Chapter 45 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 45

Question 1

Type: MCSA

The mother of a newborn tells the nurse, I am concerned about my baby. When she first goes to sleep, her eyes dart around under her eyelids, she doesnt breathe regularly, and she sometimes twitches. What advice should the nurse give this mother?

1. Please bring your baby in immediately for a checkup.

2. These are common behaviors in newborns and are normal.

3. You should ask the physician about these symptoms at your next checkup.

4. If your baby does this again, take her to the emergency department.

Correct Answer: 2

Rationale 1: There is no need for the mother to bring the baby in for an immediate checkup.

Rationale 2: These are indications of normal REM sleep in the newborn. The mother should be reassured that this is normal.

Rationale 3: Having the mother wait until the next checkup unnecessarily delays reassurance that this is normal sleep behavior for a newborn.

Rationale 4: This is normal sleep behavior for a newborn. The baby does not need to be seen in the emergency department.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Identify the characteristics of the NREM and REM sleep states.

MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a clients state of rest.

Page Number: 1068

Question 2

Type: MCSA

The parents of a 6-month-old tell the nurse that they are exhausted because their baby wakes up several times every night. What advice should the nurse give these parents?

1. Be certain that the baby is truly awake before picking him up for feeding.

2. Let the baby cry it out for a few nights until he can sleep through the night.

3. Continue to respond to the baby whenever he is restless during the night.

4. Bring the baby in for a possible sleep study to check for sleeping disorders.

Correct Answer: 1

Rationale 1: Babies often move and make noises while sleeping that do not indicate wakefulness. The parents should be certain the baby is awake before picking him up to feed, change, or comfort.

Rationale 2: Letting the baby cry it out is not appropriate if he really needs care.

Rationale 3: Continuing to respond to the baby whenever he is restless during the night is not necessary and may result in parental exhaustion.

Rationale 4: There is no indication for need of a sleep study for this baby.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe interventions that promote sleep.

MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a clients state of rest.

Page Number: 1069

Question 3

Type: MCSA

The 70-year-old client tells the nurse, I can go to sleep without a problem, but then I wake up in a couple of hours and cant go back to sleep. What nursing action would help promote rest and sleep in this client?

1. Have the client develop a bedtime ritual of quiet music and a glass of wine.

2. Encourage the client to avoid taking pain medication prior to sleep.

3. Evaluate if the client perceives sleeplessness to be a serious problem.

4. Have the client perform moderate exercises before bedtime.

Correct Answer: 3

Rationale 1: Alcohol can interfere with sleep.

Rationale 2: If the client has pain, the nurse should not encourage avoidance of medication.

Rationale 3: The first intervention is to determine what the pattern of sleeplessness means to the client. Many older clients will nap off and on through the day and night and spend wakeful times engaged in activity, even if the active times are not during traditional active hours.

Rationale 4: Exercise can interfere with sleep.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Describe interventions that promote sleep.

MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a clients state of rest.

Page Number: 1071

Question 4

Type: MCSA

A client complains of not being able to stay awake during the day even after sleeping throughout the night. What should the nurse suggestion to this client?

1. Go to your physician for a physical examination.

2. Go to a mental health professional for evaluation of possible depression.

3. Purchase an over-the-counter sleep aid to deepen nighttime sleep.

4. Drink more caffeinated beverages in the daytime to stay awake.

Correct Answer: 1

Rationale 1: Daytime hypersomnia is often due to medical conditions such as kidney, liver, or metabolic disturbances. The nurse should suggest that the client be evaluated by a physician.

Rationale 2: Daytime hypersomnia is rarely caused by psychologic issues.

Rationale 3: An over-the-counter sleep aid is not a good choice, as the client already sleeps well at night and sleep aids can sometimes cause future sleep disturbances.

Rationale 4: Caffeinated beverages may increase daytime wakefulness, but will not help any underlying problem that may be present.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe common sleep disorders.

MNL Learning Outcome: 4.12.3. Relate common sleep disorders to their associated clinical manifestations.

Page Number: 1073

Question 5

Type: MCSA

The nurse is developing a plan of care for a client diagnosed with narcolepsy. Which intervention should the nurse include in this plan of care?

