The nurse is caring for a 96-year-old client who has been admitted for treatment of a urinary tract infection. The nurse notices that the client takes two one-hour naps each day, one mid-morning and the other late afternoon. What intervention should the nurse implement?
Encourage the client to try ways to stay awake during the day.
Substitute physical therapy for one of the client's usual nap times.
Ask the physician to order a sleeping pill for the client to take at night.
Do nothing, as no action is necessary in this situation.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. pH 7.29: A respiratory rate of 6 breaths per minute suggests hypoventilation, which can lead to respiratory acidosis due to retention of carbon dioxide (CO2). A decrease in pH (acidosis) is expected in this scenario.
B. PaCO2 54: In respiratory acidosis, PaCO2 levels are elevated due to inadequate ventilation, leading to CO2 retention. Therefore, an elevated PaCO2 level would be anticipated in this situation.
C. pH 7.51: A pH of 7.51 indicates alkalosis, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
D. PaO2 72: Oxygenation may be impaired in opioid overdose due to respiratory depression, but this PaO2 level is within the normal range. Hypoxemia is not typically a prominent feature of respiratory acidosis unless there are concurrent respiratory conditions or complications. Therefore, this choice is not anticipated.
E. PaCO2 31: A PaCO2 level of 31 indicates hypocapnia, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
Correct Answer is C
Explanation
C. Dehydration is a state of insufficient fluid intake or excessive fluid loss, leading to electrolyte imbalances and increased concentrations of solutes in the blood. The elevated sodium level (hypernatremia) and slightly elevated glucose level in the context of dehydration are consistent with the laboratory findings. Dehydration can also cause elevated BUN due to decreased kidney perfusion and impaired renal function secondary to hypovolemia. Therefore, dehydration is the most likely condition based on the laboratory findings.
A. SIADH is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia (low sodium levels). In this case, the sodium level is elevated, which is not consistent with SIADH. Therefore, SIADH is unlikely.
B. Low-protein diet is not typically associated with the laboratory findings presented. Low protein intake would not directly cause elevated sodium, potassium, glucose, or BUN levels. Therefore, this option is unlikely.
D. Renal failure is characterized by impaired kidney function, resulting in electrolyte imbalances, elevated BUN, and abnormal creatinine levels. However, the creatinine level in this case is within the normal range, suggesting preserved kidney function. Additionally, the elevated sodium level is not typically associated with renal failure. Therefore, renal failure is less likely.
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