Exam 3 flashcards study

What is the purpose of National Patient Safety Goals?

To help health care organizations in obtaining/retaining their accreditation and to reduce the incidence of deaths/injuries among clients receiving care.

Name a common injury that occurs in infancy.

Suffocation or choking due to objects in the mouth.

What should be done to prevent burns in health care settings?

Ensure functioning fire extinguishers and smoke alarms, and have a family exit plan.

What does RACE stand for in fire safety protocols?

Rescue, Alarm, Confine, Extinguish.

What are Class B fire extinguishers used for?

Flammable liquids and gas fires.

What is carbon monoxide poisoning caused by?

It is caused by unintentional exposure to carbon monoxide, which is colorless, odorless, and tasteless.

List one common cause of asphyxiation.

Drowning.

What precautions can be taken to prevent electrical shock?

Ensure equipment is grounded and educate on the dangers of water near electrical devices.

What are the main characteristics of latex sensitization?

Allergic response to latex proteins which may lead to contact dermatitis or acute hypersensitivity.

Identify a reason why older adults are prone to falls.

Visual impairments and decreased coordination.

What should be done in case of a seizure?

Stay with the patient, protect their head, and call for help.

What does the ABCDE principle stand for in emergency care?

Airway, Breathing, Circulation, Disability, Exposure.

What should you do to manage bleeding in first aid?

Identify the source of bleeding and apply direct pressure to the wound.

What is the recommended action for a patient experiencing heat stroke?

Provide rapid cooling and remove excess clothing.

How often should restraints be re-evaluated?

Every 2 hours.

A nurse is oriented to the National Patient Safety Goals. What is the primary focus of these goals in a healthcare facility?

A) Reducing healthcare-associated costs
B) Obtaining and retaining accreditation
C) Increasing nurse-to-patient ratios
D) Improving patient satisfaction scores

Answer: B
Rationale: The National Patient Safety Goals are established to help healthcare organizations obtain/retain accreditation and specifically reduce the incidence of preventable deaths and injuries.

A nurse is teaching a new mother about safety. Identify the most common cause of injury in infants.

A) Falling from a high chair
B) Poisoning from household cleaners
C) Suffocation or choking on small objects
D) Burns from hot bath water

Answer: C
Rationale: Infancy is characterized by putting objects in the mouth, making suffocation and choking the leading causes of injury and death in this age group.

A fire is detected in a client's wastebasket. Which of the following actions should the nurse take first?

A) Pull the fire alarm
B) Extinguish the fire with a Class A extinguisher
C) Close the door to the room
D) Move the client to a safe area

Answer: D
Rationale: Following the RACE protocol, the first step is Rescue. The nurse must immediately move the client from danger before taking further action.

A nurse is teaching a family about fire safety. When using a fire extinguisher, what does the acronym PASS represent?

A) Pull, Aim, Squeeze, Sweep
B) Push, Aim, Shout, Spray
C) Pull, Activate, Squeeze, Secure
D) Plan, Aim, Squeeze, Sweep

Answer: A
Rationale: PASS stands for Pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep from side to side.

Which type of fire extinguisher should the nurse select for a fire involving flammable liquids or gas?

A) Class A
B) Class B
C) Class C
D) Class K

Answer: B
Rationale: Class B fire extinguishers are specifically designed for flammable liquids and gas fires. Class A is for combustibles (wood/paper), and Class C is for electrical fires.

True or False: Carbon monoxide is easily detectable because of its distinct 'rotten egg' smell.

Answer: False
Rationale: Carbon monoxide is a dangerous gas because it is colorless, odorless, and tasteless, making it impossible to detect without a specialized alarm.

A nurse is assessing a group of older adult clients. Which factor contributes most significantly to their increased risk for falls?

A) Increased muscle mass
B) Improved tactile sensation
C) Visual impairments and decreased coordination
D) Use of a single daily multivitamin

Answer: C
Rationale: Older adults experience physiological changes such as decreased vision, slower reaction times, and reduced coordination, which significantly increase fall risk.

