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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Discouraging the family from talking about death can hinder their grieving process and may prevent the dying client from having important conversations and finding closure. Open communication about death and dying is often therapeutic for both the client and their family members, allowing them to express emotions and support each other.
Choice B rationale
Informing the family that the client may soon be out of danger when the client is actively dying of renal failure is providing false reassurance and can erode trust between the nurse and the family. It is crucial to be honest and compassionate about the client's prognosis, preparing the family for the impending death rather than offering false hope.
Choice C rationale
While rest is important for a dying client, encouraging the family to leave the client alone may deprive both the client and the family of valuable time for connection and saying goodbye. The presence and support of loved ones can provide comfort to the dying person and begin the grieving process for the family.
Choice D rationale
Informing the family that it is time to bid farewell acknowledges the reality of the situation and provides an opportunity for the family to express their love, say their goodbyes, and find closure. This supportive action respects the dying process and the emotional needs of the family members as they face the imminent loss of their loved one. .
Correct Answer is D
Explanation
Choice A rationale
Anticipatory Grieving is a normal response to an expected loss, such as the impending death of oneself or a loved one. While the client is facing death, her statement "Why me, Lord" and inability to pray suggest a struggle with her spiritual beliefs and meaning in the face of this event, rather than primarily focusing on the emotional preparation for loss.
Choice B rationale
Ineffective Coping refers to an inability to manage stressors effectively. While the client's distress indicates difficulty coping with her situation, the specific mention of spiritual questioning and inability to pray points towards a disturbance in her spiritual well-being, which is more accurately described by spiritual distress.
Choice C rationale
Low Self-Esteem involves negative feelings about oneself and one's worth. While facing death can impact self-esteem, the client's direct questioning of her faith and inability to connect spiritually are the more prominent indicators in this scenario, suggesting a conflict or disruption in her spiritual domain rather than primarily a devaluation of self.
Choice D rationale
Spiritual Distress is characterized by a disruption in one's belief or value system that provides strength, hope, and meaning to life. The client's cry of "Why me, Lord" and her inability to pray indicate a struggle with her faith and a potential feeling of abandonment or questioning of her spiritual beliefs in the face of death. This aligns directly with the defining characteristics of spiritual distress.
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