FINAL EXAM - BLOCK 1 QUESTIONS & ANSWERS 2024 UPDATE | 100% CORRECT

FINAL EXAM - BLOCK 1 QUESTIONS & ANSWERS 2024 UPDATE | 100% CORRECT A nurse explains a surgical procedure in detail to a patient in order to obtain informed consent. How would this action be deemed? A. Appropriate since the patient needs the surgery and the nurse is aware of the risks. B. Appropriate because the nurse is acting on behalf of the surgeon. C. Inappropriate because the nurse may not know about the recovery phase of surgery. D. Inappropriate since this is the responsibility of the surgeon. The patient has right-sided hemiplegia as a result of a stroke (brain attack) and wants a cup of hot coffee. Even though the patient is insistent, the nurse does not permit her to drink the coffee unsupervised. This nurse is using the ethical principle of A. Autonomy B. Fidelity C. Nonmaleficence D. Justice Trina, an RN on the nursing unit, states to the student nurse, “I see you are working with Beth today. Make sure you watch your patient carefully because I think Beth is one of our worst nurses.” The student knows that this statement could be considered A. Libel B. Slander C. Fraud D. Invasion of privacy The most correct definition of “critical thinking” is A. A problem-solving process that enables one to show others they are wrong B. An examination of one’s own beliefs in order to defend them intelligently C. Purposeful, analytical thinking that results in a reasoned decision D. Rational thinking that results in obtaining the one correct answer Identify the priority nursing diagnosis A. Impaired verbal communication related to altered central nervous system as evidenced by patient’s expressive aphasia B. Fluid volume excess related to compromised regulatory mechanism as evidenced by fine crackles in the lungs C. Impaired physical mobility related to discomfort as manifested by the patient’s need for opioids prior to therapy D. Activity intolerance related to generalized weakness as manifested by needing frequent rest periods when ambulating The client has reddened skin and an open abrasion on his elbow from prolonged bedrest. In examining the components of the nursing diagnosis “Impaired Skin Integrity,” the reddened skin and open abrasion would be A. The related factors B. The risk factors C. The defining characteristics D. The diagnostic label It is a very busy day on the nursing unit. The RN asks the nursing assistive personnel (NAP) to complete the following tasks. He delegates inappropriately when asking the NAP to A. Make sure the client takes his pills after his meal B. Ambulate the postsurgical client to the bathroom C. Bathe the client who is listed as a fall risk D. Feed the client with severe visual impairment Which style of leadership describes a nurse leader who assumes control over the decisions and activities of the group? A. Autocratic leadership B. Democratic leadership C. Laissez-faire leadership D. Transformational leadership Which patient need has the highest priority? A. A patient who needs to ambulate to prevent DVT B. A patient who is in isolation and feels lonely C. A patient who recently lost her husband D. An elderly patient who is at risk for falls Which type of care uses additional care measures during times of illness? A. Allopathic B. Curative C. Alternative D. Complementary A nurse in the hospital is handing off a patient to a nurse in an extended-care facility using the ISBARQ framework of communication. Which step is performed correctly? A. The nurse introduces the patient to the new nurse. B. The nurse discusses the patient’s background. C. The nurse assesses the patient’s vital signs. D. The nurse questions the patient about comfort level. Which action is a priority emphasized in the RACE acronym guide to fire safety? A. Run to the nearest fire alarm. B. Act in a calm manner to prevent panic. C. Confine the fire by closing doors and windows. D. Evacuate the entire facility as quickly as possible. During which stage of infection is the patient most contagious? A. Incubation period B. Prodromal stage C. Full stage of illness D. Convalescent period Which of the following are considered adequate for routine mechanical cleansing of the hands and removal of most transient microorganisms? A. Soap and detergents B. Warm water C. Antimicrobial scrubs D. Saniclothes or wipes Which nursing intervention is an example of secondary prevention? A. Teaching a group of older adults about a heart healthy diet B. Screening school-aged children for scoliosis C. Rehabilitation for a patient after recovery from a stroke D. Teaching an adult patient about the need to be immunized with the flu vaccine annually What is colonization? A. Describes microorganisms present without host inference or interaction B. Indicates host interaction with the organism C. The infected host displays a decline in wellness caused by the infection D. Organisms that have been recently acquired and are likely to be shed in a relatively short period of time Which precaution includes wearing a face mask, but the door may remain open because transmission is limited to close contact? A. Universal B. Droplet C. Airborne D. Contact The client has a draining abdominal wound