A nurse witnesses a client begin to have a tonic-clonic seizure. Which action should the nurse take?

A) Place a padded tongue blade in the client's mouth
B) Restrain the client's limbs to prevent injury
C) Stay with the client and protect the head from injury
D) Offer the client a sip of water to calm them

Answer: C
Rationale: The priority is to stay with the patient and ensure safety by protecting the head. Never place objects in the mouth or restrain a patient during a seizure.

A nurse is using the ABCDE principle during a primary survey in emergency care. What does the 'C' represent?

A) Consciousness
B) Circulation
) Comfort
D) Communication

Answer: B
Rationale: In the ABCDE principle, C stands for Circulation. The nurse assesses heart rate, blood pressure, and capillary refill.

A client is brought to the emergency department with heat stroke. Which of the following is the priority intervention?

A) Administering oral fluids
B) Providing rapid cooling and removing excess clothing
C) Administering prophylactic antibiotics
D) Placing the client in a warm blanket

Answer: B
Rationale: Heat stroke is a medical emergency requiring rapid cooling (ice packs, cooling blankets) and the removal of clothing to lower the core body temperature.

A clinical instructor is observing a student nurse care for a client in soft wrist restraints. Which action by the student requires intervention?

A) Checking the skin under the restraint every 2 hours
B) Attaching the restraint to the side rails of the bed
C) Ensuring two fingers can fit under the restraint
D) Using a quick-release knot

Answer: B
Rationale: Restraints should never be attached to side rails, as this can cause injury if the rail is lowered or moved. They must be attached to the non-moving part of the bed frame.

A nurse is caring for a client with a suspected latex allergy. Which of the following items should the nurse ensure is removed from the room?

A) Cotton blankets
B) Stainless steel bedpans
C) Rubber-based suction tubing
D) Synthetic vinyl gloves

Answer: C
Rationale: Many medical supplies, including specific types of suction tubing and catheters, contain latex. Synthetic vinyl and nitrile are safe alternatives.

True or False: A nurse can apply restraints to a client whenever the nurse feels the client is being 'difficult' or 'non-compliant.'

Answer: False
Rationale: Restraints are a last resort and should only be used when the client poses an immediate physical threat to themselves or others. They are never used for convenience or punishment.

A nurse is applying first aid to a client with active external bleeding. What is the priority action?

A) Elevate the extremity above the heart
B) Apply direct pressure to the wound
C) Perform a neurovascular check
D) Apply a tourniquet immediately

Answer: B
Rationale: The first step in managing external bleeding is identifying the source and applying direct pressure to control the flow.

In the RACE fire protocol, what does the 'C' stand for?

A) Call for help
B) Contain/Confine the fire
C) Carry clients out
D) Clear the hallway

Answer: B
Rationale: C stands for Confine or Contain the fire, which is typically done by closing doors and windows to prevent the spread of smoke and flames.

How often must a nurse re-evaluate and document the status of a restrained client, including skin integrity and range of motion?

A) Every 30 minutes
B) Every 1 hour
C) Every 2 hours
D) Once per shift

Answer: C
Rationale: Standard practice and safety guidelines require that restraints be released and the client be re-evaluated every 2 hours.

Which of the following is a common cause of asphyxiation in school-aged children and adults?

A) Electrical shock
B) Drowning
C) Latex exposure
D) Carbon monoxide

Answer: B
Rationale: Drowning is a leading cause of asphyxiation. Other causes include choking and gas inhalation.

A nurse discovers a piece of equipment with a frayed electrical cord. What is the appropriate action?

A) Wrap the cord in medical tape and continue use
B) Use the device but keep it away from water
C) Remove the equipment from service and tag it for repair
D) Wait until the end of the shift to report it

Answer: C
Rationale: Damaged electrical equipment poses a shock and fire hazard. It must be removed from the patient area immediately and tagged for biomedical evaluation.

