The nurse is assessing a client's sleep patterns. Which statement made by the client would require additional questioning by the nurse? "My partner tells me that:
I snore so loudly that I wake her up several times a night."
neither of us sleeps well after we have a big fight."
I sleep so soundly it's like waking the dead to get me up."
she's heard me tell jokes in my sleep."
The Correct Answer is A
A. This statement suggests that the client may have sleep-disordered breathing, such as obstructive sleep apnea, which can disrupt the client's sleep patterns and affect their overall sleep quality. The nurse may want to inquire further about the frequency and severity of the snoring, as well as any associated symptoms such as daytime fatigue or observed pauses in breathing during sleep.
B. This statement indicates that emotional stressors, such as arguments or conflicts, may impact the client's sleep patterns. The nurse may want to explore how often these conflicts occur and how they affect the client's ability to fall asleep or stay asleep. Additionally, the nurse may inquire about coping strategies or interventions that the client and their partner use to address conflicts and minimize their impact on sleep.
C. This statement suggests that the client experiences deep or heavy sleep, which may or may not be problematic depending on the context. While deep sleep can be indicative of good sleep quality, it may also raise concerns about the client's ability to awaken in the event of an emergency or the presence of a sleep disorder such as hypersomnia. The nurse may want to inquire further about the client's overall sleep duration, sleep latency, and any difficulties with waking up in the morning.
D. This statement suggests that the client may experience sleep talking, which is a common sleep phenomenon. While sleep talking itself is typically benign, it may indicate underlying sleep disturbances such as sleep fragmentation or abnormal sleep cycles. The nurse may want to ask additional questions to assess the frequency and content of the sleep talking, as well as any potential impacts on the client's sleep quality or daytime functioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Isotonic solutions have a similar osmolarity to that of blood plasma, meaning they exert the same osmotic pressure as blood. This equilibrium prevents the movement of water across cell membranes, thereby maintaining cell volume and preventing cellular dehydration or swelling. Examples of isotonic solutions commonly used for intravenous fluid replacement include 0.9% saline (normal saline) and lactated Ringer's solution.
B. Hypotonic solutions have a lower osmolarity than blood plasma, meaning they exert less osmotic pressure than blood. When administered, hypotonic solutions cause water to move into cells, leading to cellular swelling. While hypotonic solutions can help hydrate cells and replenish intracellular fluid, they are not typically used for rapid volume replacement because they can exacerbate extracellular fluid deficits and cause complications such as cerebral edema or cardiovascular collapse.
C. Hypertonic solutions have a higher osmolarity than blood plasma, meaning they exert greater osmotic pressure than blood. When administered, hypertonic solutions cause water to move out of cells, leading to cellular shrinkage. Hypertonic solutions are often used to expand intravascular volume in cases of severe hypovolemia or shock, as they rapidly increase blood osmolarity and draw fluid from the interstitial space into the bloodstream. Examples of hypertonic solutions include 3% saline and 5% dextrose in 0.9% saline.
D. Hyperosmotic solutions have an elevated osmolarity compared to blood plasma, indicating a higher concentration of solutes. These solutions exert osmotic pressure that draws water out of cells, leading to cellular dehydration. While hyperosmotic solutions are not commonly used for rapid volume replacement due to their pot
Correct Answer is A
Explanation
A. Confidentiality refers to the ethical duty of healthcare providers to safeguard patient information and maintain privacy. Upholding confidentiality means that healthcare providers must not disclose sensitive information about a patient to unauthorized individuals without the patient's consent. In this scenario, if the client asks the nurse not to disclose their medical diagnosis to their family members, respecting this request would uphold the principle of confidentiality by protecting the privacy of the patient's health information.
B. Justice in healthcare refers to the fair and equitable distribution of resources and the provision of healthcare services. While justice is an important ethical principle, it is not directly applicable to the client's request regarding the disclosure of their medical diagnosis to their family members.
C. Veracity, also known as truthfulness, is the ethical principle of honesty and truthfulness in communication with patients. Upholding veracity means providing patients with accurate and truthful information about their health condition and treatment options. In this scenario, if the nurse complies with the client's request not to disclose their medical diagnosis to their family members, it may involve withholding information and not fully disclosing the truth to the family members. Therefore, upholding the client's request may conflict with the principle of veracity.
D. A healthcare proxy is a legal document that allows an individual (the proxy) to make healthcare decisions on behalf of another person (the principal) if the principal is unable to make decisions for themselves. The existence of a healthcare proxy does not directly relate to the client's request regarding the disclosure of their medical diagnosis to their family members.
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