that has become infected. In caring for the client, the nurse will implement A. Contact precautions B. Droplet precautions C. No precautions D. Airborne precautions The clinic nurse is reviewing the blood pressure readings from the client’s home self-monitoring device. The client states “Look, yesterday my blood pressure jumped up to 150/90 mm Hg. I should be taking more medicine.” The nurse’s best response is A. “Yes, that is dangerously high. What were you doing?” B. “Yes, I’m sure your physician will want to increase the dose.” C. “The doctor will first look at the pattern of your results.” D. “Don’t worry, I’m sure it’s just because you were stressed.” Which of the following can be provided to a patient by the nurse without a prescriber order? A. Administer pain medication in an emergency situation. B. Education regarding an upcoming ordered procedure. C. Starting fluids to a new patient experiencing nausea. D. Attachment to a cardiac monitor in place of an ECG. Which concept includes the beliefs, habits, likes and dislikes, and customs and rituals learned from one’s family? A. Religion B. Culture C. Ethnography D. Spirituality Which process occurs when people assume differences in the cultures without obtaining information on that culture? A. Prejudice B. Discrimination C. Stereotyping D. Ethnocentrism Which is an example of an acute illness? A. Diabetes B. Rheumatoid arthritis C. Pneumonia D. Osteoporosis What information is utilized to create the nursing plan of care? A. Facts obtained from the health assessment. B. Data collected from the prescriber’s notes. C. Insurance reimbursement diagnostic codes. D. Review of past medical and surgical history. What is an age-related change in the body system of the older adult? A. Decreased blood pressure B. Decreased cardiac output C. Increase bone density D. Increased salivation The elder client’s daughter is vice president of a large company. She is experiencing great conflict in trying to care for her mother while managing her work-related responsibilities. In planning to help the daughter, the nurse focuses on which component of the daughter’s self-concept? A. Body image B. Role performance C. Personal identity D. Self-esteem The charge nurse of a unit tries, as a rule, to admit Hispanic clients to a room at the end of the hall so that “the noise from the family will not disturb others.” This nurse is exhibiting A. Racism B. Prejudice C. Discrimination D. Sexism The nurse is assessing the dorsalis pedis pulses on an 88-year-old client. She notes the feet to be cool and assesses weak, thready pulses. The nurse’s next action would be to A. Assess the popliteal and femoral pulses B. Assess a one minute apical pulse C. Notify the provider immediately D. Apply a warm pack and reassess in twenty minutes What is the adult learning philosophy in relation to new materials? A. Adults like to have information presented all at once. B. Adults want to know information that can be used immediately. C. Adults are most receptive to receiving visual information. D. Adults do better with abstract information over concrete ideas. What would be the best teaching strategy to teach a patient how to care for an indwelling catheter? A. Lecture B. Role modeling C. Discovery D. Demonstration Which patient need has the highest priority? A. A patient who is going through a divorce. B. A patient who is in isolation and is lonely. C. A patient who recently lost her housing. D. An elderly patient who is in moderate pain. Which environment is most conducive for a nurse to perform a physical assessment on a patient? An environment: A. where the physical exam is performed first so that the patient can get the most anxiety-provoking part of the visit over. B. that is dimly lit so that the patient’s privacy can be respected. C. where there is plenty of time to always perform a “complete” exam. D. that is well lit and warm to provide maximum comfort. The nurse is caring for a patient whose BMI is 32. Based on this assessment finding, what should the nurse do first? A. Refer the patient to a dietician so that a meal plan can be created B. Notify the practitioner so that a cholesterol-lowering medication can be started C. Assess the patient’s dietary intake, using a 24-hour food recall D. Reassess the patient’s BMI in 6 months When providing oral care for the unconscious patient, the nurse should A. Place the patient on his or her side with the head of the bed in a lowered position. B. Skip brushing the teeth as the patient could aspirate. C. Swab the patient's lips and oral cavity with lemon glycerin swabs at least hourly. D. Place the patient in an upright position and brush his or her teeth with a sponge brush. A name-brand ice cream contains the following nutrition information for each serving: 30 g carbohydrates, 19 g fat, 5 g protein. The total number of calories in a serving would be A. 366 B. 311 C. 435 D. 176 When providing education regarding incentive spirometry, what will the nurse include in the instructions? A. Use the device when you feel like you need to cough. B. There is no need to use the device once you are able to ambulate. C. You should achieve ten goals at least every hour when awake. D. Be