A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care?

Cluster nursing activities so that the patient has uninterrupted rest periods.

Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.

Administer sedatives or opioids at bedtime to promote sleep.

Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep

Answer and Explanation

The Correct Answer is A

A. Clustering nursing activities helps to minimize interruptions, allowing the patient to have longer periods of uninterrupted rest, which is essential for recovery and reducing sensory disturbances from sleep deprivation.

B. Silencing alarms could compromise patient safety and is not recommended.

C. Administering sedatives or opioids should be done cautiously and is not a first-line approach for promoting sleep, especially if non-pharmacological methods can be effective.

D. While reducing nighttime assessments may help with sleep, it is not always feasible and should be balanced with the need for monitoring the patient’s condition.

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Correct Answer is B

Explanation

A. While lowering BP to 120/80 may be an ultimate goal, it is not the initial target in a hypertensive emergency.

B. Rapid reduction in blood pressure can cause hypoperfusion of vital organs such as the brain, heart, and kidneys, leading to ischemic injury. The aim is to reduce the BP gradually to prevent these complications.

C. IV antihypertensive medications generally have a rapid onset, not a slow one.

D. While gradual reduction is important, it is not done to allow rest but to protect organ perfusion.

A. Spironolactone B. Furosemide C. Metoprolol D. Nitroglycerin

Correct Answer is B

Explanation

A. Spironolactone is a potassium-sparing diuretic, so it would not cause hypokalemia.

B. Furosemide is a loop diuretic that causes the kidneys to excrete potassium, leading to hypokalemia.

C. Metoprolol is a beta-blocker and does not directly affect potassium levels.

D. Nitroglycerin is a vasodilator and does not affect potassium levels.

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A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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