Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep?
Eyes closed, lying supine in bed, respirations 22, heart rate 66.
Eyes closed, mumbling to self, respirations 16, heart rate 68.
Eyes closed, tossing in bed, respirations 18, heart rate 80.
Eyes closed, lying quietly, respirations 12, heart rate 60.
The Correct Answer is D
Choice A reason: Respirations of 22 and heart rate of 66 suggest arousal or light sleep, not deep NREM sleep, which features slower, regular breathing (12-16 breaths/min) and lower heart rate. This indicates discomfort or instability, not comfortable sleep. Assuming this reflects NREM sleep risks overlooking signs of inadequate rest or stress in ICU patients.
Choice B reason: Mumbling to self indicates partial arousal or REM sleep, not NREM sleep, which is characterized by minimal movement and stable vitals. This suggests discomfort or neurological disturbance. Assuming NREM sleep misidentifies the sleep stage, potentially missing interventions to promote deeper, restorative sleep critical for ICU patient recovery.
Choice C reason: Tossing in bed with respirations of 18 and heart rate of 80 indicates restlessness or light sleep, not deep NREM sleep, which involves calm, slow vitals. This suggests discomfort or pain. Assuming NREM sleep risks neglecting interventions like pain management, critical for ensuring restorative sleep in ICU settings.
Choice D reason: Eyes closed, lying quietly, with respirations of 12 and heart rate of 60 indicate deep NREM sleep, characterized by slow, regular breathing and low heart rate, reflecting parasympathetic dominance. This confirms comfortable, restorative sleep, critical for healing in ICU patients, guiding nurses to maintain conditions supporting this optimal sleep state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Asking the family about normal behavior provides subjective context but lacks standardized cognitive assessment. Cognitive function requires objective tools like the MMSE to evaluate memory, orientation, and attention. Relying solely on family input risks missing subtle deficits, delaying diagnosis of conditions like dementia or delirium critical for patient management.
Choice B reason: Asking for name, location, and month tests orientation, a component of cognitive assessment, but is too limited. The MMSE offers a comprehensive evaluation of memory, language, and visuospatial skills. This narrow approach risks overlooking broader cognitive impairments, potentially missing early dementia or other neurological conditions requiring targeted interventions.
Choice C reason: The HHIE-S assesses hearing impairment, not cognitive function. Hearing loss may affect communication but isn’t a direct cognitive measure. Using this tool for cognition misdirects assessment, risking failure to identify cognitive deficits like memory loss, delaying diagnosis and management of conditions such as Alzheimer’s disease or acute confusional states.
Choice D reason: Administering the MMSE is a standardized, comprehensive tool to assess cognitive function, evaluating orientation, memory, attention, language, and visuospatial skills. It detects impairments in conditions like dementia or delirium, guiding diagnosis and treatment. Its structured approach ensures reliable identification of cognitive deficits, critical for planning care and interventions in clinical settings.
Correct Answer is D
Explanation
Choice A reason: Non-Hispanic Blacks are projected to grow, but their growth rate is slower than Hispanics due to lower birth rates and immigration patterns. By 2060, they will remain a significant group, but demographic data indicate they will not outpace Hispanics, making this incorrect for the fastest-growing ethnic group.
Choice B reason: Multiracial individuals are increasing due to intermarriage, but their growth rate is lower than Hispanics. Projections show they will form a smaller population share by 2060 compared to Hispanics, driven by high birth rates and immigration. This choice is incorrect, as it underestimates Hispanic growth trends.
Choice C reason: Asians are a fast-growing group due to immigration, but their growth rate is surpassed by Hispanics, who benefit from both immigration and higher fertility rates. By 2060, Asians will increase significantly, but demographic forecasts confirm Hispanics as the fastest-growing group, making this choice incorrect.
Choice D reason: Hispanics are projected to be the fastest-growing racial/ethnic group by 2060, driven by high birth rates, immigration, and a younger population. Census projections estimate they will account for nearly 30% of the US population, surpassing other groups in growth rate due to demographic trends, making this the correct choice.
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