1. Encourage the client to take an over-the-counter medication to improve nighttime sleep.

2. Be certain the client has the prescription for modafinil (Provigil) filled.

3. Have the client purchase sodium oxybate (Xyrem) over the counter to prevent daytime drowsiness.

4. Be certain the client obtains antihistamines to control nasal stuffiness.

Correct Answer: 2

Rationale 1: In narcolepsy, nighttime sleep is not affected.

Rationale 2: The medication modafinil (Provigil) is prescribed to control the daytime drowsiness associated with narcolepsy.

Rationale 3: Sodium oxybate (Xyrem) is a prescription medication that has very limited availability.

Rationale 4: The client should avoid antihistamines, as they can cause daytime drowsiness to increase.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Describe common sleep disorders.

MNL Learning Outcome: 4.12.3. Relate common sleep disorders to their associated clinical manifestations.

Page Number: 1074

Question 6

Type: MCSA

The client is being treated with a nasal continuous positive airway pressure device (CPAP) for sleep apnea. What finding indicates that this treatment has been helpful to the client?

1. The client has lost 7 pounds since treatment began.

2. The client sleeps so soundly that he snores.

3. The clients diabetes is now under control.

4. The client reports a decrease in morning headache.

Correct Answer: 4

Rationale 1: Weight loss is not a direct result of CPAP therapy.

Rationale 2: Snoring is a sign of apnea, not sound sleeping.

Rationale 3: Successful treatment for sleep apnea will not help control diabetes.

Rationale 4: The fact that the client experiences a decrease in morning headache indicates the client is sleeping better.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.3. Relate common sleep disorders to their associated clinical manifestations.

Page Number: 1074

Question 7

Type: MCSA

The nurse is admitting a critically ill client to the intensive care unit. What question should the nurse ask regarding this clients sleep history?

1. No questions should be asked.

2. When do you usually go to sleep?

3. Do you have any problems with sleeping?

4. What are your bedtime rituals?

Correct Answer: 1

Rationale 1: When the client is critically ill or being admitted for an outpatient procedure, sleep history can be omitted or deferred.

Rationale 2: Because the client is critically ill, the sleep assessment can be done at a later time.

Rationale 3: Because the client is critically ill, the sleep assessment can be done at a later time.

Rationale 4: Because the client is critically ill, the sleep assessment can be done at a later time.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify the components of a sleep pattern assessment.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1075

Question 8

Type: MCSA

The client who has sleep apnea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

1. Disturbed Sleep Pattern related to difficulty staying asleep

2. Risk for Impaired Gas Exchange related to sleep apnea

3. Disturbed Thought Processes related to chronic insomnia

4. Risk for Injury related to somnambulism

Correct Answer: 4

Rationale 1: Although this diagnosis may be applicable for the client, it is not the priority.

Rationale 2: Although this diagnosis may be applicable for the client, it is not the priority.

Rationale 3: Although this diagnosis may be applicable for the client, it is not the priority.

Rationale 4: The priority is Risk for Injury related to somnambulism because it reflects the most dangerous situation for the client.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1077

Question 9

Type: MCSA

The nurse is working with a client to develop an expected outcome for the nursing diagnosis Disturbed Sleep Pattern, difficulty staying asleep related to anxiety secondary to multiple life stressors. Which expected outcome would be most applicable to this clients situation?

1. The client will sleep at least 8 hours each night.

2. The client will list three positive coping mechanisms for anxiety relief.

3. The client will report getting sufficient sleep to provide energy for daily activities.

4. The client will manifest less anxiety after taking prescribed medications.

Correct Answer: 3

Rationale 1: The client may require more than 8 hours of sleep to feel rested and have sufficient energy.

Rationale 2: Simply listing coping mechanisms for anxiety relief is not as helpful as actually getting sleep.

Rationale 3: The best outcome statement for this client is to report getting sufficient sleep to provide energy for daily activities.

Rationale 4: Antianxiety medications are probably not the most important factor for this client.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1077

Question 10

Type: MCSA

The nurse is planning interventions for a client who has difficulty falling asleep. Which intervention regarding sleep times would be most helpful?

1. Maintain a regular bedtime and wake-up time for all days of the week.

2. If bedtime is delayed on one night, go to bed that much earlier the next night.

3. If daytime drowsiness occurs, go to bed earlier that night.

4. Sleep at least 1 hour later on mornings you dont have to go to work.

Correct Answer: 1

Rationale 1: The best intervention is to have the client establish and maintain a regular bedtime and wake-up time for all days of the week.

