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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Discuss the client's condition with a nurse on another unit: Sharing a client’s condition with a nurse on another unit without a need-to-know basis violates confidentiality rules. Discussions about client conditions should be limited to personnel involved in care.
B. Fax client information with a cover sheet: A fax cover sheet protects the confidentiality of client information by identifying the contents and indicating that it is confidential. This ensures that the information is not exposed to unauthorized individuals during transmission.
C. List the client's name and condition on board at the nurses station: Displaying client information in public or semi-public areas, violates confidentiality. Client information should be kept private and only accessed by those who are involved in the client’s care.
D. Post client diagnosis on message board in their room: Posting the client’s diagnosis in their room is a violation of confidentiality, as other individuals (like visitors or hospital staff) may have access to that information without a need to know.
Correct Answer is B
Explanation
A. Call the provider to discuss the client's preference with them and their family: While involving the provider and family is important, the first step should be to educate the client about their options for designating a decision-maker.
B. Explain to the client the process of designating another individual to make decisions for them: The nurse should first provide information about how the client can designate a trusted individual to make decisions for them, such as through a durable power of attorney for healthcare. This allows the client to make an informed decision.
C. Ask the client to discuss these preferences with their family first: The nurse should first empower the client by explaining the process of designating a decision-maker. It is crucial to respect the client’s autonomy in making this decision before involving family.
D. Ask the client if they would like their wishes documented in their health care records: Before documenting, the nurse should ensure the client understands the process of assigning a decision-maker. Documentation is important, but the client needs to understand their options first.
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