sure to blow forcefully into the device every time. The nurse understands that which assessment finding is the best indicator of fluid retention? A.Tachycardia B.Weight gain C.Crackles in the lungs D.Increased blood pressure What is the most common symptom associated with hypertension? A.Headache B.Slurred speech C.Fainting and dizziness D. Hypertension is often asymptomatic The nurse is teaching a patient how to relax using guided imagery. What should be included in this teaching plan? A.Tensing and releasing the muscles is part of this therapy B.Meditation and relaxation are combined C.It involves distraction from distressing situations by using words, phrases, or images D.Joke-telling is involved to elicit laughter An older patient was admitted for a hip fracture after a fall in his home. On admission he was alert and oriented. On postoperative day 1 the patient is confused, withdrawn, and restless. For what should the nurse evaluate the patient? A.Depression B.Hallucinations C.Delirium D.Withdrawal When is a medical condition considered chronic? A. 1 month B. 3 months C. 6 months D. 1 year What is the most common affective or mood disorder of old age? A.Dementia B.Insomnia C.Incontinence D.Depression Which of the following is a series of actions, changes, or functions intended to bring about a desired result? A. Process B. Science C. Philosophy D. Theory Which of the following is the central theme in theoretical frameworks of nursing? A. The person receiving the care B. The health care environment C. The nursing plan of care D. The person providing the care The nurse incorporates Hispanic beliefs about “hot and cold” into her plan of care for her client. This nurse is providing care based on the nursing theory of A.Florence Nightingale B.Patricia Benner C.Jean Watson D.Madeleine Leininger The nurse documents the following: “Patient able to administer own insulin per subcutaneous injection using correct technique.” In Focus Charting, this statement would be followed by which letter? A. D B. R C. P D. E The nurse sits at the unit computer to begin her shift documentation for her client. She notes the previous user of the computer, the physical therapist, did not log off appropriately. The nurse should A. Report the physical therapist to the unit manager. B. Complete the log off for the physical therapist before beginning her documentation. C. Proceed with her documentation because it will be in a different screen. D. Call the physical therapist and have her come back and log off. Nurses should practice according to evidence-based practice (EBP) principles because EBP: A. Uses valid research findings to determine patient health care. B. Is unique to nursing practice in guiding interventions based on best evidence. C. Provides a standardized way to deliver health care to prevent patient errors. D. Uses current best evidence to include patient values and preferences in making health care decisions. A nurse wants to know whether the use of moist heat or wet heat is most effective in reducing patient pain when starting an IV catheter. What is the appropriate intervention the nurse should then take to answer this clinical question according to evidence-based practice principles? A. Refer to a nursing textbook for answers. B. Alternate methods of IV starts in practice and ask patients which method was less painful. C. Complete a survey of the nursing staff about what method is most successful for placing IVs. D. Review the literature to see whether the clinical question has been answered by research studies. An elderly person who is placed in a nursing home by his family is remorseful about the loss of his financial independence. What is the term for the type of loss he is experiencing? A. Physical loss B. Psychological loss C. Actual loss D. Perceived loss Which defense mechanism is portrayed in the following scenario. After throwing his lunch tray on the floor, a patient complains to the nurse manager about the quality of the food he is being fed during his hospital stay. A. Denial B. Displacement C. Rationalization D. Reaction formation Which awareness context occurs when the patient and the family, and the health care professionals are aware that the patient is dying but pretend otherwise? A.Closed B.Suspected C.Mutual pretense D.Open A family is asking why their father with end stage COPD is being referred to hospice care. The best response from the nurse would be: A.Hospice care provides complete pain control. B.Hospice assists the family and patient to prepare for death. C.Hospice will follow the patient’s choice for “DNR” status. D.Hospice is provided in the home and will allow the family to be involved in the decisions for care. A patient who is dying wants to talk to the RN about fears of dying. The patient tells the RN, “I know I am dying, aren’t I?” What is an appropriate nursing response? A. “This must be very difficult for you.” B. “Tell me more about what’s on your mind.” C. “I am sorry. I know exactly how you feel.” D. “You know you are dying?” When caring for a patient having a hypoglycemic episode, the nurse knows which symptom requires immediate intervention? A.Hunger B.Confusion C.Headache D.Tachycardia