Rationale 2: Moving bedtime according to previous delays does not promote a sleep routine.

Rationale 3: Moving bedtime according to drowsiness does not promote a sleep routine.

Rationale 4: Changing awake times according to work schedules does not promote a sleep routine.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1077

Question 11

Type: MCSA

The client reports difficulty sleeping. Which environmental intervention should the nurse recommend?

1. Play soft music throughout the night.

2. Keep a television on in the bedroom.

3. Provide white noise with a fan.

4. Play a talk radio station.

Correct Answer: 3

Rationale 1: Music can promote wakefulness.

Rationale 2: Television can promote wakefulness.

Rationale 3: Noise should be kept to a minimum. Extraneous noise can be blocked by white noise from a fan, air conditioner, or white noise machine.

Rationale 4: Talk radio can promote wakefulness.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1077

Question 12

Type: MCSA

The client reports difficulty sleeping and awakening several times during the night. What intervention should the nurse recommend for the client when unable to sleep?

1. Get out of bed, go into another room, and pursue some relaxing activity until drowsy.

2. Get out of bed, go into another room, and exercise until tired before trying to go back to sleep.

3. Sit in bed and watch the bedroom television until drowsy.

4. Stay in bed with eyes closed and do some mental arithmetic until sleepy.

Correct Answer: 1

Rationale 1: The bed should be used only for sleep or sexual activity, so it is associated with sleep. The client should get up, go into a different room, and pursue some relaxing activity until drowsiness returns.

Rationale 2: Exercise within 2 hours of attempting to sleep may cause wakefulness.

Rationale 3: Sitting in the bed while watching television will strengthen the association between wakefulness and bed.

Rationale 4: Lying awake in bed will strengthen the association between wakefulness and bed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1077

Question 13

Type: MCSA

The hospitalized client requests a bedtime snack. Which food should the nurse offer this client?

1. Hot chocolate

2. Tea and crackers

3. Cereal with milk

4. Chips and salsa

Correct Answer: 3

Rationale 1: Hot chocolate contains caffeine, which can cause wakefulness and nocturia.

Rationale 2: Tea contains caffeine, which can cause wakefulness and nocturia.

Rationale 3: The nurse should offer the client a light carbohydrate (cereal) and milk.

Rationale 4: Chips and salsa is a spicy snack, and may cause gastrointestinal upsets that disturb sleep.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe interventions that promote sleep.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1077

Question 14

Type: MCSA

The client has been prescribed zolpidem (Ambien) for the short-term management of insomnia. What information should the nurse include when teaching the client about this medication?

1. For best results, take the medication just prior to bedtime.

2. Take the medication at dinnertime to avoid gastric upset.

3. Do not take the medication with any liquid that contains calcium.

4. Drink an entire glass of water with the dose to avoid kidney stones.

Correct Answer: 1

Rationale 1: Zolpidem (Ambien) has a rapid onset of action, so for best results and decreased sedation while awake, the client should take the medication just prior to bedtime.

Rationale 2: The client should not take the medication at dinnertime, which is probably some hours before bedtime.

Rationale 3: There is no reason to avoid calcium when taking this medication.

Rationale 4: There is no need for extra water when taking this medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1080

Question 15

Type: MCSA

The client who has obstructive sleep apnea is being treated with a nasal continuous positive airway pressure (CPAP) device, but has just been prescribed modafinil (Provigil). What client statement indicates that teaching about these therapies has been effective?

1. I am so glad that I wont have to sleep in this machine anymore.

2. Once I get regulated on the Provigil, I will wean myself off the CPAP.

3. I will continue using my CPAP machine at night.

4. I can turn down the pressure on my CPAP machine in about 1 week.

Correct Answer: 3

Rationale 1: Provigil is a medication that is for the treatment of narcolepsy, not sleep apnea. It will not prevent sleep apnea, so the client must continue to use the CPAP machine as it was used prior to the Provigil.

Rationale 2: Provigil is a medication that is for the treatment of narcolepsy, not sleep apnea. It will not prevent sleep apnea, so the client must continue to use the CPAP machine as it was used prior to the Provigil.

Rationale 3: Provigil is a medication that is for the treatment of narcolepsy, not sleep apnea. It will not prevent sleep apnea, so the client must continue to use the CPAP machine as it was used prior to the Provigil.

