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 B

Explanation

A. Musical sounds or high-pitched, tinkling noises are not typically considered normal bowel sounds. These types of sounds might indicate increased bowel activity or bowel obstruction. They are usually associated with abnormal conditions like bowel obstruction or early signs of a bowel problem.
B. This description is consistent with normal bowel sounds. Bowel sounds are usually described as clicks and gurgles that occur irregularly. They are typically heard as a mix of low to moderate pitched sounds and are a normal part of the gastrointestinal activity. Normal bowel sounds usually have an irregular pattern and may vary in frequency and intensity.
C. High-pitched tinkling sounds are not considered normal and could indicate abnormal bowel activity. These sounds are often associated with increased intestinal motility, which can occur in conditions such as bowel obstruction. They suggest that the bowel is more active than normal, which could be a sign of an underlying problem.
D. Prolonged gurgling sounds can sometimes be heard in cases of increased bowel activity but are not typical of normal bowel sounds. Normal bowel sounds are generally intermittent and irregular rather than prolonged. Prolonged gurgles might suggest issues like increased bowel activity or a bowel condition requiring further investigation.

A. "Can you recall the date the Twin Towers in New York were destroyed?" B. "What is the difference between a hamster and a rabbit as a pet?" C. "Should someone who lives in a glass house throw stones?" D. "Do you write checks if you know the bank account is overdrawn?"

Correct Answer is C

Explanation

A. This question assesses a client's recent memory, not their judgment.
B. This question assesses a client's knowledge and understanding of animals, not their judgment.
C. This question evaluates a client's judgment by assessing their ability to make sound decisions based on hypothetical situations. It requires the client to consider potential consequences and make a logical inference.
D. This question assesses a client's financial knowledge and decision-making skills, but it doesn't directly evaluate their judgment in a hypothetical situation.

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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

The nurse places the diaphragm of a warmed stethoscope on a client's abdomen to auscultate the bowel sounds. Which finding is considered normal?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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