The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?

History of seasonal allergies and nasal congestion.

Amount and type of caffeinated drinks before bedtime.

Urinary frequency and episodes of nocturia.

Usual bed time and time of awakenings.

Answer and Explanation

The Correct Answer is D

A.   A history of seasonal allergies and nasal congestion can affect sleep quality due to discomfort or breathing difficulties. While this information is relevant for identifying possible physical factors that might influence sleep, it is not the first piece of data to obtain when trying to understand the overall sleep pattern.
B.   The consumption of caffeinated drinks before bedtime can significantly impact sleep quality. Caffeine is a stimulant that can disrupt sleep patterns and contribute to difficulty falling asleep. This assessment is important, but it should follow an initial understanding of the client’s overall sleep schedule and habits to determine how much caffeine might be affecting their sleep.
C.   Urinary frequency and nocturia (waking up frequently to urinate during the night) can interfere with sleep and contribute to disturbances. This information is valuable for identifying potential causes of disrupted sleep but is typically assessed after understanding the client’s basic sleep patterns and schedule.
D.   Understanding the client’s usual bedtime and time of awakenings provides essential information about their sleep schedule and overall sleep patterns. This data is crucial as it establishes a baseline for assessing the client’s sleep routine and helps identify any deviations or irregularities in their sleep behavior.

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Correct Answer is C

Explanation

A. Significant weight loss can be a concern for overall health and may be related to various conditions, including nutritional deficiencies. However, weight loss alone does not specifically indicate the need for bone density screening. It may be a factor in a broader health assessment but is not a direct indicator for bone density measurement.
B. A diminished appetite can affect nutritional intake, which in turn may impact bone health over time. However, diminished appetite itself does not directly suggest a need for a bone density screening unless it leads to significant weight loss or is part of a broader concern about nutritional status affecting bone health.
C. Decreased height is a key indicator that may suggest osteoporosis or significant bone loss. This can be due to vertebral compression fractures, which are common in individuals with osteoporosis. A reduction in height over time can be a direct sign that warrants a bone density screening to assess bone health and risk for fractures.
D. A lower BMI can be associated with lower bone mass and increased risk for osteoporosis, particularly in individuals who are underweight. However, while a low BMI can be a risk factor for osteoporosis, it is not as specific as decreased height for prompting a bone density screening.

A. Notify the healthcare provider. B. Observe for eye opening to a painful stimulus. C. Check the pupillary response to light. D. Ask the client to open his eyes.

Correct Answer is B

Explanation

A. While notifying the healthcare provider is important if there are significant changes in the client's level of consciousness, it should not be the immediate next step. Before alerting the provider, the nurse needs to perform additional assessments to determine the extent of the client's unresponsiveness and gather more information about their neurological status.
B. Observing for eye opening in response to a painful stimulus is a critical step in assessing the depth of unconsciousness. This response helps determine the client's level of consciousness and can provide information about the severity of their condition.
C. Checking the pupillary response to light is important in evaluating neurological function and can provide information about brainstem activity and potential neurological deficits. However, it is secondary to checking for responses to stimuli like painful stimuli if the client is not opening their eyes spontaneously. Pupillary response should be assessed as part of a comprehensive neurological exam.
D. Asking the client to open his eyes might not be effective if the client is unresponsive or has impaired consciousness. If the client is not responding spontaneously, it is likely that verbal commands will also be ineffective. This step is less useful when assessing levels of consciousness compared to more objective assessments like responses to painful stimuli.

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The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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