Rationale 4: Provigil is a medication that is for the treatment of narcolepsy, not sleep apnea. It will not prevent sleep apnea, so the client must continue to use the CPAP machine as it was used prior to the Provigil.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1080

Question 16

Type: MCSA

A client questions why a medication that is used to treat Parkinsons disease has been prescribed for the diagnosis of periodic limb movement disorder (PLMD). What should the nurse do?

1. Contact the physician.

2. Assure the client that medications used to treat Parkinsons disease are also used to treat PLMD.

3. Tell the client not to take the medication because there is most likely an error.

4. Check with the pharmacy to make sure the correct medication has been provided to the client

Correct Answer: 2

Rationale 1: The nurse does not need to contact the physician. The nurse can discuss the prescribed medication with the client.

Rationale 2: Medications that are commonly prescribed for the treatment of Parkinsons disease are also prescribed for the treatment of PLMD.

Rationale 3: This is not an error. Medications used to treat Parkinsons disease are also prescribed for PLMD.

Rationale 4: This action is not necessary. Medications used to treat Parkinsons disease are also prescribed to treat PLMD.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1075

Question 17

Type: MCSA

The client has complained of stiffness and muscle tension in his back. The nurse suggests a back rub, but the client declines the offer. What action should the nurse take?

1. Encourage the client to accept the back rub, saying how much it will relax the back muscles.

2. Document that the client is noncompliant with the nursing plan of care.

3. Accept the declination but tell the client to call if he changes his mind.

4. Instruct the UAP to rub the clients back while assisting him to change into a clean gown.

Correct Answer: 3

Rationale 1: The nurse should not force the client to have a back rub if one is not desired.

Rationale 2: The client is not noncompliant; he is simply stating his preference.

Rationale 3: Some clients are eager to have a back rub, but others are not comfortable with the close physical contact this intervention requires. Respect the clients decision, but keep the offer open if he changes his mind.

Rationale 4: The UAP should not attempt to rub the clients back without permission.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe interventions that promote sleep.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1078

Question 18

Type: MCSA

A 5-year-old client has recurrent night terrors. What nursing intervention should the nurse use to help alleviate this problem?

1. Have the child walk around in the room when night terrors occur.

2. The next morning, ask the child to describe the event.

3. Have the child empty the bladder prior to going to bed.

4. Use an additional pillow behind the childs head at night.

Correct Answer: 3

Rationale 1: Because this is a partial awakening, walking the child around the room will not help and the child will probably not awaken.

Rationale 2: The child will have no memory of the event the next morning.

Rationale 3: Night terrors are partial awakenings that are sometimes related to excessive tiredness or a full bladder. Having the child empty the bladder before going to bed might be helpful.

Rationale 4: There is no reason to add an additional pillow behind the childs head.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1071

Question 19

Type: MCMA

The nurse is completing the admission assessment on a client who has obstructive sleep apnea. Which findings should the nurse expect when assessing this client?

Standard Text: Select all that apply.

1. Reddened uvula

2. Large soft palate

3. Obesity

4. Short neck

5. Deviated septum

Correct Answer: 1, 2, 3

Rationale 1: Clients with obstructive sleep apnea are likely to have a reddened uvula.

Rationale 2: Clients with obstructive sleep apnea are likely to have an enlarged soft palate.

Rationale 3: Clients with obstructive sleep apnea are likely to be obese.

Rationale 4: A large, thick neck (over 17.5 inches) is more likely to be problematic than is a short neck.

Rationale 5: Deviated septum is an unlikely cause of obstructive sleep apnea.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe common sleep disorders.

MNL Learning Outcome: 4.12.3. Relate common sleep disorders to their associated clinical manifestations.

Page Number: 1076

Question 20

Type: MCMA

The nurse is working on a hospital committee tasked with reducing environmental distractions to sleep within the hospital. Which recommendations by the committee would be helpful?

Standard Text: Select all that apply.

1. Turn off all overhead lights on the unit and use night-lights and flashlights.

2. Establish a time at which radios and televisions should be turned off or down.

3. Discontinue use of the paging system after 2100.

4. Conduct nursing reports in the hallway.

5. Open curtains between beds in semiprivate rooms.

Correct Answer: 2, 3

Rationale 1: It is not possible to turn off all overhead lights and use only night-lights and flashlights, but those lights that can be eliminated should be.

Rationale 2: Establishing a time at which radios and televisions should be turned off or down will reduce the amount of disturbance to clients.

