Which client likely faces a risk for the nursing diagnosis of Disturbed Sleep Pattern: Difficulty Remaining Asleep?

A client whose opioid analgesics result in central nervous system depression.

A client whose physical therapy has been scheduled for 4:30 p.m.

A client who requires blood glucose checks 4 times daily.

A client who receives IV antibiotics every 3 hours.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Opioid analgesics, while causing central nervous system depression and potentially leading to drowsiness and difficulty falling asleep, are less likely to directly cause difficulty *remaining* asleep. Their primary effect on sleep is usually at the initiation stage due to their sedative properties.

Choice B rationale

Physical therapy scheduled for 4: p.m. might cause some fatigue, potentially aiding sleep onset. However, unless it causes significant pain or discomfort later in the night, it's unlikely to be a primary factor in difficulty remaining asleep.

Choice C rationale

Frequent blood glucose checks, while potentially disruptive, are typically brief interventions. Unless the client experiences significant fluctuations in blood sugar levels that cause nocturnal symptoms like sweating or palpitations, these checks are less likely to be the main cause of difficulty remaining asleep. Normal fasting blood glucose ranges from 70 to 100 mg/dL.

Choice D rationale

Intravenous antibiotics administered every 3 hours necessitate frequent awakenings throughout the night to maintain therapeutic drug levels. These repeated interruptions to the sleep cycle directly interfere with the ability to remain asleep, fragmenting sleep patterns and preventing the client from achieving restorative sleep.

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Correct Answer is A

Explanation

Choice A rationale

Emptying a Foley catheter bag and reporting the urine volume is a routine task that does not require complex assessment or clinical judgment. Unlicensed care providers are typically trained in this procedure and can accurately measure and report the output to the nurse.

Choice B rationale

Helping a first-time mother achieve a good latch during breastfeeding requires specialized knowledge and assessment skills to ensure proper positioning and infant feeding. This task involves teaching and evaluating, which falls within the scope of nursing practice and should not be delegated to an unlicensed care provider.

Choice C rationale

Assessing the size and quantity of blood clots in a postpartum client's bedpan requires clinical judgment to determine if the findings are within normal limits or indicative of a potential complication. This assessment should be performed by a registered nurse who can interpret the findings in the context of the client's overall condition.

Choice D rationale

Administering medication, including anti-inflammatory drugs, is a nursing responsibility that requires knowledge of pharmacology, potential side effects, and client assessment. Medication administration should not be delegated to unlicensed care providers. .

A. The nurse must follow the physician's orders. B. The physician's order creates a barrier to establishing an effective nurse-client relationship. C. The nurse faces an ethical dilemma about inconsistent courses of action. D. The nurse is unable to provide care for the client.

Correct Answer is C

Explanation

Choice A rationale

While nurses are generally expected to follow physician's orders, they also have a professional and ethical responsibility to advocate for their patients. In situations where an order conflicts with the patient's wishes and ethical principles, blindly following the order can lead to moral distress.

Choice B rationale

The physician's order, which contradicts the patient's explicit request, can indeed create a barrier to establishing an effective nurse-client relationship built on trust and respect for the patient's autonomy. The nurse may feel conflicted in carrying out an unwanted intervention.

Choice C rationale

The situation creates an ethical dilemma for the nurse because there are conflicting courses of action with moral implications. The nurse faces a conflict between the duty to follow the physician's order and the ethical principle of respecting the patient's autonomy and right to refuse treatment, even life-sustaining measures at the end of life.

Choice D rationale

The nurse is not unable to provide care but faces a complex ethical challenge in determining the most appropriate and ethical course of action that respects the patient's wishes while navigating the physician's order.

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Which client likely faces a risk for the nursing diagnosis of Disturbed Sleep Pattern: Difficulty Remaining Asleep?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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