A nurse is reinforcing teaching with a client about healthful sleep habits.
Which of the following statements should the nurse identify as an indication that the client needs further instructions?

“I watch television until I fall asleep at night.”

“I have a small snack and take a bath before going to bed each day.”

“I don’t take naps throughout the day.”

“I go to bed and get up at the same times each day.”.

Answer and Explanation

The Correct Answer is A

Watching television until falling asleep at night is a poor sleep habit because it can interfere with the body’s natural sleep-wake cycle and make it harder to fall asleep and stay asleep. Television can also expose the eyes to bright light and stimulating or stressful content, which can affect the production of melatonin, a hormone that regulates sleep.

Choice B is wrong because having a small snack and taking a bath before going to bed each day are good sleep habits that can promote relaxation and sleep quality.

Choice C is wrong because not taking naps throughout the day is a good sleep habit that can help maintain a consistent sleep schedule and avoid disrupting the night-time sleep.

Choice D is wrong because going to bed and getting up at the same times each day is a good sleep habit that can reinforce the body’s circadian rhythm and make it easier to fall asleep and wake up.

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Correct Answer is C

Explanation

This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.

Choice A. Ineffective tissue perfusion is wrong because anemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.

Choice B. Activity intolerance is wrong because anemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.

Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.

Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women; normal ranges for hematocrit are 38.8 to 50% for men and 34.9 to 44.5% for women; normal ranges for red blood cell count are 4.7 to 6.1 million/mm3 for men and 4.2 to 5.4 million/mm3 for women; normal ranges for reticulocyte count are 0.5 to 1.5% of red blood cells.

A. The runner may lose consciousness due to heat stroke. B. It is not necessary to call 911. C. It is normal to vomit and not sweat during a marathon. D. Getting the patient to a cooler, air-conditioned place will reverse the heat exhaustion.

Correct Answer is A

Explanation

Heat stroke is a serious condition caused by overheating of the body, usually as a result of prolonged exposure to or physical exertion in high temperatures. It can damage the brain and other internal organs, and can be fatal if not treated promptly.

Some of the symptoms of heat stroke are:

• High body temperature of 104 F (40 C) or higher

• Altered mental state or behavior, such as confusion, agitation, slurred speech, seizures or coma

• Lack of sweating despite the heat

• Red, hot and dry skin

• Rapid and strong pulse

• Throbbing headach

• Nausea and vomiting

Choice B is wrong because it is necessary to call 911 if someone has heat stroke. Heat stroke is a medical emergency that requires immediate attention and cooling of the body.

Choice C is wrong because it is not normal to vomit and not sweat during a marathon. Vomiting and lack of sweating are signs of dehydration and heat stroke, which indicate that the body is unable to regulate its temperature properly.

Choice D is wrong because getting the patient to a cooler, air-conditioned place will not reverse the heat exhaustion.

Heat exhaustion is a milder form of heat-related illness that can lead to heat stroke if not treated. Heat exhaustion symptoms include heavy sweating, weakness, dizziness, nausea and muscle cramps. Getting the patient to a cooler place may help with heat exhaustion, but heat stroke requires more aggressive cooling measures such as immersing the patient in cold water or applying ice packs to the body.

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A nurse is reinforcing teaching with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instructions?

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Naxlex Comprehensive Predictor Exams

Which of the following nursing diagnoses would typically NOT be associated with anemia?

Correct Answer is C

Explanation

A nurse is cheering on participants in a marathon and one runner collapses nearby. He begins to vomit and complain of a throbbing headache. The nurse notes that he is not sweating, yet his skin is red and very hot to touch, and his pulse is 170 bpm and strong. The nurse knows that:

Correct Answer is A

Explanation

A person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:

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A nurse is reinforcing teaching with a client about healthful sleep habits.
Which of the following statements should the nurse identify as an indication that the client needs further instructions?