The nurse promotes good quality sleep for their clients based on the knowledge that sleep: (SELECT ALL THAT APPLY)

decreases pain tolerance.

increases blood pressure.

helps cope with stress.

restores mind and body.

helps conserve energy.

Answer and Explanation

Correct Answer : C,D,E

C. Sleep plays a crucial role in stress management and resilience. Adequate sleep helps regulate stress hormones such as cortisol, promotes emotional regulation, and enhances coping mechanisms. Chronic sleep deprivation can lead to increased stress levels and reduced ability to cope with stressors.
D. Sleep is essential for the restoration and repair of both the mind and body. During sleep, the body undergoes processes such as tissue repair, muscle growth, and memory consolidation. Sleep also allows the brain to clear toxins and waste products accumulated during wakefulness, promoting cognitive function and overall well-being.

E. One of the functions of sleep is to conserve energy. During sleep, metabolic rate and energy expenditure decrease, allowing the body to conserve resources for essential physiological processes. Sleep helps replenish energy stores, repair cellular damage, and prepare the body for the next day's activities.
A. Sleep has been shown to have analgesic effects and can improve pain tolerance. Adequate sleep helps reduce the perception of pain and promotes the release of endogenous pain-relieving substances in the body.
B. During sleep, blood pressure typically decreases as part of the normal sleep-wake cycle. However, certain sleep disorders, such as sleep apnea, may lead to fluctuations in blood pressure during sleep. Overall, quality sleep is important for maintaining cardiovascular health and regulating blood pressure.

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Correct Answer is C

Explanation

C. This is a critical initial step before administering enteral feedings. Aspirating stomach contents helps confirm the placement of the nasogastric tube in the stomach rather than the respiratory tract. Checking the pH of the aspirate can further confirm gastric placement, as gastric fluid typically has an acidic pH (usually less than 5). This step ensures that the feeding will be delivered to the correct location, minimizing the risk of aspiration.
A. While it's important for the formula to be at an appropriate temperature for administration to prevent discomfort or complications such as cramping, this is not typically the first action to take. It can be done concurrently with other preparatory steps.
B. Proper labeling of the feeding container is essential for patient safety and adherence to institutional policies. However, this is not the first action to be completed. It's usually done after preparing the feeding and confirming the tube placement.
D. Assessing residual volume involves checking for any residual contents in the stomach from previous feedings. This step helps determine how much of the previous feeding remains in the stomach and whether it's safe to administer the next feeding. However, it typically follows confirming tube placement, as it's essential to know the tube is in the correct position before assessing residual volume.

A. Administer an intravenous sedative B. Assess the client for seizure activity C. Assist the client in slowed breathing techniques D. Check the client's blood pressure

Correct Answer is C

Explanation

C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.

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The nurse promotes good quality sleep for their clients based on the knowledge that sleep: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer an enteral tube feeding to a client via a nasogastric tube. Which nursing action should be completed first?

Correct Answer is C

Explanation

A client is hyperventilating due to an acute psychologic stressor. The arterial blood gas results show that the client is in respiratory alkalosis. What is the nurse's initial intervention?

Correct Answer is C

Explanation

The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (SELECT ALL THAT APPLY)

The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?

Which of the following are physiologic manifestations which occur in the alarm stage of the General Adaptation Syndrome? (SELECT ALL THAT APPLY)

A client is admitted with a suspected opioid overdose and a respiratory rate of 6 breaths per minute. Which of the following data would the nurse anticipate? (SELECT ALL THAT APPLY)

Two clients have been in a similar motor vehicle accident, and have similar injuries. The nurse observes each client's different responses to this stressor. The nurse understands that the degree of stress each client experiences from the crash may be influenced by their: (SELECT ALL THAT APPLY)

The nurse is caring for a client who is discussing being placed on hospice care. Which statement by the client indicates an understanding of hospice care?

A nurse caring for a client who has a peripheral intravenous saline lock understands that its purpose is to:

The physician has discussed the need for surgery with a client and has obtained informed consent. The nurse determines that the client does not understand the risks and benefits of the procedure. What is the nurse's best action?