolepsy; therefore, it is important for patients to understand its side effects.

Which of the following statements made by the nurse shows the best understanding of the therapeutic value of a support system for a client experiencing stress? A. "They will be there when you need them and make sure you will have your needs met." B. "They will provide you with someone to talk with about your problems and support your decisions." C. "When you are experiencing stress, it is always comforting to have people who care about you nearby." D. "These individuals have experienced what you are going through and can offer you effective suggestions."

ANS: B A support system of family, friends, and colleagues who will listen, offer advice and provide emotional support benefits a client experiencing stress. The individuals need not have actually experienced the same stressors nor is it necessary or reasonable to expect that they will meet all your needs.

The response to stress for older adults may be manifested differently than in younger adults. The nurse recognizes that. For the older adult client, the nurse is aware that: A. Losses are more stress-provoking B. Anxiety disorders are most prevalent C. Psychosocial factors are the greatest threats D. Timing of stress-inducing events is not significant

ANS: B Anxiety disorders are the most prevalent disorders in later life and are continuations of life-long illnesses. Losses in later life may be less stress-provoking than generally assumed, partly because certain life transitions are anticipated and people prepare by coping in advance.

A patient has sleep deprivation. Which statement by the patient will indicate to the nurse that outcomes are being met? A. "I wake up only once a night to go to the bathroom." B. "I feel rested when I wake up in the morning." C. "I go to sleep within 30 minutes of lying down." D. "I only take a 20-minute nap during the day."

ANS: B Being able to sleep and feeling rested would indicate that outcomes are being met for sleep deprivation. Limiting a nap to 20 minutes is an intervention to promote sleep. Going to sleep within 30 minutes indicates a goal for insomnia. Waking up only once may indicate nocturia is improving but does not relate to sleep deprivation.

The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which action should the nurse take next? A. Talk with the adolescent's parent about staying up with friends and the need for sleep. B. Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness. C. Refer the adolescent for counseling about alcohol abuse problems. D. Take no action for this normal occurrence.

ANS: B Discussion regarding adolescent sleep needs should first occur with the adolescent. Although it may be common for this adolescent to want to visit with friends and experience activities that go late into the night, these activities can and do impact the hours of sleep and the physical needs of the adolescent, no matter the reason for the late nights, and they do need to be addressed. The nurse will address the adolescent, not the parents. Addressing alcohol abuse problems is not the next step but may be required later. While staying up late may be a normal occurrence for this adolescent, action is required

The husband of a client with terminal cancer has expressed a high degree of stress over his role as caregiver. When asked whether he has suicidal or homicidal thought he answered, "Sometimes." Which of the following nursing statements is most therapeutic initially? A. "What is the hardest part about your wife's impending death?" B. "Can you describe your plan for killing yourself and your wife?" C. "What can I do to help make caring for your wife less stressful?" D. "Can you tell me how caring for your wife has affected you personally?"

ANS: B If a client indicates suicidal or homicidal ideations, the nurse should first determine in a caring and concerned manner if the person has a plan and determine how lethal the means are.

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next? A. Do nothing, no harm has occurred. B. Notify the health care provider. C. Complete an incident report. D. Assess the patient.

ANS: B Report immediately to physician or health care provider if the patient sustains a fall or an injury. The nurse must provide safe care, and doing nothing is not safe care. The scenario indicates the nurse has already assessed the patient. After the patient has stabilized, completing an incident report would be the last step in the process.

The nurse is beginning a sleep assessment on a patient. Which question will be most appropriate for the nurse to ask initially? A. "What is going on?" B. "How are you sleeping?" C. "Are you taking any medications?" D. "What did you have for dinner last night?"

ANS: B Sleep is a subjective experience. Only the patient is able to report whether or not it is sufficient and restful. Asking patients how they are sleeping is an introductory question. After this beginning question is asked, problems with sleep such as the nature of the problem, signs and symptoms, onset and duration of the issue, severity, predisposing factors, and the effect on the patient can be assessed. What is going on is too broad and open ended for information about sleep to be obtained specifically. Medications and food intake can be part of the detailed assessment of sleep issues.

