A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

I don't take naps throughout the day."

I have a small snack and take a bath before going to bed each day."

I go to bed and get up routinely at the same time each day."

I watch tevision until I fall asleep at night."

Answer and Explanation

The Correct Answer is D

A) "I don't take naps throughout the day": This statement indicates a good sleep habit, as avoiding daytime naps can help promote better sleep at night.
B) "I have a small snack and take a bath before going to bed each day": This statement suggests a bedtime routine, which can be beneficial for promoting relaxation and signaling the body that it's time to sleep.
C) "I go to bed and get up routinely at the same time each day": Consistency in sleep schedule is an essential aspect of healthy sleep habits, as it helps regulate the body's internal clock and promotes better sleep quality.
D) "I watch television until I fall asleep at night": This statement indicates a poor sleep habit. Screen time before bedtime, especially from devices like televisions, computers, or smartphones, can interfere with the body's natural sleep-wake cycle and make it harder to fall asleep. The blue light emitted by screens can suppress the production of melatonin, a hormone that regulates sleep, leading to difficulty falling asleep and poor sleep quality. Therefore, this statement suggests a need for further teaching about avoiding screen time before bedtime to promote better sleep hygiene.

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Correct Answer is A

Explanation

A. Severity
In the PQRST mnemonic for pain assessment, "S" stands for Severity. When the nurse asks the client to rate the pain on a scale of 0 to 10, they are assessing the severity of the pain. This helps the nurse understand the intensity of the client's pain experience and provides a baseline for evaluating the effectiveness of pain management interventions.

B. Precipitating cause
This component relates to factors that exacerbate or alleviate the pain and is represented by the "P" in the PQRST mnemonic. Asking about activities or events that preceded the onset of pain helps identify potential triggers or causes.

C. Region
The "R" in PQRST represents Region, referring to the specific location or area where the client experiences pain. Assessing the region helps localize the source of pain and guide further diagnostic evaluations or interventions.

D. Quality
Quality, represented by the "Q" in PQRST, refers to the characteristics or nature of the pain, such as sharp, dull, throbbing, or burning. Understanding the quality of pain provides additional information about its underlying cause and can aid in selecting appropriate treatment strategies.

A. Cheyne-Stokes respirations B. Kussmaul respirations C. Apneustic respirations D. Stridor

Correct Answer is A

Explanation

A) Cheyne-Stokes respirations:
Cheyne-Stokes respirations are characterized by a cycle of gradually increasing and then decreasing respirations followed by a period of apnea. This pattern repeats in a regular cycle. It is commonly observed in clients with conditions affecting the central nervous system, such as traumatic brain injury, stroke, or brain tumors. Cheyne-Stokes respirations can also occur during the dying process. The alternating periods of hyperventilation and apnea result from fluctuations in oxygen and carbon dioxide levels in the blood.

B) Kussmaul respirations:
Kussmaul respirations are deep, rapid, and labored breathing patterns often observed in clients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.

C) Apneustic respirations:
Apneustic respirations are characterized by prolonged inspiratory gasps followed by insufficient expiration. This irregular breathing pattern typically indicates damage to the pons, a part of the brainstem involved in regulating breathing. Apneustic respirations are different from the pattern described in the scenario.

D) Stridor:
Stridor is a high-pitched, noisy respiratory sound heard on inspiration that indicates upper airway obstruction, such as from swelling, foreign body aspiration, or tumors. It is not associated with the alternating pattern of hyperventilation and apnea described in Cheyne-Stokes respirations.

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A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

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