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."

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. It is important to recognize and respect the client's natural sleep patterns, especially considering their age and current health status. Napping during the day can be a normal and beneficial behavior for older adults, helping to replenish energy levels and promote overall well-being. As long as the client's napping does not interfere with their ability to sleep at night or their daily activities, no intervention may be necessary.
A. Encouraging the client to stay awake during the day may not be appropriate, especially considering the client's age and natural sleep patterns. Older adults often experience changes in their sleep-wake cycle, including more frequent napping during the day.
B. Physical activity is important for maintaining mobility and overall health but substituting physical therapy for one of the client's usual nap times may not be feasible or beneficial. The client's need for rest and sleep should be respected, especially if they are experiencing fatigue or illness.
C. Prescribing a sleeping pill for the client may not be appropriate, especially if they are already napping during the day. Sleep medications can have side effects, including drowsiness, confusion, and increased risk of falls, particularly in older adults.

A. Elevate the extremity on a pillow B. Immediately remove the catheter C. Keep the catheter in place D. Place a cool compress on the area

Correct Answer is B

Explanation

B. When a client experiences symptoms of extravasation, such as pain, burning, and swelling, especially with a vesicant medication, the priority is to stop the infusion and remove the catheter immediately to prevent further tissue damage. Removing the catheter promptly helps minimize the amount of medication that may have leaked into the surrounding tissues.
A. Elevating the extremity on a pillow may help reduce swelling and discomfort in some cases, but it is not the first action the nurse should take when a vesicant medication has caused pain, burning, and swelling at the IV site.
C. Keeping the catheter in place is not advisable when extravasation has occurred, especially with a vesicant medication. Continuing the infusion could lead to further tissue damage and exacerbate the client's symptoms. Removing the catheter is necessary to prevent additional medication from entering the surrounding tissues.
D. While applying a cool compress may provide temporary relief from discomfort, it is not the first action the nurse should take when managing extravasation caused by a vesicant medication. The priority is to stop the infusion, remove the catheter, and assess the extent of tissue damage. Cool compresses may be used after the catheter removal to help reduce swelling and discomfort.

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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:

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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