Card Set Information

2012-04-11 11:45:37
Foundations Test Review

Test #4 Sensory, Sleep, End of Life care, Caring and Cam, Ethics, philosophy
Show Answers:

  1. There are four adult clients who see the nurse for complaints of fatigue. The adult client at greatest risk is the one who gets:
    A. 6 hours of sleep
    B. 4.5 hours of sleep
    C. 10 hours of sleep
    D. 7 hours of sleep
    • C. 10 hours of sleep
    • Rationale: Data from over one million adult
    • Americans revealed that the group that slept more than 8.5 hours each night had
    • the greatest mortality.
  2. The nurse knows that the client understands education about promoting restful sleep when the client says:
    A. "I'll make a list of things to do the next day and put it by my bedside to look at before I go to bed.“
    B. "I bought some flannel sheets to help me stay warm at night.“
    C. I'll do push-ups before bedtime so I will be worn out and tired.“
    D. "I won't take my water pill anymore because it makes me get up in the night to go to the bathroom."
    • Answer B.
    • "I bought some flannel sheets to help me stay warm at night."
    • Rationale: A comfortable, quiet, and calmenvironment induces sleep. Mental and physical exercise stimulate the mind andbody, preventing sleep. Diuretics taken earlier in the day will prevent nocturia.
  3. During a preschool screening, a parent asks how many hours of sleep a child of 3 years requires each night. What is the correct answer?
    A. 8-10 hours
    B. 14-16 hours
    C. 12-14 hours
    D. 10-12 hours
    • D. 10-12 hours
    • Rationale: Growing children require more sleep than adults. Toddlers need 10-12 hours per day. About 20-30% is REM sleep. Children of this age usually spend about 50% or a little less sleeping at night. Bedtime is disliked, but is facilitated with rituals.
  4. A) client was sexually assaulted two days ago. She is afraid to go to sleep. The most appropriate nursing diagnosis related to the sleep problem is:
    A. Fear of Injury related to sleep deprivation, difficulty falling asleep
    B. Disturbed Sleep Pattern, difficulty falling asleep related to fear
    C. Insomnia related to sleep pattern disturbance
    D. Fatigue related to fear and difficulty falling asleep
    • B.) Disturbed Sleep Pattern, difficulty falling asleep related to fear
    • Rationale: Fear is the etiology of difficulty falling asleep. Insomnia is a type of sleep-pattern disturbance. The client does not complain of fatigue.
  5. A client complains of inadequate sleep quantity and quality for the past month. The client wakes in the morning feeling tired. Which question provides the nurse with the best information about factors that may be contributing to this
    sleep problem?
    A. How old are you?
    B. What are you currently doing to improve your sleep?
    C. What has your spouse noticed when you sleep?
    D. What brought this on?
    • D.) What brought this on?
    • Rationale: Insomnia usually has an identifiable cause. What brought this on? addresses factors contributing to the problem. All of the incorrect responses do provide information about sleep, but do not directly address factors contributing to the problem.
  6. List the types of Restorative/Continuing Care
    • Environmental Controls Comfort
    • Physiological Disturbances
    • Pharmacological Approaches (Medication hypnotics)