Which of the following is the treatment for managing Type 1 Diabetes in its early stages? A.Diet changes and exercise only B.Monitoring blood glucose levels C.Intensive insulin therapy D.Weight reduction measures This classification of medications has known side effects of hyperglycemia and insomnia so it is best to monitor the patient’s blood glucose and administer the drug in the morning when the patient is receiving it. A. Benzodiazepines. B. Serotonin antagonists. C. Beta 1 receptor blockers D. Corticosteroids. While monitoring a patient who has fluid overload, the nurse would be most concerned about which assessment finding? A.Bounding pulse B.Neck vein distention C.Pitting edema in the feet D.Presence of crackles in the lungs A patient has been having frequent liquid diarrhea for the last 24 hours. A stool sample was sent to the laboratory to confirm possible Clostridium difficile infection. The nurse should monitor the patient for which electrolyte imbalance? A.Dehydration B.Hypokalemia C.Hyponatremia D.Hypocalcemia A 25-year-old student has been taken to an urgent care clinic because of dehydration. She says she has had “the flu,” with vomiting and diarrhea “all night” and has had very little to eat or drink. She says the GI symptoms have subsided, but she feels weak. The nurse expects which type of rehydration to occur? A. Oral rehydration therapy starting with ice chips B. Oral rehydration therapy with weak tea and broth C. Oral rehydration therapy with water as tolerated D. Oral rehydration therapy with glucose and electrolytes Which term describes a condition in which 24-hour urine output is less than 50 mL? A. Dysuria B. Glycosuria C. Pyuria D. Anuria What is the intended effect of furosemide? A. Diuresis B. Hypokalemia C. Hearing loss D. Weight gain The nurse needs to collect a urine specimen from a patient with an indwelling catheter. How should the nurse obtain the specimen? A. From the drainage port on the drainage bag. B. By attaching a new urinary drainage bag. C. From the upper port on the tubing. D. By removing and inserting a new catheter. Four nurses are inserting catheters in their clients. Which nurse’s statement related to this intervention is incorrect? I am inserting this catheter to . A. Empty your bladder prior to your procedure. B. Treat your problem of leaking urine. C. Obtain a sterile urine specimen. D. Measure the amount of urine left after you emptied your bladder. There is a 24-hr urine collection in process for a client. The nursing assistive personnel (NAP) inadvertently empties one specimen into the toilet instead of the collection “hat.” The nurse should A. Continue with the collection of urine until the 24-hr time period is finished. B. Make a note to the lab to inform them that one specimen was missed during the collection. C. Begin filling a new collection container and take both containers to the lab at the end of the collection period. D. Dispose of the urine already collected and begin an entirely new 24-hr collection. Which is the correct order to complete an abdominal assessment? A. Inspection, auscultation, palpation, and percussion B. Auscultation, inspection palpation, and percussion C. Percussion, palpation, inspection, and auscultation D. Palpation, percussion, auscultation, and inspection What is the definition of bolus feeding through enteral tube? A. Small amount of volume over a small time frame. B. Large amount of volume over a large time frame. C. Set amount of volume to be infused at all times. D. A set volume is infused as the patient tolerates it. Which of the following statements are true for a patient with a descending colostomy? A. Diarrhea will not be a concern in the future. B. The patient will need to modify dietary intake. C. Regular bowel habits can be established. D. It will be impossible to do a colonoscopy. A 24-hour urine collection is scheduled to start at 0100. When should the nurse start the procedure? A. At 0100, with or without a specimen B. At the first specimen that was voided at 0400 C. 2 hours after the urine was discarded D. After discarding the 0100 specimen The new nurse is caring for a patient with chronic cloudy, foul smelling urine. The patient denies dysuria. What is the nurse’s best action? A. Collect a urine specimen for culture. B. Notify the provider. C. Nothing as this is normal. D. Draw labs for a renal panel. The nurse is completing an admission assessment. Which interview question best reflects a belief related to holistic healthcare? A. “Can you tell me the names of the medications you are taking?” B. “Can you tell me how you normally handle stress?” C. “Can you tell me how long you have had your symptoms?” D. “Can you tell me your age and where you live?” The patient newly diagnosed with Type II DM needs to make lifestyle changes. In relation to the trans-theoretical model of change, which nursing action would best support the patient during the “contemplation” stage? A. Showing the patient how to use the fingerstick blood glucose monitor B. Providing information about various types of exercise to facilitate weight loss C. Teaching the patient about the purpose for having his HbA1C tested monthly D. Telling the patient that