NUR 229 Exam 4 -ATI Questions with
Complete Answers 2025-2026 Graded
A+.
A nurse is teaching a client about the sleep-wake cycle. The nurse should include that which of
the following factors can interfere with the sleep-wake cycle?
Drinking caffeinated beverages in the evening
Emotional stress
A bright light
A 20 min nap during the day
A regular bedtime schedule - Answer Drinking caffeinated beverages in the evening is correct.
Caffeine is a stimulant that can interfere with the sleep-wake cycle. The client should limit
caffeine intake to the morning.
Emotional stress is correct. Stress can cause excessive worry that can interfere with the sleep-
wake cvcle. The client should try to perform relaxation activities to reduce stress and increase
sleep.
A bright light is correct. Darkness causes release of melatonin, which promotes sleep.
A 20 min nap during the day is incorrect. Naps should be limited to 20 min or less to avoid
interfering with the sleep-wake cycle.
A regular bedtime schedule is incorrect. A regular bedtime and wake-up schedule promotes
sleep
A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe
what the pain feels like. The nurse is using which of the following components of the OLDCART
mnemonic?
A. Characterisitics
B. Aggrivating
C. Onset
D. Location - Answer Characteristics
Characteristics describe how the pain feels such as dull, achy, sharp, or severity.
,B. Brainstem injury
C. Enlarged tonsils
D. Heart failure - Answer C. Enlarged tonsils
Enlarged tonsils can cause obstructive sleep apnea
A nurse is assessing a client for manifestations of pain. Which of the following findings is an
objective indicator of pain?
A. The client states the pain is located on their abdomen.
B. The client rates their pain as an 8 on a scale of 0 to 10.
C. The client reports a burning sensation.
D. The client grimaces when they move. - Answer The client grimaces when they move.
Objective indicators of pain are determined by manifestations the nurse can observe or
measure. Grimacing is an objective indicator of pain.
A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the
following findings is the priority?
A. Pain level
B. Level of sedation
C. Pulse oximetry
D. Blood pressure - Answer Pulse oximetry
Using the airway, breathing, circulation framework, the nurse should identify that pulse
oximetry is the priority. The client is at risk for opioid-induced ventilatory impairment or
respiratory depression following an opioid narcotic.
A nurse is caring for a client who reports insomnia. The nurse should monitor the client for
which of the following adverse effects of sleep deprivation?
(Select all that apply.)
, Depression - Answer Tension headaches is correct. Sleep deprivation can cause migraine and
tension headaches.
Mood swings is correct. Sleep deprivation can cause mood swings and strokes.
Depression is correct. Sleep deprivation can cause depression and decreased motivation.
Hyperreflexia is incorrect. Sleep deprivation can cause decreased reflexes and delayed response
time which places the client at risk for accidents.
Altered taste is is incorrect. Sleep deprivation can cause blurred vision.
A nurse is teaching a class about the stages of sleep. The nurse should explain that vivid
dreaming occurs during which of the following stages of sleep?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4 - Answer Stage 4
Stage 4 is the dreaming stage. During stage 4 sleep, there is a loss of skeletal muscle tone and
vivid, color dreams occur.
A nurse is teaching a client about over-the-counter medications used to treat insomnia. The
nurse should include that which of the following is an adverse reaction of diphenhydramine?
A. Memory loss
B. Dry mouth
C. Hypertension
D. Hallucinations - Answer Dry mouth
Diphenhydramine can cause dry mouth, blurred vision, tinnitus, and urinary retention. The
client should rinse their mouth out as needed and perform frequent oral hygiene to reduce dry
mouth.
A nurse is assessing a client for manifestations of pain. Which of the following findings is a
subjective indicator of pain?
Complete Answers 2025-2026 Graded
A+.
A nurse is teaching a client about the sleep-wake cycle. The nurse should include that which of
the following factors can interfere with the sleep-wake cycle?
Drinking caffeinated beverages in the evening
Emotional stress
A bright light
A 20 min nap during the day
A regular bedtime schedule - Answer Drinking caffeinated beverages in the evening is correct.
Caffeine is a stimulant that can interfere with the sleep-wake cycle. The client should limit
caffeine intake to the morning.
Emotional stress is correct. Stress can cause excessive worry that can interfere with the sleep-
wake cvcle. The client should try to perform relaxation activities to reduce stress and increase
sleep.
A bright light is correct. Darkness causes release of melatonin, which promotes sleep.
A 20 min nap during the day is incorrect. Naps should be limited to 20 min or less to avoid
interfering with the sleep-wake cycle.
A regular bedtime schedule is incorrect. A regular bedtime and wake-up schedule promotes
sleep
A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe
what the pain feels like. The nurse is using which of the following components of the OLDCART
mnemonic?
A. Characterisitics
B. Aggrivating
C. Onset
D. Location - Answer Characteristics
Characteristics describe how the pain feels such as dull, achy, sharp, or severity.
,B. Brainstem injury
C. Enlarged tonsils
D. Heart failure - Answer C. Enlarged tonsils
Enlarged tonsils can cause obstructive sleep apnea
A nurse is assessing a client for manifestations of pain. Which of the following findings is an
objective indicator of pain?
A. The client states the pain is located on their abdomen.
B. The client rates their pain as an 8 on a scale of 0 to 10.
C. The client reports a burning sensation.
D. The client grimaces when they move. - Answer The client grimaces when they move.
Objective indicators of pain are determined by manifestations the nurse can observe or
measure. Grimacing is an objective indicator of pain.
A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the
following findings is the priority?
A. Pain level
B. Level of sedation
C. Pulse oximetry
D. Blood pressure - Answer Pulse oximetry
Using the airway, breathing, circulation framework, the nurse should identify that pulse
oximetry is the priority. The client is at risk for opioid-induced ventilatory impairment or
respiratory depression following an opioid narcotic.
A nurse is caring for a client who reports insomnia. The nurse should monitor the client for
which of the following adverse effects of sleep deprivation?
(Select all that apply.)
, Depression - Answer Tension headaches is correct. Sleep deprivation can cause migraine and
tension headaches.
Mood swings is correct. Sleep deprivation can cause mood swings and strokes.
Depression is correct. Sleep deprivation can cause depression and decreased motivation.
Hyperreflexia is incorrect. Sleep deprivation can cause decreased reflexes and delayed response
time which places the client at risk for accidents.
Altered taste is is incorrect. Sleep deprivation can cause blurred vision.
A nurse is teaching a class about the stages of sleep. The nurse should explain that vivid
dreaming occurs during which of the following stages of sleep?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4 - Answer Stage 4
Stage 4 is the dreaming stage. During stage 4 sleep, there is a loss of skeletal muscle tone and
vivid, color dreams occur.
A nurse is teaching a client about over-the-counter medications used to treat insomnia. The
nurse should include that which of the following is an adverse reaction of diphenhydramine?
A. Memory loss
B. Dry mouth
C. Hypertension
D. Hallucinations - Answer Dry mouth
Diphenhydramine can cause dry mouth, blurred vision, tinnitus, and urinary retention. The
client should rinse their mouth out as needed and perform frequent oral hygiene to reduce dry
mouth.
A nurse is assessing a client for manifestations of pain. Which of the following findings is a
subjective indicator of pain?