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event? A. No blood incompatibility occurs with a blood transfusion. B. A surgical sponge is left in the patient's incision. C. Pulmonary embolism after lung surgery D. Stage II pressure ulcer

ANS: B The Centers for Medicare and Medicaid Services names select serious reportable events as Never Events (i.e., adverse events that should never occur in a health care setting). A surgical sponge left in a patient's incision is a Never Event. No blood incompatibility reaction is safe practice. Pulmonary embolism after certain orthopedic procedures is like a total knee and hip replacement. Stage III and IV pressure ulcers are Never Events.

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately? A. Respiratory rate B. Temperature C. Apical pulse D. Blood pressure

ANS: B The temperature indicates the patient is experiencing hypothermia. Homeless individuals are more at risk for hypothermia. While all the vital signs are low, the most critical vital sign at this time is the temperature.

Which of the following clients shows the greatest risk factor for stress coping related to situational stressors? A. An 18 year old high school athlete who breaks his leg just before college football tryouts B. A 74 year old widow whose only son is severely injured in an automobile accident C. A 36 year old who loses his job days after his marriage to his high school sweetheart D. A 60 year old who is diagnosed with prostate cancer after deciding to retire from his job of 26 years

ANS: B The timing of stress-inducing events significantly influences older adults' ability to cope. The fact that older adults have several stressful events occur within a short period of time often results in negative effects on coping ability.

Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? A. "I'll give the baby a bottle to help her fall asleep." B. "We'll place the baby on her back to sleep." C. "We put the baby's stuffed animals in the crib to make her feel safe." D. "I know the baby will not need to be fed until morning."

ANS: B This is based on the current evidence that shows that parents need to place an infant on his or her back to prevent suffocation. Bottles, stuffed animals, and pillows should not be placed in the bed with an infant.

The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order. A. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. B. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." C. "I'm calling to ask if you would order a hypnotic such as zolpidem to use on a prn basis." D. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1°C (98.8°F).

ANS: B, A, D, C SBAR is Situation, Background, Assessment, and Recommendation. This is the correct sequence of steps in SBAR for the patient and sleep problem

Which of the following are symptoms of secondary traumatic stress and burnout that commonly affect nurses? (Select all that apply.) A. Regular participation in a book club B. Lack of interest in exercise C. Difficulty falling asleep D. Lack of desire to go to work E. Anxiety while working

ANS: B, C, D, E Nurses are particularly susceptible to the development of secondary traumatic stress and burnout—the components of compassion fatigue. Symptoms include decline in health, emotional exhaustion, irritability, restlessness, impaired ability to focus and engage with patients, feelings of hopelessness, inability to take pleasure from activities, and anxiety

A community health nurse is providing an educational session at the senior center on how to promote sleep. Which practices should the nurse recommend? (Select all that apply.) A. Take a nap in the afternoon. B. Sleep where you sleep best. C. Use sedatives as a last resort. D. Watch television right before sleep. E. Decrease fluids 2 to 4 hours before sleep. F. Get up if unable to fall asleep in 15 to 30 minutes.

ANS: B, C, E, F The nurse should instruct the patient to sleep where he or she sleeps best, to use sedatives as a last resort, to decrease fluid intake to cut down on bathroom trips, and, if unable to sleep in 15 to 30 minutes, to get up out of bed. Naps should be eliminated if they are not part of the individual's routine schedule, and if naps are taken, they should be limited to 20 minutes or less a day. Television can stimulate and disrupt sleep patterns.

Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply.) A. Give patients a cup of coffee 1 hour before bedtime. B. Plan vital signs to be taken before the patients are asleep. C. Turn television on 15 minutes before bedtime. D. Have patients follow at-home bedtime schedule. E. Close the door to patients' rooms at bedtime.

ANS: B, D, E Bedtime routines relax patients in preparation for sleep. Patients in the hospital should follow their at-home bedtime routine. Taking vital signs before sleep onset prevents disruption of sleep and improves sleep duration and quality. Closing the door to patients' rooms decreases noise that can disrupt sleep. Noise is one of the main factors contributing to poor sleep in hospitalized patients. Excessive stimulation, such as watching television, should be avoided close to bedtime

A nurse working on a medical patient care unit states, "I am having trouble sleeping, and I eat nonstop when I get home. All I can think of when I get to work is how I can't wait for my shift to be over. I wish I felt happy again." What are the best responses from the nurse manager? (Select all that apply.) A. "I'm sure this is just a phase you are going through. Hang in there. You'll feel better soon." B. "I know several nurses who feel this way every now and then. Tell me about the patients you have cared for recently. Did you find it difficult to care for them?" C. "You can take diphenhydramine over the counter to help you sleep at night." D. "Describe for me what you do with your time when you are not working." E. "The hospital just started a group where nurses get together to talk about their feelings. Would you like for me to email the schedule for you?"

