The nurse awakens a client while the client is experiencing rapid eye movement sleep. What statement made by the client indicates they were awakened during REM sleep?
"I heard you immediately when you came in my room"
"I feel really cold"
"It feels like I just went to sleep”
"I was having a great dream and I remember all of it”
The Correct Answer is D
A. "I heard you immediately when you came in my room": In REM sleep, the brain is highly active, but the body is in a state of paralysis. A person in REM sleep is less likely to respond quickly to external stimuli, such as hearing someone enter the room.
B. "I feel really cold": Feeling cold is not typically associated with REM sleep. It could be due to other factors like body temperature regulation or environmental conditions but is not a key feature of REM sleep.
C. "It feels like I just went to sleep": This suggests the person was likely in a deeper stage of non-REM sleep. REM sleep typically has an active brain with vivid dreams, making it unlikely for the client to feel like they just fell asleep.
D. "I was having a great dream and I remember all of it": Vivid dreams and memory recall are characteristic of REM sleep. This stage is when the brain is most active in terms of dreaming, making it common for individuals to remember their dreams if they are awakened during this phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Teaching about adhering to a low-sodium diet: This is tertiary prevention because it aims to manage an existing condition—heart failure—and prevent its complications or recurrence. Educating the client about dietary changes helps reduce fluid overload and risk of readmission.
B. Assessing for risk factors for heart disease: This is considered primary prevention, as it focuses on identifying and addressing potential causes of disease before symptoms occur. It is not appropriate for someone who already has a diagnosed condition.
C. Screening for tuberculosis: Tuberculosis screening is a form of secondary prevention aimed at early detection of disease in asymptomatic individuals. It does not apply to managing an existing chronic illness like heart failure.
D. Screening for breast cancer every 5 years: This is secondary prevention used for early disease detection in people without symptoms. It does not represent managing or preventing worsening of a diagnosed condition.
Correct Answer is C
Explanation
A. Lung sounds: While important for respiratory assessment, lung sounds are not directly affected by diarrhea or dehydration unless complications such as aspiration or infection develop, which are less common in this context.
B. Activity level: Changes in activity may occur due to weakness or fatigue caused by fluid and electrolyte imbalances, but this is a less specific and less immediate indicator of dehydration risk.
C. Skin turgor: Assessing skin turgor helps evaluate hydration status. Poor skin turgor indicates fluid loss and dehydration, which is a common risk with prolonged diarrhea and can lead to more serious complications if untreated.
D. Heart sounds: Heart sounds can reveal cardiac abnormalities, but they are not the primary focus in assessing dehydration. However, monitoring heart rate and rhythm can provide additional information about circulatory status in severe cases.
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