The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?

History of seasonal allergies and nasal congestion.

Amount and type of caffeinated drinks before bedtime.

Urinary frequency and episodes of nocturia.

Usual bed time and time of awakenings.

Answer and Explanation

The Correct Answer is D

A.   A history of seasonal allergies and nasal congestion can affect sleep quality due to discomfort or breathing difficulties. While this information is relevant for identifying possible physical factors that might influence sleep, it is not the first piece of data to obtain when trying to understand the overall sleep pattern.
B.   The consumption of caffeinated drinks before bedtime can significantly impact sleep quality. Caffeine is a stimulant that can disrupt sleep patterns and contribute to difficulty falling asleep. This assessment is important, but it should follow an initial understanding of the client’s overall sleep schedule and habits to determine how much caffeine might be affecting their sleep.
C.   Urinary frequency and nocturia (waking up frequently to urinate during the night) can interfere with sleep and contribute to disturbances. This information is valuable for identifying potential causes of disrupted sleep but is typically assessed after understanding the client’s basic sleep patterns and schedule.
D.   Understanding the client’s usual bedtime and time of awakenings provides essential information about their sleep schedule and overall sleep patterns. This data is crucial as it establishes a baseline for assessing the client’s sleep routine and helps identify any deviations or irregularities in their sleep behavior.

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Correct Answer is C

Explanation

A. While physical touch, such as placing a hand on the client’s shoulder, can sometimes be reassuring, it might not always be appropriate or welcomed, especially if the client is already expressing frustration or anger. It’s important to assess the client's comfort with physical contact before proceeding with such gestures.
B. Ignoring the client's angry outburst is not advisable because it fails to acknowledge the client’s feelings and may escalate their frustration. Addressing emotional responses is crucial in maintaining a therapeutic relationship and ensuring that the client feels heard and respected.
C. This response is the best choice because it acknowledges the client’s emotional state and invites them to share their feelings. By addressing the client's anger directly and expressing a willingness to listen, the nurse helps to validate the client’s emotions and opens the door for a more productive dialogue.
D. While this response acknowledges the client's feelings, it might come across as dismissive of their immediate needs and could imply that their concerns are not worth addressing at this time. It also does not actively engage with the client's emotions or attempt to resolve the frustration.

A. Inspection. B. Percussion. C. Palpation. D. Auscultation.

Correct Answer is A

Explanation

A. In the context of detecting papilledema, "inspection" refers to using an ophthalmoscope to examine the optic disc for swelling. Papilledema, which is swelling of the optic disc due to increased intracranial pressure, can only be observed through this direct examination of the eye’s interior. This technique is the most appropriate and accurate for confirming papilledema as it allows the nurse to visually inspect the optic disc for signs of swelling or other abnormalities.
B. Percussion involves tapping on the body to assess underlying structures and is commonly used in evaluating lung and abdominal sounds. It is not used for assessing the optic nerve or papilledema. Therefore, percussion is not relevant for confirming the presence of papilledema.
C. Palpation involves feeling the body’s surface to assess for abnormalities such as swelling or
tenderness. It is used for evaluating various parts of the body but does not apply to detecting papilledema. Papilledema involves changes to the optic nerve head, which cannot be assessed through palpation.
D. Auscultation involves listening to internal body sounds using a stethoscope, such as heartbeats, lung sounds, or abdominal sounds. This technique is not used to assess the optic disc or detect papilledema. It is not relevant for the diagnosis of conditions affecting the optic nerve.

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The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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