ANS: B, D, E This nurse is experiencing symptoms of compassion fatigue. The nurse manager needs to establish a therapeutic relationship with the nurse. Acknowledging personal thoughts and feelings and talking with other nurses to identify coping strategies can help this nurse work through the feelings associated with compassion fatigue. Engaging in healthy behaviors and establishing a good work-life balance may also help.

A patient has obstructive sleep apnea. Which assessment is the priority? A. Gastrointestinal function B. Neurological function C. Respiratory status D. Circulatory status

ANS: C In obstructive sleep apnea, the upper airway becomes partially or completely blocked, diminishing nasal airflow or stopping it. The person still attempts to breathe because the chest and abdominal movement continue, which results in loud snoring and snorting sounds. According to the ABCs of prioritizing care, airway and respiratory status takes priority over gastrointestinal, circulatory, and neurologic functioning.

The patient presents to the clinic with reports of irritability, being sleepy during the day, chronically not being able to fall asleep, and being tired. Which nursing diagnosis will the nurse document in the plan of care? A. Anxiety B. Fatigue C. Insomnia D. Sleep deprivation

ANS: C Insomnia is experienced when the patient has chronic difficulty falling asleep, frequent awakenings from sleep, and/or short sleep or nonrestorative sleep. It is the most common sleep-related complaint and includes symptoms such as irritability, excessive daytime sleepiness, not being able to fall asleep, and fatigue. Anxiety is a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. Fatigue is an overwhelming sustained sense of exhaustion with decreased capacity for physical and mental work at a usual level. Sleep deprivation is a condition caused by dyssomnia and includes symptoms caused by illness, emotional distress, or medications.

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals? A. Identifies patient with one identifier before transporting to x-ray department B. Initiates an intravenous (IV) catheter using clean technique on the first try C. Uses medication bar coding when administering medications D. Obtains vital signs to place on a surgical patient's chart

ANS: C One of the National Patient Safety Goals is to use medicines safely. For example, proper preparation and administration of medications, use of patient and medication bar coding, and "smart" intravenous (IV) pumps reduce medication errors. Identifying patients correctly is a national patient safety goal, and two identifiers are needed, not one. Another goal is to prevent infection; starting an IV should be a sterile technique, not a clean technique. While obtaining vital signs is a component of safe care, it does not meet a national patient safety goal.

The nurse is caring for a patient who is having trouble sleeping. Which action will the nurse take? A. Suggest snug-fitting nightwear. B. Provide a favorite beverage. C. Encourage deep breathing. D. Walk with the patient.

ANS: C Relaxation exercises such as slow, deep breathing for 1 or 2 minutes relieve tension and prepare the body for rest. Instruct patients to wear loose-fitting nightwear. Walking and drinking a favorite beverage would not necessarily encourage sleep.

The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working? A. The patient continues to get up from the chair at the nurses' station. B. The patient gets restless when the sitter leaves for lunch. C. The patient folds three washcloths over and over. D. The patient apologizes for being "such a bother."

ANS: C Restraint alternatives include more frequent observations, social interaction such as involvement of family during visitation, frequent reorientation, regular exercise, and the introduction of familiar and meaningful stimuli (e.g., involve in hobbies such as knitting or crocheting or looking at family photos) within the environment or folding washcloths. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Getting restless when the sitter leaves indicates the alternative is not working.

The son of a client is diagnosed with moderately advanced Alzheimer's disease shows concern over the care his mother will receive after making the decision to institutionalize her. Which of the following statements made by the admitting nurse is most therapeutic in addressing the son's concerns? A. "We care deeply for all our clients and take great pride in the care and attention we give each one of them." B. "Please feel free to talk to our staff and to the other clients about care and attention we give to each of our clients." C. "I hope that you will be able to visit your mother often and offer us suggestions on how best to meed her physical and emotional needs." D. "I know is has been a difficult decision, and you must have concerns about leaving her, but rest assured we have her best interest at heart."

