The nurse assesses a patient's sleep for NREM (non-rapid eye movement) sleep because this sleep has the characteristics of:.
offering the most rest.
irregular respirations.
increased heart rate.
daytime activity.
The Correct Answer is A
Choice A rationale:
NREM (Non-Rapid Eye Movement) sleep is characterized by slow-wave sleep and is often considered restorative. It is the stage of sleep where the body repairs and regenerates tissues, and it is essential for feeling rested and rejuvenated. NREM sleep consists of three stages, with stages 3 and 4 being the deepest and most restful, also known as slow-wave sleep. These stages are essential for physical recovery.
Choice B rationale:
NREM sleep is not characterized by irregular respirations. Irregular breathing patterns are more commonly associated with certain sleep disorders, such as sleep apnea, rather than NREM sleep itself.
Choice C rationale:
NREM sleep is not characterized by increased heart rate. In fact, during NREM sleep, the body typically experiences a decrease in heart rate and blood pressure. The body's physiological functions tend to slow down during NREM sleep to promote rest and recovery.
Choice D rationale:
NREM sleep is not characterized by daytime activity. In contrast, NREM sleep occurs during the night and is a state of deep rest, during which the body is not engaged in daytime activities. It is essential for physical and mental recovery, especially after a day of activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Constipation is not a common adverse effect of pain medication administered by the epidural route. Pain medication primarily affects the central nervous system and does not typically impact the gastrointestinal system in a way that would lead to constipation.
Choice B rationale:
Hypoventilation is the correct answer. When opioids or other potent pain medications are administered by the epidural route, they can depress the respiratory center in the brain, leading to hypoventilation (slow or inadequate breathing). This is a critical concern and the most important adverse effect to monitor because it can lead to respiratory compromise or even respiratory arrest.
Choice C rationale:
Nausea can be a side effect of some pain medications, but it is not the most important adverse effect to monitor in a patient receiving epidural pain medication. Nausea can often be managed with antiemetic medications.
Choice D rationale:
Headache is not a common adverse effect of epidural pain medication. The administration of pain medication into the epidural space is localized to the spinal area and does not typically lead to headaches.
Correct Answer is A
Explanation
Choice A rationale:
If a patient with a Fentanyl patch is experiencing symptoms like abnormal sleepiness, slurred speech, and unsteadiness when ambulating, it could indicate an overdose or adverse reaction to the Fentanyl. In such cases, the patch should be removed immediately to stop the further absorption of the drug. Wiping off the skin can also help remove any residual medication. This is the correct choice as it addresses the issue at its source.
Choice B rationale:
Applying ice to the skin around the Fentanyl patch is not the appropriate action in this situation. Ice will not counteract the effects of a Fentanyl overdose or adverse reaction. The priority is to remove the patch and seek medical attention.
Choice C rationale:
Elevating the head of the bed and offering coffee or cola may be useful in combating some forms of sleepiness but would not be effective for someone experiencing an overdose or adverse reaction to Fentanyl. This choice does not address the problem's root cause and is not the appropriate action to take.
Choice D rationale:
Putting up the side rails on the bed does not address the issue of Fentanyl patch overdose or adverse reactions. This choice is not relevant to the situation and should not be chosen.
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