The nurse is assessing the vital signs of a sleeping patient at 0400 a.m. and notes the patient is experiencing stage IV non-rapid eye movement (NREM) sleep. The nurse should expect which of the following findings?
Small muscle twitching.
An increase in temperature.
Difficult to arouse.
An increase in pulse rate.
The Correct Answer is C
A. Small muscle twitching. Small muscle twitching is more common during REM sleep, not Stage IV NREM sleep.
B. An increase in temperature. Stage IV NREM sleep is associated with stable body temperature rather than an increase.
C. Difficult to arouse. Stage IV NREM sleep is known as deep sleep, and individuals are indeed difficult to arouse during this stage.
D. An increase in pulse rate. Stage IV NREM sleep typically features a stable or decreased pulse rate, not an increase.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Small muscle twitching. Small muscle twitching is more common during REM sleep, not Stage IV NREM sleep.
B. An increase in temperature. Stage IV NREM sleep is associated with stable body temperature rather than an increase.
C. Difficult to arouse. Stage IV NREM sleep is known as deep sleep, and individuals are indeed difficult to arouse during this stage.
D. An increase in pulse rate. Stage IV NREM sleep typically features a stable or decreased pulse rate, not an increase.
Correct Answer is C
Explanation
A. Assess the patient for physiological indicators of pain. While assessing physiological indicators (such as increased heart rate, blood pressure, or sweating) can provide clues about pain, these signs are not always reliable and can be influenced by other factors. This option does not directly address the patient’s verbal and non-verbal communication about their pain.
B. Observe the patient for behavior that is indicative of pain. Observing the patient’s behavior can be helpful, but it is not sufficient on its own. The patient’s cultural background may influence how they express pain, and relying solely on observation might lead to underestimating their pain.
C. Involve the patient in the pain assessment by asking more direct questions. This is the best option because it respects the patient’s cultural background and encourages a more accurate and detailed assessment of their pain. By asking direct questions, the nurse can gain a better understanding of the patient’s pain experience and provide appropriate care.
D. Compare the patient's facial expression to a FACES pain scale. Using a FACES pain scale can be useful, especially for patients who have difficulty verbalizing their pain. However, this option does not involve the patient in a more detailed discussion about their pain, which is crucial given the cultural context and the patient’s reluctance to openly admit to pain.
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