Exam 4 Review Fundys

Nurse Aria is discussing the care plan with her patient, Arjun. Which outcome would indicate that the care plan has been effective in promoting Arjun's rest and sleep?

• Arjun expresses his inability to sleep without medications

• Arjun continues his habit of reading in bed for hours each night

• Arjun identifies factors that interfere with his normal sleep pattern

• Arjun reports minimal improvement in the quality of his rest and sleep

An older adult client on the orthopedic unit complains of difficulty sleeping due to nocturia. When you do a medication review, you question which order that should be addressed by the provider?

• Metoprolol 0800

• Furosemide 0800 and 2000

• Warfarin at 1200

• Melatonin at 2000

Michael and Maya are new parents to their baby. As a nurse, you are educating them about infants and sleep. What is the most important point you would emphasize to them regarding this topic?

• promote a safe sleeping environment 

• promote a consistent bedtime routine

• encourage placement of a comfort item in the crib

• encourage prone position for sleep 

A client is being seen in the clinic due to insomnia that has been increasing in severity and frequency in recent months. What question(s) would the nurse include in an assessment of this client's health problem?

• "Do you have all of your vaccines up to date?"

• "Do you smoke?"

• "What medications are you currently taking?"

• "What is your routine for preparing for bed?"

• "How would you state your mood is lately?"

During which stage of the sleep cycle does dreaming occur and is thought to play a role in learning, memory and adaptation?

• Stage II NREM

• Stage IV NREM

• REM Sleep

• Stage 1 NREM

What is a recommended nursing intervention for problems related to immobility?

• for impaired skin integrity, reposition the client every 4-6 hours

• for constipation, increase fluid intake to 2-3 liters per day and increase fiber in the diet

• for ineffective breathing pattern, encourage shallow, careful breathing and splinting when coughing

• for increased cardiac workload, instruct the client to lie in prone position and use the Valsalva maneuver during repositioning

What is the best way to improve venous return in an immobile client?

• anticoagulants

• supine positioning

• compression stockings or SCDs

• taking a bed bath

A nurse observes two nursing assistants reposition a client. Which technique should the nurse educate the nursing assistants about to help prevent back stress and injury? 

• spread the feet shoulder-width apart to broaden base of support

• use the strength of the back muscles during strenuous activities

• hold the object that you are lifting/moving away from the body

• pull equipment, rather than pushing it, when possible

A client was admitted to the hospital for a Chronic Obstructive Pulmonary Disease (COPD) exacerbation. The client is having trouble catching their breath while walking to the bathroom and are requiring increased supplemental oxygen for activity. The client also reports dizziness and lightheadedness when they stand up. It takes the client 15 minutes to return to their baseline breathing pattern after ambulating to the bathroom. What is the most appropriate nursing diagnosis/clinical problem for this client?

• Fatigue related to inadequate oxygenation

• Activity intolerance related to inadequate oxygenation 

• Impaired bed mobility related to difficulty getting out of bed without dizziness

• Self-care deficit related to an inability to ambulate to the bathroom

The nurse auscultates bilateral breath sounds on a postoperative client and notes the breath sounds are absent in the bases. The nurse should suspect which postoperative complication?

• pneumonia

• atelactasis

• pulmonary embolim

• arterial thrombus