A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

Decreased judgment

Decreased activity

Increased reﬂexes

Increased auditory alertness

Answer and Explanation

The Correct Answer is A

Decreased judgment is a common sign of sleep deprivation. When a person is sleep deprived, their cognitive function can be impaired, leading to difficulty making decisions and exercising good judgment.

Options b, c, and d are not necessarily indicative of sleep deprivation. Decreased activity can be a sign of many diﬀerent conditions, including fatigue or depression. Increased reﬂexes and increased auditory alertness are not commonly associated with sleep deprivation.

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Correct Answer is C

Explanation

The nurse should arrange for a video conference with an interpreter who speaks the client's language to provide discharge instructions. This ensures that the client receives accurate and complete information in a language they understand. The other

a. Assistive personnel may not be trained or qualified to provide medical interpretation.

b. Family members may not have the necessary medical knowledge to accurately translate medical information.

d. Simply indicating printed instructions in the client's language may not be sufficient to ensure the client understands the information.

A. Palpate the abdomen B. Administer an antiemetic. C. Oﬀer pain medication. D. Auscultate bowel sounds.

Correct Answer is D

Explanation

A. Palpate the abdomen: Palpating the abdomen before auscultating bowel sounds could potentially alter the findings by stimulating peristalsis or causing discomfort in the client, particularly in cases of appendicitis or other acute abdominal conditions.

B. Administer an antiemetic:A thorough assessment, including auscultation of bowel sounds, is needed first to rule out conditions like a bowel obstruction or paralytic ileus where antiemetics may be contraindicated.

C. Offer pain medication:Pain medication can mask symptoms and interfere with the nurse's or physician's ability to accurately assess the underlying cause of the client's symptoms, such as appendicitis.

D. Auscultate bowel sounds:Auscultating bowel sounds is the first action the nurse should take because it is a non-invasive assessment that can provide critical information. It helps determine if bowel sounds are present, hyperactive, hypoactive, or absent, which can guide further interventions and diagnostic steps.

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A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hours. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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