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","C","E"]
Explanation
A. This action could pose a significant liability risk as it violates the standard of care, which includes providing thorough and accurate handoff communication to ensure continuity of care. Failing to provide a report before transferring a client to ICU could lead to miscommunication, errors in treatment, and compromised patient safety.
C. Documenting vital signs taken by another nurse is generally acceptable as long as the nurse ensures the accuracy of the information and documents according to institutional policies and standards. However, if the nurse knowingly documents false or inaccurate vital signs, it could pose a liability risk.
E. Using equipment with a frayed cord poses a significant liability risk as it could lead to electrical hazards, equipment malfunction, or patient injury. Nurses have a duty to ensure the safety and integrity of equipment used in patient care and should promptly report any defects or safety concerns to prevent harm to patients.
B. Completing the admission assessment is a standard nursing responsibility and is not inherently a liability risk. However, liability could arise if the assessment is incomplete, inaccurate, or not documented appropriately, leading to errors in care or failure to identify and address the client's needs
D. Calling the physician to request an order for pain medication is a routine nursing responsibility and is not inherently a liability risk. However, liability could arise if the nurse fails to communicate important information about the client's condition or medication history, resulting in inappropriate or unsafe prescribing practices.
Correct Answer is A
Explanation
A. Gradual tapering of benzodiazepines under medical supervision is recommended to minimize withdrawal symptoms and rebound insomnia. The client should continue taking the medication as prescribed while discussing a tapering plan with their physician.
B. Abruptly stopping benzodiazepines can lead to withdrawal symptoms, including rebound insomnia, anxiety, agitation, and even seizures. Planning to stop medication on a specific day without medical guidance can increase the risk of withdrawal symptoms occurring during the workweek.
C. While it may be challenging to sleep without benzodiazepines initially, continued use can lead to dependence and tolerance, making it even more challenging to discontinue them in the future. Gradual tapering under medical supervision is the preferred approach.
D. Antihistamines are not typically used as substitutes for benzodiazepines in managing insomnia. Additionally, abruptly stopping benzodiazepines and switching to another medication without medical guidance can lead to withdrawal symptoms and inadequate management of insomnia.
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