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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hemoglobin of 11.3 g/dL is low but not specific to malnutrition, as it may indicate anemia from various causes, like iron deficiency or chronic disease. Malnutrition affects protein levels more directly. This value requires further investigation but does not confirm malnutrition, as it reflects red blood cell status, per hematological assessment.
Choice B reason: Creatinine of 1.9 mg/dL suggests renal impairment, as it exceeds normal ranges (0.6-1.2 mg/dL), reflecting reduced kidney filtration. Malnutrition typically lowers creatinine due to muscle wasting, not elevates it. This value indicates kidney dysfunction, not nutritional status, making it irrelevant to malnutrition assessment, per renal physiology.
Choice C reason: Hematocrit of 56% indicates hemoconcentration, often from dehydration, not malnutrition. Malnutrition may cause anemia, lowering hematocrit. Elevated hematocrit reflects increased red blood cell proportion, unrelated to protein-energy deficits. This finding does not align with malnutrition’s impact on nutritional biomarkers, per laboratory diagnostic standards.
Choice D reason: Serum albumin of 2.8 g/dL (normal 3.5-5.0 g/dL) indicates malnutrition, as low levels reflect reduced protein synthesis due to inadequate dietary intake. Albumin is a sensitive marker of chronic nutritional status, decreasing in protein-energy malnutrition. This finding directly correlates with malnutrition’s physiological impact, per nutritional assessment guidelines.
Correct Answer is B
Explanation
Choice A reason: Pursed lip breathing (PLB) prolongs exhalation to reduce air trapping in COPD but does not directly prevent atelectasis, which is alveolar collapse from shallow breathing or obstruction. PLB maintains positive airway pressure, improving gas exchange, but atelectasis prevention requires deep breathing exercises, making this statement incorrect for PLB’s primary function.
Choice B reason: Pucker the lips like whistling is the correct technique for pursed lip breathing, creating a small opening to slow exhalation. This increases airway pressure, preventing alveolar collapse in COPD and improving oxygen saturation. By prolonging exhalation, PLB reduces hyperinflation, enhancing respiratory efficiency, making this the accurate description of the technique.
Choice C reason: Breathing slowly through the mouth for 4 counts describes inhalation timing, not specific to pursed lip breathing’s exhalation focus. PLB involves nasal inhalation and slow exhalation through pursed lips to reduce air trapping in COPD. Incorrect inhalation instructions can disrupt the technique’s effectiveness in maintaining airway pressure and improving gas exchange.
Choice D reason: Breathing out fast through the mouth for 2 counts contradicts pursed lip breathing’s purpose of slow, controlled exhalation. Rapid exhalation in COPD exacerbates air trapping, worsening hyperinflation. PLB prolongs exhalation through pursed lips to maintain airway pressure, improving oxygenation and reducing respiratory distress, making this statement incorrect.
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