if he does not change his lifestyle, he will die To maintain proper posture, it is important to A. Sleep on the softest mattress possible. B. Avoid arching shoulders forward when sitting. C. Keep your knees locked when standing upright. D. Keep your stomach muscles relaxed to prevent back spasms. Of the following interventions for the client who is immobile, the nurse will give priority to A. Encouraging a diet high in fiber and extra fluids B. Administering the PRN medication for sleep C. Having the client use his or her incentive spirometer q 2hrs D. Massaging the client’s legs every hour Identify the true statement about devices used when assisting clients to ambulate. A. The client should stand a foot back from the back legs of a walker. B. A cane should be used by the client to support the weakest side of the body. C. A transfer belt should be placed around the client’s chest for maximum lift. D. Each crutch-walking gait begins with the client in the tripod position. Which statement is false about magnetic resonance imaging? A. Credit cards with magnetic strips may be erased. B. Nonremovable cochlear implant devices can become inoperable. C. Transdermal patches that have a thin layer of aluminized backing must be covered with gauze. D. Jewelry and hair clips must be removed before the MRI is performed. When is it acceptable for the nurse to manipulate the weights for someone in skeletal traction? Select all that apply A. When the order reads to increase the weight from ten pounds to fifteen pounds. B. When the patient is experiencing a medical emergency. C. When the patient asks the nurse to relieve some of the pressure on the leg. D. When the patient is out of bed for meals and therapy. When the patient is sent for medical imaging studies. How often must the nurse inspect the traction pin site for signs of inflammation and evidence of infection? A. Every 8 hours B. Every 12 hours C. Every 16 hours D. Every 24 hours Which of the following is an example of poor standing posture? A. abdominal muscles contract B. gluteal muscles contract C. knees are slightly flexed D. head is shifted forward How long does a patient taking bisphosphonates minimally need to stay upright after administration? A. 10 minutes B. 20 minutes C. 30 minutes D. 120 minutes It is most important for the nurse to understand the various ways in which pain is classified so that he or she can A. document the client’s pain using accurate terms B. be clear in communication with the physician C. develop an effective pain management plan D. educate the client thoroughly The nurse is assessing the confused client. In trying to determine the client’s level of pain, the nurse should A. Be aware that confused clients do not feel as much pain due to their confusion. B. Observe the client carefully for changes in behavior or vital signs. C. Ask the client’s family how much pain the client normally has. D. Use only pain scales that feature numbers or “faces” the client can point to. Mr. Zenobia’s chronic cancer pain has recently increased, and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse? A. “If you take more morphine, it will not change your pain relief.“ B. “I’ll call the physician and ask for an increased dose.” C. “The amount you are taking now is all I can give you.” D. “I’m worried if we increase your dose that you will stop breathing.” Which patient would benefit most from the use of a patient-controlled analgesia pump? A. 75-year-old woman in the last stages of the dying process who is experiencing occasional episodes of confusion B. 60-year-old man who is mentally alert and is experiencing left-sided weakness after a stroke C. 42-year-old man who is mentally alert and is recovering from a fractured femur D. 15-year-old girl who is recovering from a head injury from an automobile accident An older patient with heart failure is admitted with severe dyspnea and chronic pain. The patient expresses frustration and a sense of hopelessness with his illness. The nurse should advocate for the patient by requesting which type of consult services? A. Hospice care B. Palliative care C. Rehabilitation D. Pastoral/clergy The home hospice nurse is evaluating a patient who is dying of end-stage chronic obstructive pulmonary disease (COPD). The patient indicates that she is not in pain but wants something “to help my breathing.” There is a list of standing orders for the hospice program. Which prescribed action by the nurse would be most helpful for this patient? A. Provide 50% oxygen via facemask. B. Administer prochlorperazine 25 mg suppository every 8 hours as needed. C. Administer lorazepam elixir 1 mg orally, and instruct the family to give 0.5 mg or 1 mg every 4 hours. D. Administer morphine solution (20 mg/1 mL solution) 0.25 to 0.5 mL sublingually every 2 hours as needed. Which respiratory organ is the site of gas exchange? A. Mediastinum B. Parietal pleura C. Alveoli D. Diaphragm Which process allows oxygenated capillary blood to pass through body tissues? A. Ventilation B. Perfusion C. Osmosis D. Circulation What is the basic concept with perfusion? A. Carbon dioxide is removed from the circulating blood. B. Oxygenated blood is carried to body