A nurse is assessing a client's sleep-wake patterns during an initial clinic visit. Which of the following findings should the nurse report to the provider?

The client reports frequently having a headache in the morning.

The client reports having vivid dreams about their childhood.

The client reports taking 30 min to fall asleep on average.

The client reports sleeping about 7 hr on average.

Answer and Explanation

The Correct Answer is A

A. The client reports frequently having a headache in the morning: Frequent morning headaches can indicate sleep-related issues such as sleep apnea or bruxism (teeth grinding), both of which can significantly affect sleep quality and overall health.

B. The client reports having vivid dreams about their childhood: Vivid dreams can occur naturally, especially during rapid eye movement (REM) sleep. Although they may be unusual, they are not typically a cause for concern.

C. The client reports taking 30 min to fall asleep on average: Taking up to 30 minutes to fall asleep is within normal limits for most people. This is not a concerning finding and does not necessarily require reporting unless the client is experiencing other sleep disturbances.

D. The client reports sleeping about 7 hr on average: Sleeping around 7 hours per night is considered within the normal range for most adults. This is generally adequate sleep, and there is no indication of a significant issue that would require reporting to the provider.

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Correct Answer is C

Explanation

A. The nurse's role is to provide the client with initial information about the procedure prior to obtaining informed consent: The nurse can provide information, but the responsibility for providing initial information and obtaining informed consent lies with the provider.

B. Clients are unable to change their mind once a consent form is signed: Clients have the right to revoke their consent at any time before the procedure, even after signing the consent form. Consent is an ongoing process, and clients can change their decision at any point.

C. The provider performing the procedure is responsible for obtaining informed consent: It is the provider's responsibility to ensure the client understands the procedure, risks, and benefits, and to obtain informed consent.

D. The provider obtains verbal consent for the procedure without witnessing the client's signature: Written consent is required for procedures, and verbal consent is only valid in specific situations, such as emergencies.

A. Infection B. Infiltration C. Air embolism D. Phlebitis

Correct Answer is B

Explanation

A. Infection: Infection typically presents with redness, warmth, and purulent drainage at the IV site, not taut and edematous skin. Infiltration, however, can cause swelling and taut skin as the fluid is infused into the surrounding tissue rather than the vein.

B. Infiltration: Infiltration occurs when the IV fluid or medication leaks into the surrounding tissue. This results in swelling, taut, edematous skin, and sometimes discomfort. It is a common complication when the IV catheter is dislodged or not properly placed.

C. Air embolism: An air embolism is a rare but serious complication where air enters the bloodstream. Symptoms include chest pain, shortness of breath, and hypotension, but it does not cause the taut, edematous skin seen with infiltration.

D. Phlebitis: Phlebitis involves inflammation of the vein and is typically characterized by redness, warmth, pain, and swelling along the vein, not taut skin around the IV site. It can be caused by irritation from the IV catheter or the fluid being infused not a leak into tissues.

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A nurse is assessing a client's sleep-wake patterns during an initial clinic visit. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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