Rationale 3: Discontinuing use of the paging system at 2100 will also reduce noise.

Rationale 4: Nursing reports should be conducted in an area away from the client beds.

Rationale 5: Closing the curtains, not opening the curtains, between beds in semiprivate rooms will decrease disturbance.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Describe interventions that promote sleep.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1078

Question 21

Type: MCSA

A client tells the nurse that because of work and life responsibilities, sleep has become optional. What is the best response the nurse should make to this client?

1. Be sure to get extra sleep when you can.

2. A lack of sleep can affect hormone levels and bodily functions.

3. Everyone has different needs for sleep to in order to function.

4. You must be very productive.

Correct Answer: 2

Rationale 1: This statement implies that the client is not getting sufficient sleep. It would be more appropriate for the nurse to suggest that the client obtain more sleep on a routine basis and not just when able.

Rationale 2: Different biological functions occur during sleep that become altered with the lack of sleep. The nurse should explain what is affected by a lack of sleep.

Rationale 3: Although this might be true, everyone needs sleep. The clients statement of sleep becoming optional indicates that the client is not getting sufficient sleep.

Rationale 4: There are studies indicating that errors occur and changes in response times are altered with a lack of sleep. The client might not be productive with a lack of sleep.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain the physiology and the functions of sleep.

MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a clients state of rest.

Page Number: 1070

Question 22

Type: MCMA

The nurse is assessing a client in the intensive care unit who is asleep. What physiological changes will the nurse observe in this client?

Standard Text: Select all that apply.

1. Lower respiratory rate

2. Increased muscle tension

3. Increased lower extremity edema

4. Lower blood pressure

5. Lower heart rate

Correct Answer: 4, 5

Rationale 1: A change in respirations is not associated with sleep.

Rationale 2: Skeletal muscles relax during sleep.

Rationale 3: Peripheral blood vessels dilate during sleep, which will reduce lower extremity edema.

Rationale 4: One physiological change that occurs during sleep is a drop in arterial blood pressure.

Rationale 5: One physiological change that occurs during sleep is a decrease in heart rate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Identify the characteristics of the NREM and REM sleep states.

MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a clients state of rest.

Page Number: 1068

Question 23

Type: MCSA

A client with diabetes asks the nurse why his blood glucose level is higher on days when he sleeps less. What should the nurse explain to the client?

1. During sleep, the hormone cortisol is inhibited. If sleep is interrupted, cortisol levels will remain elevated, impacting blood glucose.

2. Because the client is awake more, it is likely the client is eating more, which is impacting the blood glucose level.

3. There is no relationship between sleep and blood glucose levels.

4. The body needs cortisol for the extra energy created by the lack of sleep.

Correct Answer: 1

Rationale 1: The cortisol level falls during sleep. With waking, the cortisol level peaks. If the client with diabetes is not getting sufficient rest, the cortisol level will stay elevated, which will impact the control of blood glucose.

Rationale 2: The nurse has no way of knowing what the client is ingesting that would impact blood glucose level and sleep.

Rationale 3: There is a relationship between sleep and blood glucose levels.

Rationale 4: The body does not use cortisol for energy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain the physiology and the functions of sleep.

MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a clients state of rest.

Page Number: 1066

Question 24

Type: MCSA

A hospitalized client is being woken up every hour during the night for care and procedures. The nurse realizes that the lack of NREM sleep can have which physiological effect?

1. Decrease urine output

2. Increase thirst

3. Increase susceptibility to infection

4. Decrease heart rate

Correct Answer: 3

Rationale 1: The loss of NREM sleep does not impact urine output.

Rationale 2: The loss of NREM sleep does not impact thirst.

Rationale 3: The loss of NREM sleep causes immunosuppression, slows tissue repair, lowers pain tolerance, triggers profound fatigue, and increases susceptibility to infection.

Rationale 4: In NREM sleep, the heart rate decreases. With the loss of NREM sleep, this decrease would not occur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain the physiology and the functions of sleep.

MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a clients state of rest.

Page Number: 1068

Question 25

Type: MCMA

A client has not had uninterrupted sleep for several nights, and is irritable. What other assessment findings should the nurse associate with the clients lack of REM sleep?

Standard Text: Select all that apply.

1. Depression

2. Confusion

3. Disorientation

4. Impaired memory

5. Muscle weakness

Correct Answer: 1, 2, 3, 4

Rationale 1: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as depression.