ANS: C The decision to institutionalize a family member and the aftermath of that decision cause emotional distress and are a threat to family members' psychological well-being. When their role shifted from primary caregiver to advocate for the patient, the family members felt empowered. Previous studies showed that institutionalized residents have a better quality of life when family members are involved.

A 72 year old client is in a long term care facility after having had a cerebrovascular accident. The client is non-communicative, enteral feedings are not being absorbed, and respirations are becoming labored. Which of the stages of the GAS is the client experiencing? A. Alarm reaction B. Resistance stage C. Exhaustion stage D. Reflex pain response

ANS: C The exhaustion stage occurs when the body can no longer resist the effects of the stressor and when the energy necessary to maintain adaptation is depleted. During the alarm reaction, rising hormone levels result in increased blood volume, NE and E amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. During the resistance stage, the body stabilizes. Reflex pain response is not a stages of GAS.

An older-adult patient is visiting the clinic after a fall during the night. The nurse obtains information on what medications the patient takes. Which medication most likely contributed to the patient's fall? A. Melatonin B. L-tryptophan C. Benzodiazepine D. Iron supplement

ANS: C The most likely cause is a benzodiazepine. If older patients who were recently continent, ambulatory, and alert become incontinent or confused and/or demonstrate impaired mobility, the use of benzodiazepines needs to be considered as a possible cause. This can contribute to a fall in an older adult. Short-term use of melatonin has been found to be safe, with mild side effects of nausea, headache, and dizziness being infrequent. Iron supplements may be given to patients with restless legs syndrome. Some substances such as L-tryptophan, a natural protein found in foods such as milk, cheese, and meats, promote sleep; while it does promote sleep, it is not the most likely to cause mobility problems.

The patient has just been diagnosed with narcolepsy. The nurse teaches the patient about management of the condition. Which information from the patient will cause the nurse to intervene? A. Takes antidepressant medications B. Naps shorter than 20 minutes C. Sits in hot, stuffy rooms D. Chews gum

ANS: C The nurse will intervene about sitting in a hot, stuffy room as this will make the narcolepsy worse so this needs to be corrected. Patients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol, heavy meals, exhausting activities, long-distance driving, and long periods of sitting in hot, stuffy rooms). Patients are treated with antidepressants, and management techniques involve scheduling naps no longer than 20 minutes and chewing gum. Additional management techniques include exercise, light high-protein meals, deep breathing, and taking vitamins

It appears to the nurse the client is experiencing a crisis. The nurse plans to: A. Allow the client to work through independent problem-solving B. Complete an in-depth evaluation of stressors and responses C. Focus on immediate stress reduction D. Recommend ongoing therapy

ANS: C The nurse's focus for a client experiencing a crisis is immediate stress reduction. A person who has experienced a crises has changed, and the effects may last for years or for the rest of the person's life. If a person has successfully coped with a crises and its consequences, he or she becomes a more mature and healthy person, and ongoing therapy may not be necessary.

The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM? A. The patient awakens easily. B. The patient's eyes rapidly move. C. The patient is difficult to awaken. D. The patient's vital signs are elevated.

ANS: C The patient is difficult to arouse, vital signs are significantly lower, and this stage lasts about 15 to 30 minutes. Stage 4 NREM is the deepest stage of sleep. Lighter sleep is seen in stages 1 and 2, where the patient awakens easily. REM sleep is characterized by rapid eye movement.

