The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM?

The patient is difficult to awaken.

The patient’s vital signs are elevated.

The patient awakens easily.

The patient’s eyes rapidly move.

Answer and Explanation

The Correct Answer is A

Choice A reason: Stage 4 NREM (deep sleep) is characterized by slow delta brain waves, making the patient difficult to awaken. This stage promotes physical restoration, with minimal responsiveness to stimuli. The assessment finding aligns with the physiological state of deep sleep, making it the correct indicator for stage 4 NREM.

Choice B reason: Elevated vital signs are not typical of stage 4 NREM, where metabolic rate and heart rate decrease due to deep relaxation. Elevated vital signs may occur in REM or lighter sleep stages, making this finding inconsistent with the characteristics of deep NREM sleep.

Choice C reason: Easily awakening occurs in lighter NREM stages (1 or 2), not stage 4, which is the deepest sleep phase. Patients in stage 4 require significant stimuli to rouse, so this finding contradicts the expected state of deep sleep, making it incorrect.

Choice D reason: Rapid eye movement is specific to REM sleep, not NREM. Stage 4 NREM involves slow brain waves and no eye movement, focusing on physical restoration. This finding is characteristic of a different sleep phase, making it an incorrect indicator for stage 4 NREM.

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Correct Answer is A

Explanation

Choice A reason: Depression is strongly linked to insomnia in older adults, causing difficulty falling asleep due to rumination, low mood, or altered sleep architecture. Assessing for depression is critical, as it may underlie the sleep disturbance, requiring targeted interventions like therapy or antidepressants to improve sleep and mental health.

Choice B reason: Muscle fatigue may cause physical discomfort but is not a primary cause of difficulty falling asleep. It is more likely to affect sleep quality than initiation. Depression is a more common and significant contributor to insomnia in older adults, making this an incorrect choice.

Choice C reason: Hypertension can be associated with sleep apnea but is not directly linked to difficulty falling asleep. It may result from poor sleep but is less likely the cause. Depression is a more prevalent cause of insomnia, making this a less relevant condition to assess.

Choice D reason: Hypothyroidism can cause fatigue and sleepiness, not difficulty falling asleep. It is less commonly associated with insomnia compared to depression, which significantly disrupts sleep onset in older adults. This condition is less relevant to the patient’s presentation, making it incorrect.

A. Belief tool. B. The spiritual well-being scale. C. The FICA assessment tool. D. Hope scale.

Correct Answer is C

Explanation

Choice A reason: A belief tool is not a standardized method for spiritual assessment. The FICA tool specifically evaluates faith, importance, community, and action, including questions about God and purpose. Assuming a vague belief tool risks incomplete assessment, missing critical spiritual needs that influence patient coping and well-being in holistic care settings.

Choice B reason: The spiritual well-being scale measures general spiritual health but is not structured for detailed questions about God or life purpose, unlike the FICA tool’s targeted approach. Using this risks missing specific spiritual concerns, limiting the nurse’s ability to address existential needs critical for patient support in illness or end-of-life care.

Choice C reason: The FICA assessment tool (Faith, Importance, Community, Action) involves structured questions to evaluate spiritual beliefs, including relationships with God and life purpose. Its comprehensive 20-question format assesses spiritual needs, guiding holistic care. This method ensures tailored interventions, supporting emotional and spiritual well-being, critical for patients facing serious health challenges.

Choice D reason: The hope scale measures optimism but not specifically the relationship with God or life purpose, unlike the FICA tool’s broader spiritual focus. Assuming this method risks overlooking religious or existential concerns, reducing the effectiveness of spiritual care in addressing patient needs for meaning and satisfaction during health crises.

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The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient?

Correct Answer is A

Explanation

In caring for the patient’s spiritual needs, the nurse asks 20 questions to assess the patient’s relationship with God and a sense of life purpose and satisfaction. Which method is the nurse using?

Correct Answer is C

Explanation

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