A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

Caffeine use

Evening meal

Use of electronic devices

Exercise schedule

Bedtime Medications

Answer and Explanation

Correct Answer : A,C

A.   Caffeine is a stimulant and can interfere with sleep, especially if consumed in the afternoon or evening. It can lead to difficulty falling asleep and disrupt the sleep cycle.
B.   While heavy meals close to bedtime can cause discomfort or indigestion, a light evening meal generally does not significantly interfere with sleep for most individuals.
C.   The use of electronic devices, particularly before bedtime, can interfere with sleep due to the blue light emitted by screens. This light can suppress the production of melatonin, a hormone that helps regulate sleep.
D.   Regular exercise generally promotes better sleep. However, vigorous exercise close to bedtime may interfere with sleep due to the increase in adrenaline, but this is not always the case.
E.   The medications taken by the individual do not interfere with sleep.

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Correct Answer is C

Explanation

A. Immobility more commonly leads to orthostatic hypotension rather than increased blood pressure.

B. Immobility typically leads to increased calcium levels due to bone demineralization.

C. A swollen area on the calf may indicate a deep vein thrombosis (DVT), a serious complication of immobility.

D. Urinary stasis and retention, rather than frequency, are common complications of immobility.

A. "My sibling and I hired help at home for my parent. B. I found the title to the car today, signed over to me." C. Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. D. Client says, "Why don't you just leave me? I am of no use." E. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." F. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min G. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 Ib in the past month. H. Heart rate 68/min

Correct Answer is ["B","C","D","G"]

Explanation

System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

Rationale

These findings suggest significant cognitive and physical decline, potential depression, and possible suicidal ideation, all of which require immediate attention and intervention.

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A nurse is caring for a client in an outpatient clinic. Exhibits Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?

Correct Answer is C

Explanation

Correct Answer is ["B","C","D","G"]

Explanation

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A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.