The Nurse is interviewing a patient in the community clinic and gathers the following information about her: A single parent with two children who have developmental delays. She has had asthma since she was a teenager. She does not laugh or smile, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during the patient assessment? (Select all that apply) A. Post-traumatic stress disorder B. Rising hormone levels C. Chronic illness D. Insomnia E. Depression

ANS: C, D, E An increased allopathic load can result in long-term physiological and psychological problems such as chronic illness, depression, sleep deprivation, chronic fatigue syndrome, and autoimmune disorders. Post-traumatic stress disorder results from a single traumatic event. Hormone levels rise in the alarm stage

The nurse recognizes that a client experiencing anxiety related to a traumatic injury and the resulting pain is likely to experience the fight or flight response, which would cause which of the following assessment findings? (Select all that apply.) A. Rectal temperature of 102.2F B. Pulse ox of 97% on room air C. Respirations of 30 breaths/minute D. Heart rate greater than 100 beats/minute E. Fasting glucose level of 118 mg/dL F. Systolic blood pressure 26 mmHg above baseline

ANS: C, D, E, F This reaction prepares a person for action by increasing heart rate; diverting blood from the intestines to the brain and striated muscles; and increasing blood pressure, respiratory rate, and blood sugar levels. Body temperature and oxygen saturation are not typically affected by fight or flight.

A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take? A. Check on the patient once a shift. B. Encourage visitors in the early evening. C. Place all four side rails in the "up" position. D. Keep the patient on fall risk until discharge.

ANS: D A fall-reduction program includes a fall risk assessment of every patient, conducted on admission and routinely (see hospital policy) until a patient's discharge. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour.

A young mother has been hospitalized for an irregular heartbeat (dysrhythmia). The night nurse makes rounds and finds the patient awake. Which action by the nurse is most appropriate? A. Inform the patient that it is late and time to go to sleep. B. Ask the patient if she would like medication for sleep. C. Recommend a good movie that is on television tonight. D. Take time to sit and talk with the patient about her inability to sleep.

ANS: D A nurse on the night shift needs to take time to sit and talk with patients unable to sleep. This helps to determine the factors keeping patients awake. Assessment is the first step of the nursing process; therefore assessment needs to be done first and involves ascertaining the cause of the patient's inability to sleep. Patients who are admitted to the hospital for uncertain diagnoses can be stressed and worried about the testing and outcomes. In addition, a young mother can be worried about the care of her children and those caring for the children. This uncertainty and change in routine can cause difficulty in resting or falling asleep. A distraction such as a television may or may not work for the patient. After assessment is completed, a sedative may or may not be in order. Telling the patient that it is late and time to go to sleep is not a therapeutic response for an adult who is under stress.

What priority assessment area has been noticed by a nurse while working with clients who are experiencing a significant degree of stress? A. The client's primary physical needs B. What else is happening in the client's life C. How the stress has influenced the client's activities of daily living D. Determining whether the client is thinking about harming self or others

ANS: D A priority assessment is to determine if the person is suicidal or homicidal by asking directly. The priority assessment for the client who is experiencing a significant degree of stress is not the client's physical needs. The nurse should first determine if the client is a danger to self or others.

A corporate executive works 60 to 80 hours/week. The client is experiencing some physical signs of stress. The practitioner teaches the client to "include 15 minutes of biofeedback." This is an example of which of the following health promotion intervention? A. Guided imagery B. Regular exercise C. Time management D. Relaxation technique

ANS: D Biofeedback is a training program designed to develop one's ability to control the autonomic nervous system. Clients learn to monitor their functioning such as heart rate, blood pressure, skin temperature, or muscle tension, and learn to relax in response in order to create desired changes.

The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate? A. Close the door to decrease noise from unit activities. B. Adjust temperature in the patient's room to 21° C (70° F). C. Ensure that the night-light in the patient's room is working. D. Encourage the discontinuation of a soda and chocolate nightly snack.

ANS: D Discontinuing the soda and chocolate nightly snack will be most beneficial for this patient since it has two factors that will cause difficulty falling asleep. Coffee, tea, colas, and chocolate act as stimulants, causing a person to stay awake or to awaken throughout the night. Personal preference influences the temperature of the room, as well as the lighting of the room. Noise can be a factor in the unit and can awaken the patient, but caffeine can make it difficult to fall asleep.

A client is experiencing job-related stress. The nurse is working with the client in an outpatient health care setting. The nurse believes this client is dissociated as a result of observing the client: A. Avoid discussion of job problems B. Act like another colleague on the job C. Experience chronic headaches and stomach aches D. Sit quietly and not interact with any of the staff

ANS: D Dissociation is experiencing a subjective sense of numbing and a reduced awareness of one's surrounding. The client who is sitting quietly and not interacting with any of the staff may be displaying dissociation.

