The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. Which information will the nurse include in the teaching session? (Select all that apply)

Choice A reason: Respirations of 22 and heart rate of 66 suggest arousal or light sleep, not deep NREM sleep, which features slower, regular breathing (12-16 breaths/min) and lower heart rate. This indicates discomfort or instability, not comfortable sleep. Assuming this reflects NREM sleep risks overlooking signs of inadequate rest or stress in ICU patients.

Choice B reason: Mumbling to self indicates partial arousal or REM sleep, not NREM sleep, which is characterized by minimal movement and stable vitals. This suggests discomfort or neurological disturbance. Assuming NREM sleep misidentifies the sleep stage, potentially missing interventions to promote deeper, restorative sleep critical for ICU patient recovery.

Choice C reason: Tossing in bed with respirations of 18 and heart rate of 80 indicates restlessness or light sleep, not deep NREM sleep, which involves calm, slow vitals. This suggests discomfort or pain. Assuming NREM sleep risks neglecting interventions like pain management, critical for ensuring restorative sleep in ICU settings.

Choice D reason: Eyes closed, lying quietly, with respirations of 12 and heart rate of 60 indicate deep NREM sleep, characterized by slow, regular breathing and low heart rate, reflecting parasympathetic dominance. This confirms comfortable, restorative sleep, critical for healing in ICU patients, guiding nurses to maintain conditions supporting this optimal sleep state.

Choice A reason: Self-care deficit addresses physical inability to perform daily tasks, not psychological issues from sensory impairments. Hearing and visual loss primarily impact communication, leading to socialization issues. Assuming self-care deficit misaligns the diagnosis, risking neglect of psychological needs like social isolation, critical for mental health in sensory-impaired patients.

Choice B reason: Risk for falls is a physical safety concern due to sensory impairments but not psychological. Impaired socialization better addresses the psychological impact of communication barriers. Prioritizing falls risks overlooking social isolation, delaying interventions like communication aids, essential for mental well-being in patients with hearing and visual deficits.

Choice C reason: Impaired socialization, a psychological nursing diagnosis, reflects the communication barriers from hearing and visual impairments, leading to social isolation and emotional distress. This diagnosis guides interventions like assistive devices or support groups, critical for mental health, ensuring patients maintain social connections and emotional resilience despite sensory challenges.

Choice D reason: Impaired physical mobility relates to movement limitations, not psychological effects of sensory impairments. Hearing and visual loss primarily cause socialization issues, not mobility deficits. Assuming mobility misdirects care, neglecting psychological needs like social engagement, critical for preventing isolation and supporting mental health in sensory-impaired patients.