The nurse assesses a client with a sleep pattern disturbance. While developing a plan of care (POC), which assessment data should the nurse obtain first?

Amount and type of caffeinated drinks before bedtime.

Usual bed time and time of awakenings.

History of seasonal allergies and nasal congestion.

Urinary frequency and episodes of nocturia.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Amount and type of caffeinated drinks before bedtime: Caffeine intake can definitely impact sleep quality, but assessing specific contributors like caffeine is a secondary step. First, the nurse must gather broader information about overall sleep habits to identify where disturbances occur.

B. Usual bed time and time of awakenings: Establishing the client’s typical sleep and wake times is the foundation for evaluating a sleep pattern disturbance. It helps determine whether the issue lies with sleep onset, maintenance, early awakening, or overall duration, guiding the development of a targeted and effective care plan.

C. History of seasonal allergies and nasal congestion: Allergies and congestion can disrupt sleep by causing breathing difficulties, but they are secondary considerations. These should be explored after first understanding the client's general sleep routine and identifying primary sleep concerns.

D. Urinary frequency and episodes of nocturia: Nocturia can significantly disrupt sleep, especially in older adults. However, like other specific contributors, it should be assessed after the overall sleep pattern is reviewed to ensure a comprehensive understanding of the client's sleep issues.

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Correct Answer is B

Explanation

Rationale:
A. Grade 3 systolic murmur auscultated at the pulmonic site: A systolic murmur at the pulmonic area may suggest pulmonary valve disorders but is not the most direct explanation for episodes of syncope. While murmurs can be associated with some cardiac causes of syncope, orthostatic changes are a more common and direct cause.

B. Decreased blood pressure during orthostatic measurement: Orthostatic hypotension occurs when blood pressure drops significantly upon standing, reducing cerebral perfusion and leading to syncope. This finding is commonly anticipated when a client presents with episodes of fainting, especially if postural changes trigger symptoms.

C. 3+ carotid pulse volume bilaterally: A 3+ carotid pulse suggests a bounding, strong pulse, which is typically not associated with syncope. In fact, excessively strong pulses are more often seen with hyperdynamic circulatory states rather than states leading to decreased cerebral perfusion and fainting.

D. Positive jugular vein distention (JVD) bilaterally: Jugular vein distention is associated with elevated central venous pressure and conditions such as heart failure, not directly with episodes of syncope. While heart failure could contribute indirectly, JVD is not the most expected or immediate finding for isolated syncope.

A. Rapid strep test. B. Nitazine pH strip. C. Finger stick glucose. D. Urine dipstick test.

Correct Answer is D

Explanation

Rationale:
A. Rapid strep test: A rapid strep test screens for streptococcal throat infections and is unrelated to urinary symptoms. It would not help identify the cause of painful urination in a client with diabetes mellitus.

B. Nitazine pH strip: Nitazine pH testing is primarily used to assess amniotic fluid leakage in pregnant women, not for urinary tract infections (UTIs). It would not provide helpful information for evaluating dysuria in this situation.

C. Finger stick glucose: While important for monitoring diabetes management, finger stick glucose does not directly address the acute complaint of painful urination. It would not diagnose a urinary tract infection, which is the immediate concern.

D. Urine dipstick test: A urine dipstick test screens for leukocytes, nitrites, blood, and glucose in the urine and is the appropriate first screening for suspected UTI. Clients with uncontrolled diabetes are at higher risk for UTIs, and the dipstick can quickly detect infection-related changes.

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The nurse assesses a client with a sleep pattern disturbance. While developing a plan of care (POC), which assessment data should the nurse obtain first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

Correct Answer is B

Explanation

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

Correct Answer is D

Explanation

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