What is the primary characteristic of an acute hypersensitivity reaction to latex?

A) Localized dry skin
B) Redness and itching after 24 hours
C) Systemic response including hives, edema, and respiratory distress
D) Slow-developing contact dermatitis

Answer: C
Rationale: Acute hypersensitivity is an immediate, systemic allergic response that can lead to anaphylaxis, whereas contact dermatitis is a delayed, localized reaction.

Which nursing intervention is most effective in preventing falls for a client with nocturia?

A) Keeping all four side rails up
B) Providing a bedside commode and adequate lighting
C) Administering a sedative at bedtime
D) Placing the client in a room far from the nurse's station

Answer: B
Rationale: Reducing the distance to the toilet and ensuring visibility are proactive environmental modifications that prevent falls.

True or False: During a fire, Class C extinguishers are used specifically for electrical equipment fires.

Answer: True
Rationale: Class C fire extinguishers are designed for electrical fires because the extinguishing agent is non-conductive.

What is the very first step in the ABCDE primary survey?

A) Check for pulse
B) Assess airway patency
C) Look for obvious deformities
D) Measure blood pressure

Answer: B
Rationale: Airway is the first priority. If the airway is blocked, the client cannot oxygenate, regardless of their heart rate or circulation.

A nurse is educating a family on how to prevent burns in the home. Which instruction should be included?

A) Set the water heater temperature to 140^{\circ}F
B) Check smoke alarm batteries once every 5 years
C) Ensure fire extinguishers are visible and develop an exit plan
D) Use space heaters as the primary heat source

Answer: C
Rationale: Maintenance of smoke alarms and having a clear exit plan are essential fire safety measures. Water heaters should be set below 120^{\circ}F to prevent scalds.

Which of the following describes the 'D' in the ABCDE principle?

A) Debridement
B) Disability (level of consciousness)
C) Drainage
D) Dehydration

Answer: B
Rationale: D stands for Disability, referring to the assessment of the client's neurological status and level of consciousness using tools like the Glasgow Coma Scale.

True or False: After a seizure, the nurse should place the patient in a side-lying position.

Answer: True
Rationale: The side-lying (recovery) position helps maintain a patent airway and prevents aspiration of oral secretions post-ictally.

Which of the following is considered a 'restraint alternative'?

A) Soft wrist restraints
) Electronic bed alarms
C) Four side rails up
D) A vest restraint

Answer: B
Rationale: Bed alarms are a non-restrictive way to monitor client movement without physically limiting their freedom, making them a primary alternative to restraints.

A nurse is caring for an adolescent. Which safety topic is most relevant for this age group?

A) SIDS prevention
B) Preventing falls from playground equipment
C) Risk-taking behaviors and motor vehicle safety
D) Choking on small toy parts

Answer: C
Rationale: Adolescents are prone to injuries related to risk-taking, sports, and motor vehicle accidents due to a sense of invincibility and peer pressure.

A client is discovered on the floor. After ensuring the client is safe and stable, what is the nurse's next legal and facility-required action?

A) Call the family to apologize
B) Document the fall in the medical record and complete an incident report
C) Write about the incident in the shift report only
D) Hide the client's shoes

Answer: B
Rationale: Incident reports are necessary for tracking safety trends and quality improvement. The fall itself must also be documented in the clinical record (without mentioning the incident report).

Which of the following is a symptom of heat stroke that differentiates it from heat exhaustion?

A) Moist, clammy skin
B) Core temperature of 98.6^{\circ}F
C) Confusion or delirium
D) Excessive sweating

Answer: C
Rationale: Heat stroke is characterized by high core temperatures (>104^{\circ}F), hot/dry skin (lack of sweating), and central nervous system dysfunction like confusion or seizures.

True or False: In a medical emergency, the 'E' in ABCDE stands for 'Exposure,' which involves looking for hidden injuries while maintaining body temperature.

Answer: True
Rationale: Exposure involves removing clothing to perform a full assessment but also ensures the client is kept warm to prevent hypothermia.

