The nurse is assessing the vital signs of a sleeping patient at 0400 a.m. and notes the patient is experiencing stage IV non-rapid eye movement (NREM) sleep. The nurse should expect which of the following findings?

Small muscle twitching.

An increase in temperature.

Difficult to arouse.

An increase in pulse rate.

Answer and Explanation

The Correct Answer is C

A. Small muscle twitching. Small muscle twitching is more common during REM sleep, not Stage IV NREM sleep.

B. An increase in temperature. Stage IV NREM sleep is associated with stable body temperature rather than an increase.

C. Difficult to arouse. Stage IV NREM sleep is known as deep sleep, and individuals are indeed difficult to arouse during this stage.

D. An increase in pulse rate. Stage IV NREM sleep typically features a stable or decreased pulse rate, not an increase.

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Correct Answer is D

Explanation

A. The client with breast cancer who had a mastectomy. This client is facing a significant life change and physical alteration that may lead to psychosocial stressors such as body image issues and emotional distress.

B. The client with chronic obstructive pulmonary disease who requires oxygen therapy. Although this condition is challenging, the primary stressors are often physical and related to the management of the disease rather than psychosocial stressors.

C. The client with colon cancer who has a colostomy. A colostomy can affect body image and self-esteem, potentially leading to psychosocial stressors such as anxiety or social isolation.

D. The client with a left upper arm fracture who was a victim of a crime. The fracture and the trauma of being a crime victim are significant psychosocial stressors. The emotional and psychological impact of the crime can affect the client’s overall mental health.

A. Decrease in muscle mass and strength B. Lower back and neck pain C. Wrinkling and sagging skin D. Joint stiffness in fingers

Correct Answer is D

Explanation

A. Decrease in muscle mass and strength: A decrease in muscle mass and strength is common with aging, known as sarcopenia. While it should be monitored, it is not necessarily an abnormal finding requiring further investigation unless it is severe or sudden.

B. Lower back and neck pain: Lower back and neck pain can be common with aging due to degenerative changes in the spine or other musculoskeletal issues. However, persistent or severe pain should be evaluated to rule out other causes.

C. Wrinkling and sagging skin: Wrinkling and sagging skin are normal aging changes related to decreased collagen and elastin in the skin. These changes are generally expected with aging.

D. Joint stiffness in fingers: Joint stiffness can be related to aging but may also indicate conditions like arthritis. If the stiffness is significant, persistent, or accompanied by other symptoms, it requires further investigation.

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The nurse is assessing the vital signs of a sleeping patient at 0400 a.m. and notes the patient is experiencing stage IV non-rapid eye movement (NREM) sleep. The nurse should expect which of the following findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a group of clients for psychosocial stressors. Which of the following client's should the nurse identify as having this type of stressor?

Correct Answer is D

Explanation

The nurse is assessing an older adult patient during a regular office visit. The patient reports several symptoms. Which of the following symptoms are not related to the aging process and require further investigation?

Correct Answer is D

Explanation

The nurse is reviewing sleep habits with a patient who reports difficulty sleeping. When evaluating sleep disturbances, the nurse should ask which of the following? Select all that apply.

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