Rationale 2: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as confusion.

Rationale 3: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as disorientation.

Rationale 4: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as impaired memory.

Rationale 5: Muscle weakness is not associated with a loss of REM sleep.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain the physiology and the functions of sleep.

MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a clients state of rest.

Page Number: 1070

Question 26

Type: MCSA

The nurse, seeing a client asleep, turns off the television in the room. The client opens her eyes and says I was watching that. I wasnt sleeping. The nurse realizes that the client was demonstrating which stage of NREM sleep?

1. IV

2. III

3. II

4. I

Correct Answer: 4

Rationale 1: Stage IV is not a stage of NREM sleep.

Rationale 2: Stage III is the deepest stage of sleep, differing only in the percentage of delta waves recorded during a 30-second period. During deep sleep or delta sleep, the sleepers heart and respiratory rates drop 20% to 30% below those exhibited during waking hours. The sleeper is difficult to arouse. The person is not disturbed by sensory stimuli, the skeletal muscles are very relaxed, reflexes are diminished, and snoring is most likely to occur.

Rationale 3: Stage II is the stage of light sleep during which body processes continue to slow down. The eyes are generally still, the heart and respiratory rates decrease slightly, and body temperature falls. An individual in stage II requires more intense stimuli than in stage I to awaken, such as touching or shaking.

Rationale 4: Stage I is the stage of very light sleep, and lasts only a few minutes. During this stage, the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and respiratory rates drop slightly. The sleeper can be readily awakened, and might deny that she was sleeping.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Identify the characteristics of the NREM and REM sleep states.

MNL Learning Outcome: 4.12.1. Explain the physiology of sleep and its impact on a clients state of rest.

Page Number: 1067

Question 27

Type: MCSA

The parent of a preschool-age child asks the nurse what can be done to reduce the number of nightmares the child experiences. What should the nurse suggest to this parent?

1. Provide hot chocolate prior to bedtime.

2. Limit or eliminate television.

3. Engage in a physical activity before bedtime.

4. Play a computer game before bedtime.

Correct Answer: 2

Rationale 1: Chocolate is a stimulant, and could reduce the childs ability to fall asleep.

Rationale 2: Preschool children wake up frequently at night, and they might be afraid of the dark or experience night terrors or nightmares. Often, limiting or eliminating TV will reduce the number of nightmares.

Rationale 3: Physical activity is a stimulant, and could reduce the childs ability to fall asleep.

Rationale 4: Playing a computer game is a stimulant, and could reduce the childs ability to fall asleep or cause an increase in nightmares.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1069

Question 28

Type: MCSA

A client reports the need to urinate during the night and then not being able to fall back asleep. The nurse should document this assessment finding as which factor that influences sleep?

1. Illness

2. Stimulant

3. Diet

4. Lifestyle

Correct Answer: 1

Rationale 1: The need to urinate during the night disrupts sleep, and people who awaken at night to urinate sometimes have difficulty getting back to sleep.

Rationale 2: Caffeinated beverages and alcohol are stimulants that influence sleep.

Rationale 3: Body weight and the use of beverages that contain l-tryptophan are dietary influences of sleep.

Rationale 4: Hours of work, activity, and exercise are lifestyle influences of sleep.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.2. Recognize how factors that impact sleep affect the clients state of rest.

Page Number: 1071

Question 29

Type: MCSA

A client is working two jobs, caring for aged parents, and maintaining a household for the family. The nurse realizes that this emotional stress will have what impact on the clients sleep?

1. More REM sleep

2. Less Stage 1 and Stage II NREM sleep

3. More NREM sleep

4. Less deep sleep and more awakenings during the night

Correct Answer: 4

Rationale 1: Chemical changes result in less REM sleep.

Rationale 2: Chemical changes result in less NREM sleep in Stages III and IV.

Rationale 3: Chemical changes affect deep and REM sleep.

Rationale 4: Stress is considered by most sleep experts to be the number one cause of short-term sleeping difficulties. A person preoccupied with personal problems might be unable to relax sufficiently to get to sleep. Anxiety increases the norepinephrine blood levels through stimulation of the sympathetic nervous system. This chemical change results in less deep and REM sleep and more stage changes and awakenings.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify factors that affect sleep.

MNL Learning Outcome: 4.12.2. Recognize how factors that impact sleep affect the clients state of rest.