A nurse is assessing a room for electrical safety. Which observation requires immediate action?

A) A three-pronged plug in a grounded outlet
B) A technician using a double-insulated tool
C) An IV pump cord running across a high-traffic walkway
D) A green 'biomed' sticker on a heart monitor

Answer: C
Rationale: Cords in walkways are a trip hazard and can be damaged, leading to electrical shorts. They should be secured or redirected.

What is the most common manifestation of latex sensitization that is limited to the skin?

A) Anaphylaxis
B) Contact dermatitis
C) Rhinoconjunctivitis
D) Asthma

Answer: B
Rationale: Contact dermatitis is a localized skin reaction (redness, itching, scaling) that results from direct contact with latex proteins.

A nurse is teaching about poisoning. If a child ingests a toxic substance, what should the parent do first?

A) Administer syrup of ipecac
B) Give the child milk
C) Call the Poison Control Center
D) Wait to see if symptoms develop

Answer: C
Rationale: The priority is to contact experts (Poison Control) to receive specific instructions based on the substance ingested.

Which of the following clients is at the highest risk for fall-related injuries?

A) A 25-year-old with a broken arm
B) An 80-year-old with osteoporosis and vertigo
C) A 40-year-old post-appendectomy
D) A 10-year-old with a flu

Answer: B
Rationale: The combination of advanced age, balance issues (vertigo), and fragile bones (osteoporosis) makes this client extremely high risk for serious fall injuries.

A nurse uses a fire extinguisher. In the PASS sequence, what does the 'E' in Squeeze stand for (as part of the action)?

A) Escape the room
B) Empty the canister
C) Extinguish the perimeter
D) (Correction: 'S' is the action) What does the 'S' in Sweep represent?

Answer: Sweep from side to side
Rationale: Sweeping the nozzle from side to side at the base of the fire ensures the extinguishing agent covers the entire width of the fuel source.

(One-word) What is the first priority in the RACE acronym during a fire?

Rescue
Rationale: The nurse must first rescue the client from immediate danger.

(One-word) How many hours is the maximum interval for a nurse to release and re-evaluate a client in restraints?

2
Rationale: Periodic release (every 2 hours) is required to assess skin, circulation, and need for continued restraint.

(One-word) The 'A' in the ABCDE primary survey stands for what?

Airway
Rationale: Establishing a patent airway is the absolute first priority in emergency stabilization.

(One-word) Identify the tasteless, odorless gas that can cause lethal poisoning in the home.

Carbon-monoxide
Rationale: Carbon monoxide (CO) binds to hemoglobin and displaces oxygen, leading to rapid asphyxiation.

(One-word) What is the leading cause of safety-related deaths in infants related to objects in the mouth?

Suffocation
Rationale: Choking on small parts or items in the crib leads to suffocation, the primary injury risk for this age group.

What are the primary functions of sleep?

Reducing fatigue, stabilizing mood, improving blood flow to the brain, increasing protein synthesis & healing, maintaining the immune system, promoting cellular growth & repair, and improving capacity for learning & memory storage.

What are the phases of sleep?

Sleep consists of REM (Rapid Eye Movement) and three stages of NREM (Non-Rapid Eye Movement).

How does sleep requirement change as a person ages?

As a person ages, the time spent in NREM decreases while the time spent in REM sleep increases.

What is the lightest stage of NREM sleep?

Stage 1 NREM is the lightest stage of sleep, lasting 1-7 minutes, characterized by a loss of awareness and easy awakeness.

Describe Stage 2 NREM sleep.

Stage 2 NREM is a deeper sleep lasting 10-25 minutes where the body's vital signs and metabolism continue to slow.

What occurs during Stage 3 NREM sleep?

Stage 3 NREM, or deep sleep, lasts 20-40 minutes and is when psychological rest and restoration occur, making it difficult to awaken.

What characterizes REM sleep?

