A nurse is assessing the status of a patient who is sleeping.
Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?
Decreased respirations, rapid heart rate.
Rapid respirations, rapid heart rate.
Rapid respirations, slow heart rate.
Decreased respirations, slow heart rate.
The Correct Answer is B
Choice A rationale:
Decreased respirations and a rapid heart rate are not indicative of stage 3 of non-rapid eye movement (NREM) sleep. In stage 3, respirations are typically slow and regular, and the heart rate is slower than during wakefulness.
Choice B rationale:
Rapid respirations and a rapid heart rate are indicative of stage 3 of NREM sleep. During this stage, respiration and heart rate are more irregular compared to the earlier stages of sleep. This stage is characterized by increased physiological arousal compared to stages 1 and 2.
Choice C rationale:
Rapid respirations and a slow heart rate do not represent stage 3 of NREM sleep. In this stage, respiration tends to be rapid, and the heart rate, while slower than during wakefulness, is not slow.
Choice D rationale:
Decreased respirations and a slow heart rate are not consistent with stage 3 of NREM sleep. This stage is associated with more active and variable physiological processes, including rapid respirations and a relatively higher heart rate compared to later sleep stages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Taking a warm bath before trying to go back to sleep is a relaxation technique that may help with sleep but does not address the underlying causes of insomnia. It is more of a short-term coping strategy rather than a method for locating the reasons for the insomnia.
Choice B rationale:
Reviewing times in her life when she had no insomnia is not a practical approach to addressing the current issue of insomnia. It does not help in identifying the specific factors or triggers contributing to the patient's current sleep problems.
Choice C rationale:
Keeping a diary related to sleep and problems encountered is a practical and effective approach to identify the factors contributing to the patient's insomnia. This diary can help track patterns, such as bedtime routines, diet, stressors, and other variables that may be linked to the sleep problem. Identifying these factors can aid in developing a plan to address the specific causes of the insomnia.
Choice D rationale:
Discussing the problem with her friends may provide emotional support but is unlikely to help identify the root causes of the insomnia. Friends may offer advice or share their experiences, but a structured approach like keeping a sleep diary is more likely to yield valuable information.
Correct Answer is C
Explanation
Choice A rationale:
An elevated blood pressure is not a reliable indicator of a decrease in pain following the administration of an opioid narcotic. Blood pressure can be influenced by various factors, and it may not directly correlate with the relief of pain.
Choice B rationale:
The client being asleep is not a direct indicator of decreased pain following opioid administration. While opioids may cause drowsiness as a side effect, the absence of pain cannot be confirmed solely based on the patient's sleep state.
Choice C rationale:
An increased respiratory rate can be a reliable indicator of decreased pain following the administration of an opioid narcotic. Opioids often cause respiratory depression, so an increased respiratory rate may suggest that the patient's pain is adequately managed, as they are not experiencing excessive respiratory depression.
Choice D rationale:
Diaphoresis (excessive sweating) is not a direct indicator of decreased pain following opioid administration. Diaphoresis can be caused by various factors, including anxiety, and may not specifically reflect pain relief. .
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