At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?
An adult client who has a history of sleep apnea and needs help applying a continuous positive airway pressure (CPAP) before bedtime.
The parent of a child who reports the child cannot sleep because there is too much noise in the hallway.
An older adult client recently admitted from a long-term care facility who is exhibiting sundowning behaviors.
An older adult client who is anxious about an impending procedure and is worried about being unable to sleep.
The Correct Answer is A
A. Sleep apnea is a serious condition where the airway becomes blocked during sleep, which can lead to significant health issues, including heart problems and severe oxygen desaturation. The CPAP machine is crucial for managing sleep apnea by ensuring continuous airflow during sleep. If this client needs help applying the CPAP and does not get the assistance they need, they may experience severe complications from untreated sleep apnea.
B. While noise in the hallway can certainly disrupt a child’s sleep and cause distress, it is not an immediate health crisis. It is important to address environmental concerns for comfort and sleep quality but this situation is less critical compared to the potential health risks associated with untreated sleep apnea.
C. Sundowning refers to increased confusion and agitation in the late afternoon or evening, which can be distressing and challenging to manage. While important, this issue is generally not as immediately life-threatening as problems related to sleep apnea or severe anxiety about a procedure.
D. Anxiety about an upcoming procedure and difficulty sleeping are significant concerns, especially for emotional and mental well-being. However, while this client’s anxiety should be addressed to improve their comfort and preparation for the procedure, it does not present an immediate physical threat to health like the potential complications of untreated sleep apnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sleep apnea is a serious condition where the airway becomes blocked during sleep, which can lead to significant health issues, including heart problems and severe oxygen desaturation. The CPAP machine is crucial for managing sleep apnea by ensuring continuous airflow during sleep. If this client needs help applying the CPAP and does not get the assistance they need, they may experience severe complications from untreated sleep apnea.
B. While noise in the hallway can certainly disrupt a child’s sleep and cause distress, it is not an immediate health crisis. It is important to address environmental concerns for comfort and sleep quality but this situation is less critical compared to the potential health risks associated with untreated sleep apnea.
C. Sundowning refers to increased confusion and agitation in the late afternoon or evening, which can be distressing and challenging to manage. While important, this issue is generally not as immediately life-threatening as problems related to sleep apnea or severe anxiety about a procedure.
D. Anxiety about an upcoming procedure and difficulty sleeping are significant concerns, especially for emotional and mental well-being. However, while this client’s anxiety should be addressed to improve their comfort and preparation for the procedure, it does not present an immediate physical threat to health like the potential complications of untreated sleep apnea.
Correct Answer is C
Explanation
A. While practicing strength-building exercises for the arms, such as isometric exercises for the biceps and triceps, is beneficial for overall crutch use, it does not directly indicate proper crutch walking technique.
B. This choice is not correct for a three-point gait, especially in the case of a broken foot. In a three-point gait, the client should avoid bearing weight on the affected leg, as this gait is used to promote healing of a non-weight-bearing limb.
C. This behavior indicates a correct understanding of crutch walking. In the three-point gait, the client should bear weight on the crutches' handles and not on the armpits, which helps prevent nerve damage and provides better stability.
D. While it is important for safety to ensure that the rubber tips of the crutches are intact and not worn out, this behavior does not directly demonstrate the client’s understanding of the three-point gait technique.
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