REM sleep lasts 20-40 minutes, features vivid dreams, varying vital signs, and is crucial for cognitive restoration.

What can interfere with sleep?

Factors include physiological disorders, current life events, diet, exercise, fatigue, sleep environment, medications, substances, comorbidities, food/drink, safety, rituals, and circadian rhythms.

What is insomnia?

Insomnia is the most common sleep disorder characterized by the inability to get adequate sleep and feel rested.

What is sleep apnea?

Sleep apnea involves more than 5 breathing cessations per hour lasting longer than 10 seconds, resulting in decreased arterial O2 saturation levels.

List some common types of parasomnia.

Somnambulism (sleepwalking), nocturnal enuresis (bed-wetting), sleep talking, nightmares, and restless legs syndrome.

What is narcolepsy?

Narcolepsy is characterized by sudden, uncontrollable attacks of sleep, often accompanied by sleep paralysis and cataplexy.

What nursing measures can promote relaxation and sleep?

Help establish a bedtime routine, limit nighttime awakenings, promote a quiet environment, assist with personal hygiene before sleep, and engage in muscle relaxation.

Question: A nurse is collecting data from an older adult client regarding their sleep patterns. Which of the following findings should the nurse expect based on the client's age?

A. Increased time spent in NREM sleep
B. Decreased time spent in REM sleep
C. Increased time spent in REM sleep
D. No change in sleep cycles

Correct Answer: C

Rationale: According to the provided notes, as a person ages, the time spent in NREM sleep decreases while the time spent in REM sleep increases. This differs from neonates who typically have high REM percentages that stabilize later in life.

Question: A nurse is caring for a client who is having difficulty staying asleep. The nurse should identify that which of the following is a primary function of sleep?

A. Decreasing protein synthesis
B. Reducing blood flow to the brain
C. Stabilizing mood and reducing fatigue
D. Decreasing the immune system's response

Correct Answer: C

Rationale: The primary functions of sleep include reducing fatigue, stabilizing mood, improving blood flow to the brain, increasing protein synthesis, and maintaining the immune system.

Question: A nurse is monitoring a client in a sleep study. The client is in a stage of sleep that is very light, lasts approximately 1 to 7 minutes, and the client is easily awakened. The nurse should identify this as which stage?

A. Stage 1 NREM
B. Stage 2 NREM
C. Stage 3 NREM
D. REM sleep

Correct Answer: A

Rationale: Stage 1 NREM is the lightest stage of sleep, typically lasting 1 to 7 minutes where the person is easily aroused and loses awareness of their surroundings.

Question: Which stage of sleep is characterized by a decrease in the body's vital signs and metabolism, typically lasting 10 to 25 minutes?

A. Stage 1 NREM
B. Stage 2 NREM
C. Stage 3 NREM
D. REM sleep

Correct Answer: B

Rationale: Stage 2 NREM is a deeper sleep than Stage 1, lasting 10 to 25 minutes, during which vital signs and metabolism continue to slow down.

Question: A client reporting persistent exhaustion is encouraged to reach 'deep sleep' for psychological restoration. Which stage is the nurse referring to?

A. Stage 1 NREM
B. Stage 2 NREM
C. Stage 3 NREM
D. REM sleep

Correct Answer: C

Rationale: Stage 3 NREM, also known as deep sleep, lasts 20 to 40 minutes and is the period when psychological rest and restoration occur.

Question: A nurse is teaching a group of students about the cognitive benefits of sleep. Which stage of sleep is crucial for cognitive restoration and features vivid dreaming?

A. Stage 1 NREM
B. Stage 2 NREM
C. Stage 3 NREM
D. REM sleep

Correct Answer: D

Rationale: REM (Rapid Eye Movement) sleep is essential for cognitive restoration and is characterized by vivid dreaming and varying vital signs.

Question: A nurse is assessing a client for sleep apnea. The nurse should identify that sleep apnea is defined as having more than how many breathing cessations per hour?

