I have a dream (11/18)

The physiology of sleep is complex.

Which of the following is the most appropriate statement in regard to this process?

The reticular activating system is partly responsible for the level of consciousness of a person

The nurse understands that the client with which of the following conditions is at risk for obstructive sleep apnea?

Nasal polyps

Which of the following symptoms should the nurse assess with a client who is deprived of sleep?

Confusion and irritability

A new mother is concerned that her 2 week old daughter is not sleeping through the night.

The nurse should respond that infants usually develop a nighttime pattern of sleep by:

3 months

The mother of a 2 year old child is frustrated because the child does not want to go to bed at a scheduled bedtime.

The nurse should suggest that the parent:

Maintain consistency in the same bedtime ritual

An 11 year old boy in middle school is currently experiencing sleep-related fatigue during classes.

Which of the following is the most appropriate response by the school nurse when counseling the child's parents regarding this assessment?

"What are the child's usual sleep patterns?"

The nurse recognizes that the sleep patterns of older adults differ and older adults generally:

Have a decline in stage 4 sleep

Teaching for a client who is currently taking a diuretic should include information that he or she may experience:

Nocturia

New research indicates that to increase safety the nurse should instruct parents to do which of the following?

Place the infant on his or her back

A 74 year old client has been having sleeping difficulties.

To have a better idea of the client's problem, the nurse should respond:

"What do you do just before going to bed?"

Which of the following information provided by the client's bed partner is most associated with sleep apnea?

Excessive snoring

The nurse should instruct the client to do which of the following to promote good sleep hygiene at home?

Use the bedroom only for sleep or sexual activity

The nurse knows that which of the following habits may interfere with a client's sleep?

Finishing office work

It is determined that the client will need pharmacological treatment to assist with the client's sleep pattens.

The nurse anticipates that treatment with an anxiety-reducing, relaxation-promoting medication will include the use of:

Benzodiazepines

The nurse is completing an assessment of the client's sleep patterns.

A specific question that the nurse should ask to determine the potential presence of sleep apnea is:

"Do you snore loudly or experience headaches?"

Which of the following may improve the sleep of an older adult client?

Eliminating naps during the day

A client is concerned that their habit of sleeping during the day and being awake at night is not "healthy or normal."

The nurse's most therapeutic response to the client's concern is:

"Everyone has a different biological clock that controls his or her sleep cycle. As long as you are sleeping and functioning well, your habit isn't abnormal or unhealthy."

A client is discussing his recent restlessness and increased irritability.

Which of the following assessment questions is likely to be most helping in determining the cause of these complaints?

"Has anything caused you to change your usual routine lately?"

The nurse and a client are discussing possible behaviors that might be interfering with the client's ability to fall asleep.

Which of the following assessment questions is most likely to identify possible problems with the client's sleep routine that possibly are contributing to the difficulty?

"What do you do to help yourself fall asleep?"

An older adult client diagnosed as being in the early stages of Alzheimer's disease shares with the nurse that her sleep is interrupted by "the noises I hear all through the night."

The nurse explains that the most likely reason for this problem is:

The client's age

A 9 year old client asks the nurse, "Why do I need sleep?"

The nurse's most age-appropriate, informative response is:

"Your body needs to rest in order to grow and be really healthy."

A client has reported to the nurse that his sprained ankle resulted from "a careless accident. I seem so clumsy and unfocused lately."

Which of the following assessment questions is most likely to reveal information regarding the cause of these symptoms?

"Do you have any idea what is responsible for this lack of focus?"

Which of the following clients is most likely to experience difficulty returning to sleep?

A 60 year old with benign hypertropic prostatic disease

Which of the following clients experiencing disrupted sleep patterns is most at risk for obstructive sleep apnea?

A 58 year old diagnosed with chronic depression

A client shares with the nurse that "My wife complains about my snoring, and I never feel rested."

Which of the following responses best attempts to explain the cause of the problem to the client?

"Your upper airway is blocked, and this is making it difficult for you to breathe effectively, so you are spending most of the night in the light sleep stage."

