A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?

Choice A reason: Caring touch involves physical contact to convey empathy, like holding a hand. The nurse leaves the room without touching the patient or family, overwhelmed by grief. This action does not involve physical contact or comfort, making it unrelated to caring touch in this scenario.

Choice B reason: Therapeutic touch is a healing technique using energy fields, not applicable here. The nurse’s departure due to emotional overwhelm does not involve physical or energetic interaction with the family or patient, focusing instead on self-preservation, making this an incorrect type of touch.

Choice C reason: Task-oriented touch involves physical contact for procedures, like taking a pulse. The nurse’s action of leaving the room is not task-related or physical. It reflects an emotional response to grief, not a clinical task, making this an incorrect description of the nurse’s behavior.

Choice D reason: Protective touch describes actions to shield oneself or others from emotional distress, like withdrawing from overwhelming situations. The nurse, overwhelmed by the family’s grief, leaves the room to cope, demonstrating protective touch by prioritizing emotional self-preservation, making this the correct description.

Choice A reason: Pre-sleep, the transition to sleep, is not a distinct sleep cycle stage and varies widely, not consistently lasting 10-30 minutes. NREM Stage 2 has a defined duration. Misidentifying pre-sleep risks confusing staff, potentially leading to inaccurate sleep assessments and interventions in patients with sleep disorders.

Choice B reason: NREM Stage 2, lasting 10-30 minutes per cycle, involves light sleep with sleep spindles and K-complexes, consolidating memory and transitioning to deeper sleep. Accurate teaching ensures staff recognize this stage’s role in restorative sleep, guiding monitoring and interventions for patients with disrupted sleep patterns in clinical settings.

Choice C reason: REM sleep, lasting 10-20 minutes initially but up to 60 minutes later in the night, does not consistently fall within 10-30 minutes. NREM Stage 2 is more accurate. Misidentifying REM risks staff misunderstanding sleep cycles, potentially affecting sleep assessments and management in patients with insomnia or neurological conditions.

Choice D reason: NREM Stage 1, lasting 5-10 minutes, is shorter than 10-30 minutes, involving light sleep and easy arousability. NREM Stage 2 better fits the duration. Misidentifying Stage 1 confuses sleep cycle education, risking inaccurate monitoring and interventions for sleep quality, critical for patient recovery and health outcomes.