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

Battery in a legal context refers to the intentional touching of another person without their consent. Inserting a urinary catheter into a client's urethra after the client has explicitly refused the procedure constitutes a non-consensual physical contact. Even if the procedure was ordered, the lack of consent transforms the act into battery, especially if it results in injury to the client.

Choice B rationale

Dereliction of duty, a component of negligence, involves a failure to meet the accepted standard of care. While inserting a catheter against a client's will could be seen as a failure in ethical and potentially professional standards, the specific tort of battery focuses on the unauthorized physical contact, regardless of whether it was done negligently or with intent to harm (though intent to touch without consent is present).

Choice C rationale

Assault involves an intentional act that creates a reasonable apprehension of immediate harmful or offensive contact. While the client may have felt threatened or apprehensive when the nurse proceeded despite their refusal, the actual insertion of the catheter and subsequent injury constitute battery, as physical contact occurred. Assault precedes battery; battery is the actual physical contact.

Choice D rationale

Invasion of privacy pertains to the wrongful intrusion into a person's private affairs or the public disclosure of private information. While a client has a right to privacy regarding their body and medical procedures, the act of physically inserting a catheter against their will, leading to injury, primarily constitutes a physical violation and lack of consent, which falls under the definition of battery.

A. A colleague who graduated with honors at the same time as the novice nurse. B. The unit manager who is a personal friend of the novice nurse. C. An experienced nurse who was a preceptor in a previous clinical placement. D. The nurse educator in the hospital where the novice nurse has been hired.

Correct Answer is C

Explanation

Choice A rationale

A colleague who graduated at the same time lacks the experience and established professional network necessary to provide effective mentorship. Mentorship involves guidance based on practical experience and insights gained over time, which a recent graduate, regardless of academic achievements, would not possess. A mentor should offer a more seasoned perspective on navigating career challenges and professional development.

Choice B rationale

While a personal friendship might offer emotional support, a unit manager who is primarily a friend may not possess the objectivity and focus required for professional mentorship. The managerial role involves administrative and supervisory responsibilities that might overshadow the specific developmental needs of a novice nurse. Furthermore, personal relationships can sometimes blur professional boundaries, hindering effective guidance.

Choice C rationale

An experienced nurse who previously served as a preceptor has demonstrated an ability to guide and educate new nurses in a clinical setting. This individual is likely familiar with the challenges faced by novice nurses and possesses the practical knowledge and teaching skills necessary for effective mentorship. Their prior experience in a similar role makes them well-suited to provide targeted support and professional guidance.

Choice D rationale

A nurse educator primarily focuses on formal education and training programs within the hospital. While they possess valuable knowledge and expertise, their role typically involves broader educational responsibilities rather than individualized, long-term mentorship. A mentor relationship often involves a more personal and ongoing connection focused on the mentee's specific career trajectory and professional growth, which may fall outside the scope of a nurse educator's primary duties.

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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

When the nurse inserts an ordered urinary catheter into the client's urethra after the client has refused the procedure, and then the client suffers an injury, the client may sue the nurse for which type of tort?

Correct Answer is A

Explanation

The nurse has just graduated with a Bachelor of Science in Nursing and is eager to find a mentor at this early stage in her career.Which of the following individuals is most likely to be an appropriate mentor for the nurse?

Correct Answer is C

Explanation

A nurse is caring for a young client who is actively dying of renal failure.What should the nurse do when caring for the dying client's family members?

The client is a male who states his wife complains that his snoring awakens her at night.The spouse is present.To obtain further data, the nurse asks the spouse:

A dying client tells the nurse that he doesn't want to see his family because he doesn't want to cause them more sadness.Which action by the nurse is most appropriate?

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

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A nurse on a medical unit is planning care for several clients.Which of the following clients should benefit MOST from the nurse acting as an advocate?

The nurse is caring for a patient who is unconscious.Which action by the nurse is appropriate?