A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

Caffeine use

Evening meal

Use of electronic devices

Exercise schedule

Bedtime Medications

Answer and Explanation

Correct Answer : A,C

A.   Caffeine is a stimulant and can interfere with sleep, especially if consumed in the afternoon or evening. It can lead to difficulty falling asleep and disrupt the sleep cycle.
B.   While heavy meals close to bedtime can cause discomfort or indigestion, a light evening meal generally does not significantly interfere with sleep for most individuals.
C.   The use of electronic devices, particularly before bedtime, can interfere with sleep due to the blue light emitted by screens. This light can suppress the production of melatonin, a hormone that helps regulate sleep.
D.   Regular exercise generally promotes better sleep. However, vigorous exercise close to bedtime may interfere with sleep due to the increase in adrenaline, but this is not always the case.
E.   The medications taken by the individual do not interfere with sleep.

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Correct Answer is C

Explanation

A. Immobility more commonly leads to orthostatic hypotension rather than increased blood pressure.

B. Immobility typically leads to increased calcium levels due to bone demineralization.

C. A swollen area on the calf may indicate a deep vein thrombosis (DVT), a serious complication of immobility.

D. Urinary stasis and retention, rather than frequency, are common complications of immobility.

A. Lung sounds clear to auscultation B. Frequent episodes of apnea C. responds to tactile stimuli D. Temperature 36.3° C (97.3° F) E. Heart rate 158/min F. Respiratory rate 70/min G. Substernal retractions and nasal flaring noted H. Abdominal circumference increased by 1 cm (0.4 in) since the prior assessment

Correct Answer is ["B","C","D","F","G","H"]

Explanation

Frequent episodes of apnea, responds to tactile stimuli: Apnea in a neonate, especially one born preterm (at 34 weeks gestation), is not uncommon but should be carefully monitored. However, frequent apnea episodes may indicate an underlying respiratory issue, such as respiratory distress syndrome (RDS) or an infection. Apnea that requires tactile stimuli to resolve should be followed up with further assessment and possibly intervention.

Substernal retractions and nasal flaring: These are signs of respiratory distress. Substernal retractions and nasal flaring indicate the neonate is working harder to breathe, which may point to respiratory distress syndrome (RDS) or other respiratory compromise. Close monitoring and follow-up are necessary to assess the neonate's respiratory status and oxygenation.

Respiratory rate of 70/min: This is on the higher end for a neonate and may indicate respiratory distress or compensation for oxygenation issues. Close monitoring is required.

Temperature of 36.3 °C (97.3 °F): While this temperature is within the normal range for a neonate, it is on the lower end of the spectrum. Neonates, especially preterm ones, are at risk for hypothermia. The neonate is on a radiant warmer, which suggests that there may still be concerns regarding temperature regulation. This needs to be monitored closely to ensure proper thermal regulation.

Increased abdominal circumference by 1 cm (0.4 in): An increase in abdominal circumference can be a sign of feeding intolerance, such as necrotizing enterocolitis (NEC), or other gastrointestinal issues. It is important to continue monitoring for other signs of NEC or abdominal distension, which can indicate the need for intervention.

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Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

A nurse is caring for a client in an outpatient clinic. Exhibits Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?

Correct Answer is C

Explanation

Correct Answer is ["B","C","D","F","G","H"]

Explanation

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A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.