A. 2
B. 5
C. 10
D. 15

Correct Answer: B

Rationale: Sleep apnea occurs when there are more than 5 breathing cessations per hour, each lasting longer than 10 seconds.

Question: A client reports suddenly falling asleep during the day and experiencing muscle weakness when laughing. Which sleep disorder should the nurse suspect?

A. Insomnia
B. Sleep apnea
C. Narcolepsy
D. Parasomnia

Correct Answer: C

Rationale: Narcolepsy is characterized by sudden, uncontrollable sleep attacks and is often accompanied by cataplexy (sudden muscle weakness) and sleep paralysis.

Question: A nurse is planning care for a client with a sleep disorder. Which of the following interventions should the nurse include to promote sleep?

A. Encourage exercise right before bedtime
B. Wake the client frequently for assessment
C. Assist with personal hygiene and a bedtime routine
D. Provide a large meal before sleep

Correct Answer: C

Rationale: Nursing measures to promote sleep include establishing a routine, providing a quiet environment, assisting with hygiene, and limiting nighttime awakenings.

Question: A nurse is educating a client on factors that interfere with sleep. Which of the following should be included? (Select all that apply)

1. Circadian rhythms

2. Current life events

3. Diet and exercise

4. Medications

5. Consistent bedtime rituals

Correct Answer: 1, 2, 3, 4

Rationale: Factors such as life events, diet, exercise, medications, and circadian rhythms can interfere with sleep. Bedtime rituals (option 5) promote sleep rather than interfere with it.

Question: True or False: Stage 3 NREM sleep is the stage where the person is most easily awakened.

Correct Answer: False

Rationale: Stage 3 NREM is deep sleep, making it difficult to awaken the individual. Stage 1 NREM is the lightest stage where awakening is easiest.

Question: True or False: Insomnia is the most common sleep disorder, characterized by an inability to feel rested.

Correct Answer: True

Rationale: Insomnia is defined as the most common sleep disorder where individuals are unable to get adequate sleep or feel rested.

Question: True or False: Somnambulism, or sleepwalking, is considered a type of parasomnia.

Correct Answer: True

Rationale: Parasomnias include somnambulism, nocturnal enuresis (bed-wetting), sleep talking, and nightmares.

Question: True or False: REM sleep typically lasts for 20 to 40 minutes per cycle.

Correct Answer: True

Rationale: Both Stage 3 NREM and REM sleep phases are documented as lasting approximately 20 to 40 minutes.

Question: True or False: During Stage 2 NREM, metabolism increases to prepare the body for the next day.

Correct Answer: False

Rationale: During Stage 2 NREM, the body's metabolism and vital signs continue to slow down or decrease.

Question: True or False: Nocturnal enuresis refers to the condition of sleep-talking.

Correct Answer: False

Rationale: Nocturnal enuresis is the medical term for bed-wetting, which is a form of parasomnia.

Question: True or False: A lack of sleep can lead to a decrease in protein synthesis and impaired healing.

Correct Answer: True

Rationale: One of the primary functions of sleep is increasing protein synthesis and healing; therefore, sleep deprivation inhibits these processes.

Question: True or False: Muscle relaxation techniques are a nursing measure that can promote sleep.

Correct Answer: True

Rationale: Engaging in muscle relaxation is a recognized nursing intervention to help clients relax and fall asleep.

Question: True or False: Caffeine and heavy exercise within 2 hours of bedtime can promote better Stage 3 sleep.

Correct Answer: False

Rationale: Diet and exercise are factors that interfere with sleep; caffeine is a stimulant and heavy exercise late in the day often disrupts the sleep cycle.

Question: True or False: Breathing cessations in sleep apnea must last longer than 10 seconds to be clinically significant.

Correct Answer: True

Rationale: The criteria for sleep apnea involves cessations longer than 10 seconds which leads to decreased arterial O_2 saturation.

Question: A nurse is caring for a client with narcolepsy. What safety precaution is most important for this client?