Page Number: 1072

Question 30

Type: MCSA

A client who smokes cigarettes tells the nurse that sleep is light, and that he awakens easily. What should the nurse suggest to help this client with sleep?

1. Smoke no cigarettes 1 hour before sleep.

2. Smoke no cigarettes after the evening meal.

3. Limit the number of cigarettes smoked during the day.

4. Adjust to the lack of sleep, because those who smoke do not get sufficient sleep.

Correct Answer: 2

Rationale 1: Smoking up to 1 hour before sleep will be too much stimulation before sleep.

Rationale 2: Nicotine has a stimulating effect on the body, and smokers often have more difficulty falling asleep than nonsmokers do. Smokers are usually easily aroused, and often describe themselves as light sleepers. When refraining from smoking after the evening meal, the person usually sleeps better.

Rationale 3: Limiting the number of cigarettes smoked during the day will not impact the clients ability to sleep at night.

Rationale 4: The client can be instructed not to smoke after the evening meal, and should not be told to adjust to the lack of sleep, because those who smoke do not get sufficient sleep.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems.

MNL Learning Outcome: 4.12.2. Recognize how factors that impact sleep affect the clients state of rest.

Page Number: 1072

Question 31

Type: MCMA

A client tells the nurse about having problems falling and staying asleep. What should the nurse ask the client to gain more information about this client problem?

Standard Text: Select all that apply.

1. How often does this happen?

2. How much coffee do you drink each day?

3. How do you feel when you wake up in the morning?

4. When do you eat your evening meal?

5. What have you done to deal with this sleeping problem?

Correct Answer: 1, 2, 3, 5

Rationale 1: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How often does this happen?

Rationale 2: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How much coffee do you drink each day?

Rationale 3: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How do you feel when you wake up in the morning?

Rationale 4: Asking when the client ingests the evening meal might not be appropriate with the client who is experiencing a sleep disturbance.

Rationale 5: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include What have you done to deal with this sleeping problem?

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify the components of a sleep pattern assessment.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1075

Question 32

Type: MCMA

After an assessment, the nurse is concerned that an older client is experiencing changes in sleep. What findings did the nurse use to make this clinical decision?

Standard Text: Select all that apply.

1. Is wide awake around 3 am

2. Takes a nap after lunch every day

3. Returns to sleep after using the bathroom

4. Goes to sleep before 9 pm most evenings

5. Wakes up and looks at the clock every hour

Correct Answer: 1, 2, 4, 5

Rationale 1: A hallmark change with age is a tendency toward earlier wake times.

Rationale 2: Many older adults report daytime napping, which may contribute to reduced nocturnal sleep.

Rationale 3: Older adults have difficulty falling back to sleep after awakening.

Rationale 4: A hallmark change with age is a tendency toward earlier bedtime.

Rationale 5: Older adults may awaken an average of six times during the night.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe variations in sleep patterns throughout the life span.

MNL Learning Outcome: 4.12.4. Implement the nursing process in the care of the client with alterations in sleep.

Page Number: 1070

Question 33

Type: MCMA

The nurse suspects that an adult is not getting an adequate amount of nightly sleep. What information caused the nurse to have this suspicion? 

Standard Text: Select all that apply.

1. Enrolled in online classes

2. Raising two children ages 4 and 8

3. Experiences chronic pain from sciatica

4. Attends religious services every Sunday and Wednesday

5. Works one job steady night turn and another part-time late afternoon

Correct Answer: 1, 2, 3, 5

Rationale 1: The National Sleep Foundation reports that certain adults, such as students, are vulnerable for not getting enough sleep.

Rationale 2: A womans sleep pattern is more commonly affected by the birth of a child. However, both parents of infants and young children experience fatigue related to interrupted sleep or sleep deprivation.

Rationale 3: The National Sleep Foundation reports that certain adults, such as those experiencing chronic pain, are vulnerable for not getting enough sleep.

Rationale 4: Attending religious services is not identified as contributing to vulnerability for not getting enough sleep.

Rationale 5: The National Sleep Foundation reports that certain adults, such as shift workers, are vulnerable for not getting enough sleep. Adults working long hours or multiple jobs may find their sleep less refreshing.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify factors that affect sleep.

MNL Learning Outcome: 4.12.2. Recognize how factors that impact sleep affect the clients state of rest.

Page Number: 1070

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