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.

Answer and Explanation

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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Correct Answer is A, C, B, D

Explanation

Step 1: A. Inject the amount of air into the modified (cloudy) vial that is equal to the prescribed dose of modified (cloudy) insulin. This step is correct and should be done first. Injecting air into the vial of cloudy insulin (modified) helps to prevent creating a vacuum and makes it easier to withdraw the insulin.

Step 3: B. Invert the vial of non-modified (clear) insulin, then insert the needle into the vial and draw back the prescribed dose. This step should be done after air has been injected into the modified insulin vial. The clear insulin (non-modified) should be drawn first to avoid contamination of the clear insulin with the cloudy insulin.

Step 2: C. Inject the amount of air into the nonmodified (clear) vial that is equal to the prescribed dose of nonmodified (clear) insulin. This step should be done before drawing the insulin from the clear vial. Injecting air into the clear insulin vial helps to equalize the pressure and makes it easier to withdraw the insulin.

Step 4: D. Invert the vial of modified (cloudy) insulin, then insert the needle into the vial and draw back the prescribed dose. This step should be done after drawing the clear insulin. Drawing the cloudy insulin last helps to prevent any contamination of the clear insulin with the cloudy insulin.

A. Displacement B. Rationalization C. Dissociation D. Projection

Correct Answer is B

Explanation

A. Displacement: Displacement involves transferring feelings to a less threatening object or person, which is not applicable to the client’s statement.

B. Rationalization: Rationalization involves justifying behaviors or feelings with logical reasons. The client’s statement reflects an unrealistic view rather than justifying actions.

C. Dissociation: Dissociation involves a disconnection from thoughts or feelings, which is not reflected in the client's statement.

D. Projection: Projection involves attributing one’s own feelings or thoughts to others. The client is expressing their own feelings about the wheelchair rather than attributing them to others.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer prescribed modified (cloudy) and nonmodified (clear) insulin to a client with type 1 diabetes. Place the following steps in the correct order, that the nurse should take to prepare the medication. All options must be used.

Correct Answer is A, C, B, D

Explanation

The nurse is assisting a client, from the bed into a wheelchair, who had a right-side below the knee amputation one day ago. The client states, "I will not be able to do much because of this wheelchair." The client is demonstrating which of the following defense mechanisms?

Correct Answer is B

Explanation

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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?