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls? A. 55 years old B. 20/20 vision C. Urinary continence D. Orthostatic hypotension

ANS: D Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics).

The nurse adds a nursing diagnosis of ineffective breathing pattern to a patient's care plan. Which sleep condition caused the nurse to assign this nursing diagnosis? A. Insomnia B. Narcolepsy C. Sleep deprivation D. Obstructive sleep apnea

ANS: D Obstructive sleep apnea (OSA) occurs when the muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing airflow or stopping it for as long as 30 seconds. The person still attempts to breathe because chest and abdominal movements continue, resulting in snoring or snorting sounds. With narcolepsy, the person feels an overwhelming wave of sleepiness and falls asleep. Insomnia is characterized by chronic difficulty falling asleep. Sleep deprivation is a condition caused by dyssomnia. OSA is the only one of these conditions that results in blockage of the airway and impacts the ability to breathe.

The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring? A. Tile floors, cold food, scratchy linen, and noisy alarms B. Dirty floors, hallways blocked, medication room locked, and alarms set C. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach D. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning

ANS: D Specific risks to a patient's safety within the health care environment include falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in the hospital setting but are more of patient satisfaction, infection control, or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are examples of following a procedure correctly.

A client recently lost a child in a severe case of poisoning. The client tells the nurse, "I don't want to make any new friends right now." This is an example of which of the following indicators of stress? A. Spiritual indicator B. Emotional indicator C. Intellectual indicator D. Sociocultural indicator

ANS: D The client who recently experienced a loss and does not want to meet new people is an example of a sociocultural indicator of stress.

During the end of shift report the nurse notes that a client has been very nervous and preoccupied during the evening and that no family visited. To determine the amount of anxiety that the client is experiencing, the nurse should respond: A. "Would you like for me to call a family member to come support you?" B. "Would you like to talk with another client who had the same surgery?" C. "How serious do you think the illness you are experiencing really is?" D. "You seem worried about something. Would it help to talk about it?"

ANS: D The nurse learned from the client both by asking questions and by making observations of nonverbal behavior and the client's environment. To determine the amount of anxiety the client is experiencing, the nurse gathers information from the client's perspective. Noting that he seems worried and offering to discuss it is the correct response.

A single parent is discussing the sleep needs of a preschooler with the nurse. Which information will the nurse share with the parent? A. "Most preschoolers sleep soundly all night long." B. "It is important that the 5-year-old get a nap every day." C. "On average, the preschooler needs to sleep 10 hours a night." D. "Preschoolers may have trouble settling down after a busy day."

ANS: D The preschooler usually has difficulty relaxing or settling down after long, active days. By the age of 5, naps are rare for children, except those for whom a siesta is a custom. Preschoolers frequently awaken during the night. On average, a preschooler needs about 12 hours of sleep.

The nurse is caring for a client who was admitted with various physical traumas resulting from an assault by a stranger attempting to steal her purse. Which of the following statements made by the nurse is most therapeutic in assessing the degree of stress the event has caused the client? A. "Would you like to talk about the attack?" B. "What may I do to help you emotionally?" C. "Has being attacked been traumatic for you?" D. "How has this experience affected your life?"

ANS: D The vital question for a person in crisis is, "What does this mean to you; how is it going to affect your life?" What causes extreme stress for one person is not always stressful to another. The perception of the event, the situational supports, and the coping mechanisms all influence return equilibrium or homeostasis.

Which of the following statements reflects the correct interpretation of the effect of age on coping strategies? A. "The young adult client generally handles stress more effectively than does the elder adult." B. "Life provides the older adult with more opportunities to effectively manage their stressful events." C. "Children appear to be less aware of stressors in their lives and so are less negatively affected by it." D. "Stress is evident in everyone's life and we all learn to cope with it regardless of our age or life experiences."

ANS: D There are very few age-related differences in coping strategies, and older adults are just as effective at coping as younger adults.

The nurse is caring for a young-adult patient on the medical-surgical unit. When doing midnight checks, the nurse observes the patient awake, putting a puzzle together. Which information will the nurse consider to best explain this finding? A. The patient misses family and is lonely. B. The patient was waiting to talk with the nurse. C. The patient has been kept up with the noise on the unit. D. The patient's sleep-wake cycle preference is late evening.