A client hospitalized for a myocardial infarction in a cardiac critical care unit is most likely to experience sleep deprivation as a result of:

Unfamiliar environmental stimuli

The nurse is discussing child care strategies with a mother of a newborn. The mother asks the nurse, "What causes SIDS?"

Which of the following responses is most likely to answer the mother's question therapeutically?

"Research is inconclusive, but it's though to be a result of a nervous system problem that occurs when the baby is asleep."

The client asks the nurse, "How will I know if I'm really rested?"

The nurse's most therapeutic response is:

"When you are mentally, physically, and emotionally ready to go about your daily activities."

The nurse is caring for a 35 year old father of three young children who has experienced a compound fracture femur as a result of a work-related incident. He has expressed great concern over both his physical recovery and his long-term ability to work again.

This has affected both his emotional status and his sleeping patterns. The nurse's most immediate concern is that:

The lack of appropriate rest will affect his healing process

A 63 year old client is discussing the recent problem the client is experiencing with falling asleep. The nurse is discussing strategies to minimize this problem.

Which of the following bedtime snacks would be the most likely to induce sleep?

One slice of cheese on four wheat crackers and a glass of skim milk

A 70 year old client is reporting to the nurse a concern over "taking longer to fall asleep and waking up three to four times during the night."

The most therapeutic nursing response to the client's concern is:

"As we age, those kinds of problems seem more common. Does this disruption in your sleep cause you to be tired or irritable?"

The nurse and the parents of a 3 year old are discussing their child's sleep habits. They share a concern over the child's tendency to wake up several times during the night crying out loudly but not really being awake.

The nurse addresses the parents' concern more therapeutically by responding:

"It is common for children to have trouble relaxing, and this behavior is the result. It's usually temporary."

A 44 year old female client shares with the nurse that she is having difficulty falling asleep at night, even though she is exhausted.

The nurse knows that which of the following could be causing the sleeplessness?

Two cups of hot cocoa every evening

A 22 year old male client shares with the nurse that he is always tired.

In assessing the client's sleep pattern to determine the quantity of sleep the client is getting, the nurse should ask:

"On a scale from 0 to 10, how much sleep do you think you get each night?"

On a 2 week follow-up visit to the health care provider, a 64 year old female postoperative client shares with the nurse that she is having difficulty sleeping and has never had a history of sleeping problems.

The nurse shares with the client that:

The medications used for anesthesia can disturb sleep cycles for several weeks following surgery

The night nurse goes quietly into the sleeping client's room to assess him. The client wakes up as soon as the nurse is in the room.

The nurse knows that the client was most likely in which stage of sleep?

Stage 1: NREM

A 25 year old client's wife complains to the nurse that he sleepwalks during the night.

The nurse knows that his behavior normally occurs in which stage of sleep?

Stage 4: NREM

The assistive nursing personnel reports that the heart rate of the sleeping 23 year old athlete, who is hospitalized following complications of a tonsillectomy, is 56. The assistive nursing personnel states that this is 10 beats per minute slower than when she took it earlier in the evening.

The nurse knows that this is considered:

Normal, and they will continue to monitor the vital signs as ordered

A female client describes the most elaborate dreams to the nurse. She states that she could see colors, hear music, and even had the sensation of flying.

The nurse replies to the client that her dreams indicate that she must be:

Creative

A 74 year old male client who normally sleeps on his right side recently underwent a right-side hip replacement surgery and now has trouble sleeping.

One of the interventions that the nurse might try with this client is to:

Question the client to learn more about his normal sleep pattern

The nurse and a client are discussing the importance of an effective 24 hour sleep cycle.

Which of the following responses by the client may be a direct result of an inadequate sleep pattern? (SATA)

• Usually feeling cold

• Always feeling "tired"

• A heart that beats "really fast"

• Often feeling "blue" or depressed

• Feeling dizzy when getting up from a chair

Although the most common effect of obstructive sleep apnea is disrupted sleep pattern, the condition can cause a serious decline in arterial oxygen levels that may result in: (SATA)

• Hypertension

• Angina attacks

• Cardiac dysrhythmias

• Cerebral vascular accident

The nurse is preparing to discuss the management of the sleeping disorder narcolepsy.

