A nurse is assessing a client who thinks they have sleep apnea. Which of the following questions should the nurse ask?
"Do you snore loudly?"
"What time do you go to bed?"
"How often do you have trouble sleeping?"
"Do you fall asleep unexpectedly?"
The Correct Answer is A
A. "Do you snore loudly?": Loud snoring is a common symptom of sleep apnea, particularly obstructive sleep apnea. The nurse should inquire about snoring, as it may indicate airway obstruction during sleep, a key feature of the condition.
B. "What time do you go to bed?": While bedtime habits are relevant to sleep hygiene, the specific timing of going to bed is not as directly related to diagnosing sleep apnea. Other questions, such as snoring or breathing patterns, are more relevant for this assessment.
C. "How often do you have trouble sleeping?": Trouble sleeping can be a symptom of various sleep disorders, but it is not specific to sleep apnea. The nurse should focus on symptoms like snoring, choking, or stopping breathing during sleep, which are more indicative of sleep apnea.
D. "Do you fall asleep unexpectedly?": Falling asleep unexpectedly may suggest excessive daytime sleepiness, which can be a result of sleep apnea. However, snoring is a more direct and common symptom of sleep apnea that should be prioritized in the initial assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","G"]
Explanation
A. Reposition the client every 3 hr: Repositioning the client every 3 hours is crucial to prevent pressure ulcers, especially since the client has decreased mobility. Frequent repositioning helps reduce the risk of skin breakdown and maintains circulation.
B. Place the client on a donut-shaped cushion: A donut-shaped cushion is not recommended for preventing pressure ulcers. It can increase pressure on the tissue, leading to further complications. A more effective intervention is use of pressure-redistribution surfaces.
C. Elevate the head of the bed to 45°: Elevating the head of the bed can increase pressure on the sacral area and can be uncomfortable for clients with mobility and incontinence issues. The head of the bed should be elevated only when necessary for breathing or comfort, not as a routine practice.
D. Request a consult with a registered dietitian: The client has decreased intake and may be at risk for malnutrition or dehydration. A dietitian’s input is essential to assess nutritional needs, especially for a client with diabetes and decreased mobility, to ensure proper healing and management.
E. Provide a support pressure-redistribution surface: A support pressure-redistribution surface is crucial for this client to reduce the risk of pressure ulcers. These surfaces help alleviate pressure on bony prominences and distribute the body weight evenly to prevent tissue damage.
F. Perform a skin risk assessment weekly: Skin risk assessments should be done more frequently than weekly, especially for a client with decreased mobility, incontinence, and diabetes. Daily or at least twice-weekly assessments are needed to monitor for early signs of skin breakdown.
G. Use a moisture barrier ointment after cleaning the client's skin: Using a moisture barrier ointment is essential for protecting the skin, especially since the client has urinary and fecal incontinence. This will help prevent skin irritation and breakdown caused by exposure to moisture.
Correct Answer is A
Explanation
A. Offer a wet washcloth for the client to wash their face: Washing the face with a wet washcloth can promote relaxation and help signal to the body that it’s time to wind down. This calming routine can be soothing and may help improve the client’s ability to fall asleep.
B. Perform range-of-motion exercises: Doing range of motion exercises shortly before bedtime can be overstimulating. Physical activity close to bedtime may increase alertness and make it harder for the client to fall asleep.
C. Prepare hot cocoa or tea for the client: While warm drinks might seem comforting, caffeine in some teas or high sugar in hot cocoa can interfere with sleep. It’s important to avoid stimulants and opt for calming beverages, such as caffeine-free herbal teas, instead.
D. Provide a late supper: A large meal late at night can be disruptive to sleep as it may cause indigestion or discomfort. It’s better to encourage lighter, earlier meals to prevent any disturbances that could affect the client’s ability to fall asleep.
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