ANS: D This patient is awake and alert enough to do a puzzle. The individual's sleep-wake preference is probably late evening. All persons have biological clocks that synchronize their sleep-wake cycle. This explains why some individuals fall asleep in the early evening, whereas others go to bed at midnight or early morning. Waiting to talk with the nurse, being lonely, and noise on the unit may contribute to lack of sleep, but the best explanation for the patient being awake is the biological clock.

A 10-year-old girl was playing on a slide at a playground during a summer camp. She fell and broke her arm. The camp notified the parents and took the child to the emergency department according to the camp protocol for injuries. The parents arrive at the emergency department and are stressed and frantic. The 10-year old is happy in the treatment room, eating a Popsicle and picking out the color of her cast. List in order of priority what the nurse should say to the parents. A. "Can I contact someone to help you?" B. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." C. "I'll have the doctor come out and talk to you as soon as possible." D. "I want to be sure you are ok. Let's talk about what your concerns are about your daughter before we go see her."

B. "Your daughter is happy in the treatment room, eating a Popsicle and picking out the color of her cast." D. "I want to be sure you are ok. Let's talk about what your concerns are about your daughter before we go see her." C. "I'll have the doctor come out and talk to you as soon as possible." A. "Can I contact someone to help you?" First and most important the parents need to know the immediate status of their daughter. Letting them know the situation will help to relieve their immediate stress. Second, helping the parents discuss their concerns will reduce their stress and will allow them to see their daughter without increasing the 10-year-old's anxiety. Third, let the parents know that you recognize their need to talk to the doctor as soon as possible and that you will act as their advocate to get that accomplished. Last, but also important, you want to ask whether there is anyone you can call to help. There may be children who need to be picked up from camp/ day care, for example, and a neighbor or grandparent may be able to assist.

The nurse is caring for a postpartum patient. The patient's labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. Which nursing diagnosis will the nurse document in the patient's care plan? A. Insomnia B. Impaired parenting C. Ineffective coping D. Sleep deprivation

ANS: D This patient has been deprived of sleep by staying awake during a 28-hour labor. Disorientation is one potential sign of sleep deprivation. In this scenario, there is a clear cause for the patient's lack of sleep, and it is a one-time episode. Insomnia, on the other hand, is a chronic disorder whereby patients have difficulty falling asleep, awaken frequently, or sleep only for a short time. This scenario does not indicate that this has been a chronic problem for this patient. Although ineffective coping can manifest as a sleep disturbance, clear evidence shows that it was labor that deprived this patient of sleep, not an inability to cope. It could be difficult to care for an infant when sleep deprived; however, this scenario gives no evidence that this mother displays impaired parenting and is not caring adequately for her child or lacks the skills to do so.

A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up? A. "Every December is the time to change batteries on the carbon monoxide detector." B. "I will schedule an appointment with a chimney inspector next week." C. "If I feel dizzy when using the heater, I need to have it inspected." D. "When it is cold outside in the winter, I will use a non vented furnace."

ANS: D Using a nonvented heater introduces carbon monoxide into the environment and decreases the available oxygen for human consumption and the nurse should follow up to correct this behavior. Checking the chimney and heater, changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that are safe and appropriate and need no follow-up.

The nurse is evaluating how well a patient newly diagnosed with multiple sclerosis and psychomotor impairment is coping. Which statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) A. "I'm going to learn to drive a car, so I can be more independent." B. "My sister says she feels better when she goes shopping, so I'll go shopping." C. "I'm going to let the occupational therapist assess my home to improve efficiency." D. "I've always felt better when I go for a long walk. I'll do that when I get home." E. "I'm going to attend a support group to learn more about multiple sclerosis."

C. "I'm going to let the occupational therapist assess my home to improve efficiency." E. "I'm going to attend a support group to learn more about multiple sclerosis." Inviting the occupational therapist into the patient's home and attending support groups are early indicators that the patient is recognizing some of the challenges of the disease and participating in positive realistic activities to cope with the stressors related to changes in physical functioning. The other options relate to independence and other coping strategies but do not address coping with the specific challenges of the disease.