A. Ensuring the client has a high-carbohydrate diet
B. Teaching the client about the risks of cataplexy during activity
C. Encouraging the client to exercise before bed
D. Providing a dark environment during the day

Correct Answer: B

Rationale: Narcolepsy involves sudden sleep attacks and cataplexy (muscle weakness). It is vital to address safety because these attacks can occur during daily activities.

Question: A nurse explains to a student that cellular growth and repair occur primarily during which process?

A. REM Sleep
B. Exercise
C. Sleep
D. Digestion

Correct Answer: C

Rationale: Sleep is the interval where cellular growth and repair, as well as protein synthesis, are promoted for the body's maintenance.

Question: In which stage of sleep is a client most likely to experience a vivid, narrative-style dream?

A. NREM Stage 1
B. NREM Stage 2
C. NREM Stage 3
D. REM sleep

Correct Answer: D

Rationale: REM sleep is the phase associated with vivid dreaming and cognitive restoration.

Question: A client complains of a 'crawling' sensation in their legs that prevents sleep. The nurse should document this as which condition?

A. Somnambulism
B. Nocturnal enuresis
C. Restless legs syndrome
D. Sleep apnea

Correct Answer: C

Rationale: Restless legs syndrome is a type of parasomnia characterized by uncomfortable sensations in the legs and an uncontrollable urge to move them.

Question: Which of the following physiological changes occurs during sleep apnea?

A. Increased arterial O2 saturation B. Decreased arterial O2 saturation
C. Stabilized breathing patterns
D. Increased heart rate with regular rhythm

Correct Answer: B

Rationale: During sleep apnea, the cessation of breathing results in decreased arterial O_2 saturation levels.

Question: A nurse is helping a client who has insomnia. Which of the following actions should the nurse perform first?

A. Administer sleeping medication
B. Ask the client about their current life events and stress
C. Dim the lights in the hallway
D. Provide a warm snack

Correct Answer: B

Rationale: Assessment is the first step of the nursing process. Identifying factors like current life events helps determine the cause of the insomnia.

Question: How many stages of NREM sleep are identified in the provided notes?

A. 2
B. 3
C. 4
D. 5

Correct Answer: B

Rationale: The notes specify that sleep consists of REM and three stages of NREM (1, 2, and 3).

Question: A nurse is caring for a client with Stage 3 NREM deficiency. The client is at risk for which of the following?

A. Poor memory storage
B. Lack of psychological restoration
C. Increased awareness of surroundings
D. Decreased dreaming

Correct Answer: B

Rationale: Stage 3 NREM is specifically when psychological rest and restoration occur; therefore, a deficiency impacts these functions.

Question: Which statement by a client indicates an understanding of sleep hygiene?

A. 'I will drink a cup of coffee before bed to help me relax.'
B. 'I will keep my bedroom at a very warm temperature.'
C. 'I will establish a consistent bedtime routine every night.'
D. 'I will watch an action movie in bed to fall asleep faster.'

Correct Answer: C

Rationale: Establishing a consistent bedtime routine is a key nursing measure to promote relaxation and sleep.

Question: What is the duration of Stage 1 NREM sleep?

A. 1-7 minutes
B. 10-25 minutes
C. 20-40 minutes
D. 60 minutes

Correct Answer: A

Rationale: Stage 1 NREM is a short, light stage of sleep lasting only about 1 to 7 minutes.

Question: A nurse is evaluating a client's risk for sleep disturbances. Which factor refers to the body's internal 24-hour clock?

A. Comorbidities
B. Circadian rhythms
C. Rituals
D. Fatigue

Correct Answer: B

Rationale: Circadian rhythms are the internal processes that regulate the sleep-wake cycle and repeat roughly every 24 hours.

Question: A client experiences cataplexy. Which disorder is this associated with?

A. Sleep apnea
B. Narcolepsy
C. Insomnia
D. Parasomnia

Correct Answer: B

Rationale: Cataplexy, a sudden loss of muscle tone, is a classic symptom of narcolepsy.