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. Vomiting results in loss of hydrochloric acid (HCl) from the stomach, leading to a loss of chloride ions (Cl-) and hydrogen ions (H+) from the body. This loss of hydrogen ions can result in an accumulation of bicarbonate ions (HCO3-) relative to hydrogen ions, leading to metabolic alkalosis. Therefore, this client is at risk for developing metabolic alkalosis due to prolonged vomiting.
B. Client who has had diarrhea for the past 24 hours: Diarrhea leads to loss of bicarbonate ions (HCO3-) from the body along with fluid and electrolytes. However, metabolic alkalosis is less likely to occur with diarrhea alone because the loss of bicarbonate ions is usually balanced by the loss of chloride ions (Cl-) and hydrogen ions (H+). Therefore, while diarrhea can lead to metabolic acidosis in some cases, it is less likely to cause metabolic alkalosis.
C. Client who has overdosed on heroin: Heroin overdose is not directly associated with metabolic alkalosis. In the context of heroin overdose, respiratory depression leading to respiratory acidosis is a more immediate concern. Therefore, this client is not at risk for developing metabolic alkalosis due to heroin overdose.
D. Client who is admitted with an asthma exacerbation: Asthma exacerbation can lead to respiratory alkalosis due to hyperventilation and excessive elimination of carbon dioxide (CO2) from the body. However, metabolic alkalosis is not a typical consequence of asthma exacerbation alone. Therefore, while this client may experience respiratory alkalosis, they are not at risk for developing metabolic alkalosis solely due to asthma exacerbation.
Correct Answer is D
Explanation
D. The sigmoid colon is the last part of the large intestine before the rectum. It functions to store fecal material and absorb water and electrolytes. Fecal material passing through the sigmoid colon tends to become more solid as water is absorbed, resulting in a more formed stool compared to other parts of the colon.
A. The transverse colon is located in the upper abdomen and is responsible for further absorption of water and electrolytes from the stool. Fecal material passing through the transverse colon tends to become more solid as water is absorbed, but it may not be as solid as stool from the descending colon or sigmoid colon.
B. The ascending colon is where stool is in a more liquid form as it moves up from the cecum. It undergoes further absorption of water and electrolytes as it travels through the colon, but it typically does not produce solid fecal output.
C. The ileum is the final portion of the small intestine and connects to the large intestine (colon). Stool passing through the ileum is still in a relatively liquid state as it contains undigested food particles, bile salts, and digestive enzymes. The primary function of the ileum is absorption of nutrients rather than water reabsorption, so fecal output from an ileostomy is usually more liquid.
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