In addition to the prescription of stimulants and antidepressants, which of the following non-pharmaceutical strategies should be included and shared with the client? (SATA)

• Light but high-protein meals

• Regular use of chewing gum

• Adoption of a regular exercise routine

• Brief daytime naps of 20 minutes or less

Which of the following client statements made by young adults suggest a risk factor for sleep disturbance problems? (SATA)

• "I have a job that requires my attention 110% of the time."

• "My wife just found out she is pregnancy for the third time in 5 years."

• "My father recently suffered a heart attack, and Mom is so very worried about him."

• "The kids are so active in after-school things that we never have an evening at home."

Approximately two thirds of the body's total water volume exists in the _____ fluid.

Intracellular

The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as:

Osmosis

The nurse knows that edema in a patient who has venous congestion from right heart failure is facilitated by an imbalance with regard to _____ pressure.

Hydrostatic

The nurse understands that administering a hypertonic solution to a patient will shift water from the _____ to the _____ space.

Intracellular; extracellular

Which patient is most at risk for sensible water loss?

An 80-year-old patient with pneumonia

The nurse knows that the most abundant cation in the blood is:

Sodium

The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern?

Calcium of 17.5 mg/dL

The nurse would expect a patient with increased levels of serum calcium to also have _____ levels.

Decreased phosphate

The nurse knows that an imbalance of which ion causes acid-base impairment?

Hydrogen

The nurse would expect a patient with respiratory acidosis to have an excessive amount of:

Carbon dioxide.

A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother's purse.

The nurse knows that the child is at greatest risk for which acid-base imbalance?

Respiratory acidosis

A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute.

The nurse would expect the patient to have which of the following arterial blood gas values?

• pH- 7.52

• PaCO2- 48 mm Hg

• HCO3- 28 mEq/L

The nurse would not expect full compensation to occur for which acid-base imbalance?

Respiratory alkalosis

A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia.

Which assessment finding would the nurse expect?

Abdominal distention

In which patient would the nurse expect to see a positive Chvostek sign?

A 24-year-old adult admitted for chronic alcohol abuse

Which organ system is responsible for compensation of respiratory acidosis?

Renal

Which laboratory value should the nurse examine when evaluating uncompensated respiratory alkalosis?

PaCO2

The nurse is caring for a diabetic patient in renal failure.

Which laboratory findings would the nurse expect?

• pH- 7.3

• PaCO2- 36 mm Hg

• HCO3- 19 mEq/L

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient a diuretic.

What electrolyte imbalance is the nurse most concerned about?

Potassium imbalance

A chemotherapy patient has gained 5 pounds in 2 days.

Which assessment question by the nurse is most appropriate?

"How many times a day do you urinate?"

Which fluid order should the nurse question for a patient with a traumatic brain injury?

0.45% sodium chloride

The physician asks the nurse to monitor the fluid volume status of a congestive heart failure patient and a patient at risk for clinical dehydration.

What is the most effective nursing intervention for monitoring both of these patients?

Weigh the patients every morning before breakfast.

A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, elevated white blood cell count, and oral candidiasis.

The nurse knows that the purpose of starting total parenteral nutrition (TPN) is to:

Replace fluid, electrolytes, and nutrients in the patient.

A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours.

The nurse anticipates which fluid therapy initially?

0.9% sodium chloride

A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 55 mm Hg, and HCO3- of 20 mEq/L. The physician has been notified.

Which is the priority nursing intervention for this patient?

Encourage the patient to increase respirations.

The nurse knows that intravenous fluid therapy has been effective for a patient with hypernatremia when:

Serum sodium concentration returns to normal.

The nurse would select the dorsal venous plexus of the foot as an IV site for which patient?

