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 ["A","B","E"]

Explanation

A. Dyspnea, or shortness of breath, is a common symptom of heart failure exacerbation. It occurs because the heart is unable to effectively pump blood, leading to pulmonary congestion and fluid accumulation in the lungs. This symptom is significant in confirming an exacerbation of heart failure.
B. Peripheral edema, or swelling of the legs and ankles, is another common sign of heart failure exacerbation. It results from fluid buildup due to the heart's decreased ability to manage blood volume effectively. This finding is indicative of fluid retention and can confirm an exacerbation of heart failure.
C. Intercostal retractions are typically seen in respiratory distress, especially in conditions affecting the lungs or severe respiratory conditions. While they can occur with severe pulmonary congestion in heart failure, they are more directly associated with respiratory issues rather than specifically confirming heart failure exacerbation.
D. Headaches are not a typical or primary symptom of heart failure exacerbation. They can be associated with various conditions but are not specific to heart failure. This symptom is less relevant in confirming an exacerbation of heart failure.
E. Jugular venous distension is a classic sign of right-sided heart failure or fluid overload. It occurs when there is increased pressure in the venous system due to the heart's inability to handle blood volume effectively.

A. Inequality in muscle contraction. B. An intention tremor. C. Slowed capillary refill. D. Loss of peripheral sensation.

Correct Answer is D

Explanation

A. Inequality in muscle contraction is not related to the monofilament test, which assesses sensation rather than muscle strength or contraction. This finding would be more relevant to a neurological or musculoskeletal assessment rather than a sensory test.
B. An intention tremor is a type of tremor that occurs when a person is trying to make a precise movement, often associated with conditions affecting the cerebellum. This is not related to the monofilament test, which measures sensory perception and not motor function or tremors.

C. Slowed capillary refill is a sign of poor peripheral circulation and is assessed by pressing on the nail bed or skin and observing how long it takes for color to return. While it is important for assessing blood flow, it is not directly related to the monofilament test, which evaluates sensory function.
D. Loss of peripheral sensation is a direct and relevant finding for an abnormal response on the monofilament test. The monofilament test is designed to detect loss of sensation in the feet, which can be an indicator of diabetic neuropathy. An abnormal result, such as the inability to feel the monofilament or diminished sensation in certain areas, would indicate that the client is experiencing peripheral neuropathy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HP? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?

Correct Answer is D

Explanation

To assess for muscle atrophy in the legs, which action should the nurse take?

The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow-up assessment should the nurse complete?

The nurse reorients a male client to the correct time, day, date, and location, but he is only able to remember his name and where he is. Based on these findings, which should the nurse document?

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

During a routine health screening of an adult female, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?