tissues. C. The lungs complete a full inspiratory and expiratory cycle. D. The cardiac output is maintained at 120 mL per minute. A patient is to start albuterol with a meter-dosed inhaler. How will the nurse explain how this inhaler works? The inhaler . A. creates an aerosol mist that is slowly inhaled over 5 to 7 minutes. B. contains a dry powder that is absorbed through to oral mucosa. C. will create a positive airway pressure that will increase expansion of the chest. D. delivers a controlled dose of medication with each compression of the canister. What is gas exchange between the lungs and blood and between the blood and tissues? A. Diffusion B. Perfusion C. Respiration D. Ventilation The nurse understands that which of the following is the most common manifestation of pneumonia in the older adult patient? A. Fever B. Cough C. Confusion D. Weakness The nurse understands that which circumstance places the patient at the greatest risk for developing vision disturbances? A. Advanced age B. History of diabetes mellitus C. Retired construction worker D. History of working with computer After the patient’s cataract surgery has been completed, he has been brought to the recovery area. The nurse is preparing to administer eyedrops and other medications. Which order for the patient should the nurse question? A. Warfarin (Coumadin) B. Steroid ophthalmic ointment C. Antibiotic ophthalmic ointment D. Acetaminophen with oxycodone After recovery, the nurse provides postoperative teaching for the patient. Which statement by the patient indicates a need for further teaching? A. “I will wear dark sunglasses.” B. “Aspirin will help decrease discomfort.” C. “My daughter will help me if I need to lift something.” D. “My surgeon needs to know if I am experiencing reduced vision.” An 80-year-old patient presents for his annual check-up. His son reports that his hearing has significantly diminished over the past few years. The patient tells the nurse that he believes that his hearing is “just fine” and that “nothing is wrong” with him. What is the appropriate nursing response? A. “Don’t be scared of losing your hearing.” B. “You are right; there is nothing wrong with you.” C. “It must feel frightening to think about losing your hearing.” D. “Don’t you believe what your children are saying about your hearing?” The nurse understands that a patient with a long history of heart failure is at risk for developing hearing loss if: A. Heart failure alters tissue perfusion, which may affect hearing. B. The patient uses topical medications, which may be ototoxic. C. The patient has received multiple doses of furosemide. D. There is a genetic predisposition to developing hearing loss. The client who has had a stroke states to the nurse, “You know I can’t even tell where my left leg is.” This reflects lack of response to stimuli by the A. Mechanoreceptors B. Proprioceptors C. Thermoreceptors D. Chemoreceptors Mr. Arbor complains to the nurse that he is feeling anxious. He states, “I’m just so tired of all these tests they are doing, and it’s so noisy here at night.” Mr. Arbor’s pulse is 110 beats/min, and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following? A. Turn on the television to provide distraction. B. Ask the client if he would like to discuss his anxiety further. C. Close the blinds, dim the lights, and ask the patient what other measures would help him rest. D. Call the physician and obtain an order for an anti-anxiety medication for prn use. Which wound complication is caused by overhydration related to urinary and fecal incontinence? A. Necrosis B. Edema C. Desiccation D. Maceration What would be considered a normal finding in the skin assessment of an older adult? A. Elastic skin B. Uneven pigmentation C. Cherry angiomas D. Petechiae Slowing brain and body processes are associated with which stage of NREM sleep? A. NREM I B. NREM II C. NREM IV D. REM In which stage of NREM sleep does the person fall into a stage of sleep but can be aroused with relative ease? A. Stage I B. Stage II C. Stage III D. Stage IV The nurse is caring for a hospitalized client who normally works the night shift at his job. The client states, “I don’t know what is wrong with me. I have been napping all day and can’t seem to think clearly.” The nurse’s best response is A. “You are sleep deprived, but that will resolve in a few days.” B. “You are experiencing hypersomnia, so it will be important for you to walk in the hall more often.” C. “There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?” D. “I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep.” For which sleep disorder would the nurse most likely need to include safety measures in the client’s plan of care? A. Snoring B. Enuresis C. Narcolepsy D. Hypersomnia In which of the following sleep disorders does the patient have an uncontrollable ability to sleep? A. Insomnia B. Sleep apnea C. Narcolepsy D. Restless leg syndrome The patient tells the nurse that he has a history of somnambulism. The nurse will inform the unlicensed assistive personnel that the patient is at risk for which of the following? A. Grinding his teeth B. Walking in his sleep C. Screaming when sleeping D. Laughing when he is tired