The nurse is assessing a client's sleep patterns. Which statement made by the client would require additional questioning by the nurse? "My partner tells me that:
I snore so loudly that I wake her up several times a night."
neither of us sleeps well after we have a big fight."
I sleep so soundly it's like waking the dead to get me up."
she's heard me tell jokes in my sleep."
The Correct Answer is A
A. This statement suggests that the client may have sleep-disordered breathing, such as obstructive sleep apnea, which can disrupt the client's sleep patterns and affect their overall sleep quality. The nurse may want to inquire further about the frequency and severity of the snoring, as well as any associated symptoms such as daytime fatigue or observed pauses in breathing during sleep.
B. This statement indicates that emotional stressors, such as arguments or conflicts, may impact the client's sleep patterns. The nurse may want to explore how often these conflicts occur and how they affect the client's ability to fall asleep or stay asleep. Additionally, the nurse may inquire about coping strategies or interventions that the client and their partner use to address conflicts and minimize their impact on sleep.
C. This statement suggests that the client experiences deep or heavy sleep, which may or may not be problematic depending on the context. While deep sleep can be indicative of good sleep quality, it may also raise concerns about the client's ability to awaken in the event of an emergency or the presence of a sleep disorder such as hypersomnia. The nurse may want to inquire further about the client's overall sleep duration, sleep latency, and any difficulties with waking up in the morning.
D. This statement suggests that the client may experience sleep talking, which is a common sleep phenomenon. While sleep talking itself is typically benign, it may indicate underlying sleep disturbances such as sleep fragmentation or abnormal sleep cycles. The nurse may want to ask additional questions to assess the frequency and content of the sleep talking, as well as any potential impacts on the client's sleep quality or daytime functioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Metabolic alkalosis is characterized by an elevation of the bicarbonate (HCO3) levels in the blood, leading to an increase in pH above the normal range (7.35-7.45). Antacid tablets typically contain compounds such as calcium carbonate, magnesium hydroxide, or aluminum hydroxide, which can neutralize stomach acid (hydrochloric acid). Chronic ingestion of large amounts of antacids, as in the case of this client taking approximately 15 tablets per day, can result in excessive bicarbonate intake, leading to metabolic alkalosis.
B. Respiratory alkalosis occurs when there is a decrease in carbon dioxide (CO2) levels in the blood, leading to an increase in pH above the normal range. Antacid tablets do not directly affect respiratory function or CO2 levels, so respiratory alkalosis is unlikely to occur as a result of antacid ingestion.
C. Metabolic acidosis is characterized by a decrease in bicarbonate (HCO3) levels in the blood, leading to a decrease in pH below the normal range. In the context of antacid ingestion, metabolic acidosis is less likely to occur. However, if the antacids contain compounds that are absorbed systemically and excreted by the kidneys (such as aluminum-containing antacids), they may lead to renal dysfunction or electrolyte imbalances, which could potentially contribute to metabolic acidosis.
D. Respiratory acidosis occurs when there is an increase in carbon dioxide (CO2) levels in the blood, leading to a decrease in pH below the normal range. Antacid tablets do not directly affect respiratory function or CO2 levels, so respiratory acidosis is unlikely to occur as a result of antacid ingestion.
Correct Answer is A
Explanation
A. Directly asking the client how they learn best is a straightforward and effective approach for assessing their learning style preference. This allows the client to self-report their preferences, which can provide valuable insight into their preferred learning modalities, such as visual, auditory, or kinesthetic learning.
B. While assisting the client in learning skills from simple to complex can provide valuable information about their current level of understanding and skill mastery, it may not directly assess their learning style preference. This approach focuses more on the progression of learning rather than the client's preferred learning modalities.
C. Observing the client's interactions with others can provide some clues about their communication style and social preferences but may not necessarily directly assess their learning style preference. Learning style preference encompasses how individuals prefer to receive and process information, which may not be fully captured through social interactions alone.
D. Asking the client to read from a brochure primarily assesses their ability to process written information and may provide some insight into their literacy skills. However, it does not necessarily assess their preferred learning style, as individuals may have different preferences for how they prefer to receive and process information beyond reading.
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