The nurse is evaluating outcomes for a patient with insomnia. Which key principle will the nurse consider during this process?

Effective interventions are the best evaluators of sleep.

The patient is the best evaluator of sleep.

Observations of the patient are the best evaluators of sleep.

The nurse is the best evaluator of sleep.

Answer and Explanation

The Correct Answer is B

Choice A reason: Effective interventions (e.g., sedatives) improve sleep but are not evaluators. Insomnia, a disruption of sleep-regulating brain regions like the hypothalamus, is best assessed by patient-reported sleep quality. Interventions address neurotransmitter imbalances (e.g., GABA), but outcomes rely on subjective patient experience, not the intervention itself, making this incorrect.

Choice B reason: The patient is the best evaluator of sleep, as insomnia is subjective, involving perceived sleep quality and duration. Patient reports reflect hypothalamic regulation of sleep-wake cycles and neurotransmitter activity (e.g., melatonin). Subjective data, like feeling rested, provide the most accurate outcome evaluation, aligning with patient-centered care principles, making this correct.

Choice C reason: Nurse observations (e.g., restlessness) provide objective data but are less accurate than patient reports for insomnia. Sleep quality depends on subjective experience, influenced by brain regions like the reticular activating system. Observations may miss subtle sleep disturbances, making patient self-assessment the most reliable evaluator of insomnia outcomes, rendering this incorrect.

Choice D reason: The nurse is not the best evaluator of sleep, as insomnia is a subjective condition. Nurses can observe behaviors, but only patients report perceived sleep quality, reflecting circadian rhythm regulation and neurotransmitter balance. Objective assessments may overlook patient-specific experiences, making patient self-evaluation critical for accurate insomnia outcome assessment, so this is incorrect.

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Correct Answer is B

Explanation

Choice A reason: Hypertension is defined by elevated blood pressure, not an irregular heart rate. An irregular pattern at 72 bpm suggests a rhythm abnormality, not a pressure issue. Hypertension affects vascular resistance, not cardiac rhythm directly, making this incorrect for the observed finding, per cardiovascular physiology.

Choice B reason: A dysrhythmia is indicated by an irregular heart rate pattern at 72 bpm, as it reflects abnormal electrical conduction, such as atrial fibrillation or premature beats. Notifying the provider is appropriate, as dysrhythmias may impair cardiac output or indicate underlying pathology, requiring prompt evaluation, per cardiac monitoring protocols.

Choice C reason: Tachycardia is a heart rate above 100 bpm, not applicable to 72 bpm. The irregularity, not speed, is the concern. Tachycardia involves rapid but often regular rhythms, whereas this finding suggests a dysrhythmia, making this choice incorrect for the described clinical presentation, per cardiac assessment.

Choice D reason: Bradycardia is a heart rate below 60 bpm, not matching 72 bpm. The irregular pattern points to a dysrhythmia, not a slow rate. Bradycardia affects heart rate frequency, not rhythm irregularity, making this irrelevant to the finding, which requires rhythm-focused intervention, per cardiac physiology.

A. Assess the patient’s blood pressure. B. Check the patient’s apical pulse rate and rhythm. C. Obtain the pulse in the other arm. D. Notify the patient’s primary health care provider.

Correct Answer is B

Explanation

Choice A reason: Assessing blood pressure is important but does not directly confirm an irregular pulse. An irregular radial pulse may indicate arrhythmias like atrial fibrillation, affecting cardiac output. Blood pressure measurement assesses hemodynamic status but cannot verify pulse rhythm accuracy, as it relies on arterial pressure, not direct cardiac electrical activity, making it a secondary step.

Choice B reason: Checking the apical pulse, auscultated at the heart’s apex, directly assesses cardiac rhythm and rate, confirming an irregular radial pulse. Irregular rhythms, like atrial fibrillation, disrupt normal atrial-ventricular conduction, detectable via auscultation. This step ensures accurate assessment of cardiac electrical activity and stroke volume, critical for identifying arrhythmias and guiding further interventions.

Choice C reason: Obtaining the pulse in the other arm may detect peripheral inconsistencies but does not confirm cardiac rhythm. An irregular radial pulse likely reflects a cardiac arrhythmia, not a localized vascular issue. Apical pulse assessment directly evaluates heart activity, making it more relevant than bilateral radial checks for verifying rhythm disturbances and planning appropriate interventions.

Choice D reason: Notifying the healthcare provider is premature without confirming the irregular rhythm. An irregular pulse may indicate an arrhythmia, requiring validation via apical pulse to assess cardiac electrical activity. Immediate notification bypasses critical assessment steps, potentially leading to misdiagnosis or delayed care, as the nurse must first gather accurate data to inform the provider.

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The nurse is evaluating outcomes for a patient with insomnia. Which key principle will the nurse consider during this process?

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Naxlex Comprehensive Predictor Exams

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

Correct Answer is B

Explanation

The nurse is taking vital signs. The patient’s radial pulse has an irregular rhythm. What should the nurse do next?

Correct Answer is B

Explanation

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