A 2-year-old child

Which assessment finding should cause a nurse to question administering a sodium-containing isotonic intravenous fluid?

Pitting edema

A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing.

What is the minute flow rate (drops per minute)?

125 gtt/min

A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 20 mL/hr.

At what time should the infusion be completed?

0715 Tuesday

A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 4 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300 mL output. The patient has voided 400 mL of urine.

After reporting these values to the physician, what orders does the nurse anticipate?

Add a potassium supplement to replace loss from output.

A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patient's peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch.

What is the nurse's initial action?

Start a new IV line

A patient was admitted for hypovolemia and has intravenous fluid running at 250 mL/hr. The patient complains of burning at the IV insertion site. Upon assessment, the nurse does not find redness, swelling, heat, or coolness.

The nurse suspects that the:

Fluid is infusing too quickly

The nurse is caring for a patient with sepsis. The plan of care for the patient is to administer antibiotics 3 times a day for 4 weeks.

What device will be used to administer these antibiotics?

A PICC line

A nurse is preparing to administer a blood transfusion.

Which assessment finding would the nurse report immediately?

Temperature 101.3° F

A nurse has just received a bag of packed red blood cells.

The nurse knows that the blood must not remain at room temperature for longer than:

4 hours

A patient had an acute intravascular hemolytic reaction to a blood transfusion.

After discontinuing the blood transfusion, what is the nurse's next action?

Start normal saline at TKO rate using new tubing.

A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention.

The nurse recognizes that the patient is experiencing which transfusion complication?

Fluid volume overload

The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has:

A filter to ensure that clots do not enter the patient.

The nurse is caring for a patient with hyperkalemia.

Which body system would be most important for the nurse plan to monitor closely?

Cardiac

Which assessment finding would the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

Tingling of the extremities and tetany

A patient informs the nurse that he has the type of diabetes that does not require insulin.

The nurse advises the patient to make which dietary change?

Drink plenty of fluids throughout the day to stay hydrated.

When selecting a site to insert an intravenous catheter on an adult, the nurse should (SATA)?

• Choose a vein with minimal curvature.

• Check for contraindications to the extremity

• Avoid areas of flexion

Which of the following assessments would indicate that a patient's IV has infiltrated? (SATA)

• Edema of the extremity near the insertion site

• Skin discolored or bruised in appearance

• Skin cool to the touch

• Numbness or loss of sensation

When discontinuing a peripheral IV access, the nurse should (SATA):

• Keep the catheter parallel to the skin while removing it.

• Stop the infusion before removing the IV catheter.

• Apply pressure to the site for 2 to 3 minutes after removal.

A co-worker asks the nurse to explain spirituality.

What is the nurse's best response?

It is awareness of one's inner self.

The nurse is caring for a patient who professes to being an agnostic.

Which information should the nurse consider when planning care for this patient belief system?

Believes there is no known ultimate reality.

The nurse is caring for an Islamic patient who wants to pray.

Which intervention is most appropriate?

Offering to turn on their music in preparation for prayer

A nurse is teaching a patient how to meditate.

Which behavior presented by the patient indicates effective learning?

Focusing on an particular image

The nurse is admitting a patient to the hospital. The patient claims to be a very spiritual person but does not practice any specific religion.

How will the nurse interpret this finding?

This statement is reasonable.

Which patient comment should the nurse identify as a demonstration of faith?

I believe there is life after death.

A nurse is caring for a Roman Catholic patient.

Which action will the nurse plan time for?

Avoiding meat on Fridays

The nurse is caring for a patient with a chronic illness who is having conflicts with beliefs.

Which health care team member will the nurse ask to see this patient?

The clergy

The nurse caring for a terminally ill patient sits down and lightly touches the patient's hand.

Which technique is the nurse using?

Establishing presence

The nurse and the patient have the same religious affiliation.

Which action will the nurse take to support the patient spiritually?

Do not impose personal values on the patient.

A nurse makes a connection with the patient when providing spiritual care.

Which type of connectedness did the nurse experience?

Interpersonal