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 D

Explanation

Rationale:
A. Percussion: Percussion is used to assess underlying lung structures for air, fluid, or consolidation by evaluating sound changes. It is not the correct technique for assessing the physical shape or chest dimensions like the AP diameter.

B. Palpation: Palpation helps detect areas of tenderness, masses, or chest wall movement but does not accurately measure or evaluate the visual proportion of the AP to transverse chest diameter.

C. Auscultation: Auscultation is performed to assess lung sounds, such as crackles, wheezes, or diminished breath sounds. It does not provide information about the external shape or contour of the chest.

D. Observation: Observation is the correct method for assessing AP chest diameter. By visually inspecting the client from the side, the nurse can determine whether the chest is normally proportioned (approximately 1:2 AP to transverse ratio) or if there are abnormalities such as barrel chest, which can indicate chronic lung disease.

A. Axillary nodes feel soft and fatty. B. Inguinal nodes are enlarged and warm to the touch. C. Nodes feel ropey and rubbery. D. Nodes are nonpalpable.

Correct Answer is A

Explanation

Rationale:
A. Axillary nodes feel soft and fatty: In older adults, lymph nodes often become smaller, softer, and more fatty due to age-related atrophy of lymphatic tissue. Soft, fatty nodes in the axillary area are considered a normal finding and generally do not indicate infection or malignancy unless associated with other concerning symptoms.

B. Inguinal nodes are enlarged and warm to the touch: Enlarged and warm lymph nodes suggest acute infection or inflammation. This is not a normal finding at any age and would warrant further evaluation to rule out infectious processes, malignancy, or systemic disease.

C. Nodes feel ropey and rubbery: Ropey and rubbery lymph nodes can indicate abnormal conditions such as lymphoma or chronic infection. While texture can vary, this description is more consistent with pathological changes and not considered normal in a healthy older adult.

D. Nodes are nonpalpable: While nonpalpable lymph nodes can be normal, especially if small and deep, some lymph nodes—like inguinal or axillary nodes—can still be felt even in healthy individuals. Therefore, the presence of soft, fatty nodes is a more typical normal finding rather than complete nonpalpability.

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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?

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