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. This approach involves providing medication education to the client as each medication is administered. While this ensures that the client receives information about each medication in a timely manner, it may not allow for comprehensive education or adequate time for the client to ask questions or clarify information. Additionally, the client may feel overwhelmed by receiving information about multiple medications at once.
B. Incorporating medication education into another activity, such as assisting the client with his bath, can be an efficient use of time. However, it may not provide an optimal environment for focused learning and discussion. The client may be distracted or uncomfortable during the bath, limiting their ability to absorb and retain information effectively.
C. This approach involves providing medication education to the client after discharge via a follow-up phone call. While this allows for more time and flexibility in providing education, it may not address the client's immediate needs or questions prior to discharge. Additionally, the client may have already started taking the medications by the time of the follow-up call, potentially leading to missed opportunities for clarification or adjustment of the medication regimen.
D. Providing written instructions for the client to read at home is an efficient way to ensure that the client has access to information about their medications. This allows the client to review the information at their own pace and refer back to it as needed. However, written instructions alone may not be sufficient for addressing all aspects of medication education, such as potential side effects, drug interactions, or administration techniques.
Correct Answer is ["A","C"]
Explanation
A. Enteral nutrition can be used when a client is unable to consume adequate nutrition orally or when oral intake is contraindicated. It can be used as a supplement to oral intake or as the sole source of nutrition, depending on the client's condition and nutritional needs.
C. Enteral nutrition can be administered either intermittently, where feedings are given at specific times throughout the day, or continuously, where a steady infusion is delivered over an extended period, typically 16 to 24 hours. The method of administration depends on the client's tolerance, nutritional needs, and clinical condition.
B. Enteral nutrition typically consists of liquid formulas specifically designed to provide complete and balanced nutrition. These formulas come in various formulations, including standard polymeric formulas, high-protein formulas, elemental formulas, and disease-specific formulas. They are not thinned pureed food, which is typically used for clients with dysphagia or swallowing difficulties who are receiving oral feeding.
D. While some enteral nutrition formulas may contain dairy-based ingredients, such as milk protein or lactose, not all enteral formulas are milk-based. There are various types of enteral formulas available, including those that are lactose-free, soy-based, or elemental (containing predigested nutrients), to accommodate different dietary preferences and tolerances.
E. Enteral nutrition is administered directly into the gastrointestinal tract, typically through a feeding tube that is inserted into the stomach or small intestine. It is not given intravenously (through a vein), which would be parenteral nutrition.
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