NSG 100 Cumulative Final Exam
1. A nurse observes some involuntary muscle jerking in a sleeping patient.The nurse
determines that the patient is most likely in which stage of sleep?
a. Stage I NREM sleep
b. Stage II NREM sleep
c. Stage IV NREM sleep
d. REM sleep: A
2. A nurse observes a slight increase in a patient's vital signs while he is sleeping during the
night. According to the patient's stage of sleep, the nurseexpects what conditions to be true?
Select all that apply.
a. He is aware of his surroundings at this point.
b. He is in delta sleep at this time.
c. It would be most difficult to awaken him at this time.
d. This is most likely an NREM stage.
e. This stage constitutes around 20% to 25% of total sleep.
f. The muscles are relaxed in this stage.: C, E
3. A nurse working the night shift at a hospital observes the developmentalfactors that may
affect sleep. Which statements accurately describe these variations? Select all that apply.
a. REM sleep constitutes much of the sleep cycle of a preschool child.
b. By the age of 8 years, most children no longer take naps.
c. Sleep needs usually decrease when physical growth peaks.
d. Many adolescents do not get enough sleep.
e. Total sleep decreases in adults with a decrease in stage IV sleep.
f. Sleep is less sound in older adults and stage IV sleep may be absent.: D, E,F
4. A nurse is discussing with an older female patient the factors that affectsleep. What fact
does the nurse teach her?
a. Drinking a cup of regular tea at night induces sleep.
b. Using alcohol moderately promotes a deep sleep.
c. Aging decreases the amount of REM sleep a person experiences.
d. Exercising decreases REM and NREM sleep.: C
5. A nurse is assessing patients in a skilled nursing facility for sleep deficits.Which patients
would be considered at a higher risk for having sleep distur- bances? Select all that apply.
,a. A patient who has uncontrolled hypothyroidism
b. A patient with coronary artery disease
c. A patient who has gastroesophageal reflux (GERD)
d. A patient who is HIV positive
e. A patient who is taking corticosteroids for arthritis
f. A patient with a urinary tract infection: A, B, C
6. A nurse is providing discharge teaching for patients regarding their med- ications. For
which patients would the nurse recommend actions to promotesleep? Select all that apply.
a. A patient who is taking iron supplements for anemia
b. A patient with Parkinson disease who is taking dopamine
c. An elderly patient taking diuretics for congestive heart failure
d. A patient who is taking antibiotics for an ear infection
e. A patient who is prescribed antidepressants
f. A patient who is taking low-dose aspirin prophylactically: B, C, E
7. A nurse working the night shift in a pediatric unit observes a 10-year-oldmale patient
walking the hallway in a sleep state. The child is unaware of his environment and doesn't
recall the incident in the morning. Which sleepdisorder would the nurse expect?
a. Bruxism
b. Cataplexy
c. Restless leg syndrome
d. Somnambulism: D
8. A nurse is performing a sleep assessment on a patient being treated for asleep disorder.
During the assessment, the patient falls asleep in the middle of a conversation. The nurse
would suspect which disorder?
a. REM behavior disorder
b. Narcolepsy
c. Enuresis
d. Sleep apnea: B
9. A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data
would the nurse have the patient document? Select all thatapply.
a. Daily mental activities
b. Daily physical activities
,c. Morning and evening body temperature
d. Daily measurement of fluid intake and output
e. Presence of anxiety or worries affecting sleep
f. Morning and evening blood pressure readings: A, B, E
10. To promote sleep in a patient, a nurse suggests what intervention?
a. Follow the usual bedtime routine if possible.
b. Drink two or three glasses of water at bedtime.
c. Have a large snack at bedtime.
d. Take a sedative-hypnotic every night at bedtime.: A
11. A nurse formulates the following diagnosis for an elderly patient who is having trouble
getting to sleep at night: Disturbed Sleep Pattern: Initiation ofSleep. Which of the following
nursing interventions would the nurse performrelated to this diagnosis? Select all that apply.
a. Arrange for assessment for depression and treatment.
b. Discourage napping during the day.
c. Decrease fluids during the evening.
d. Administer diuretics in the morning.
e. Encourage patient to engage in some type of physical activity.
f. Assess medication for side effects of sleep pattern disturbances.: A, B, E, F
12. A nurse instructor is teaching a class of student nurses about the nature of pain. Which
statements accurately describe this phenomenon? Select all thatapply.
a. Pain is whatever the physician treating the pain says it is.
b. Pain exists whenever the person experiencing it says it exists.
c. Pain is an emotional and sensory reaction to tissue damage.
d. Pain is a simple, universal, and easy-to-describe phenomenon.
e. Pain that occurs without a known cause is psychological in nature.
f. Pain is classified by duration, location, source, transmission, and etiology.-
: B, C, F
13. One of the most common distinctions of pain is whether it is acute orchronic. Which
examples describe chronic pain? Select all that apply.
, a. A patient is receiving chemotherapy for bladder cancer.
b. An adolescent is admitted to the hospital for an appendectomy.
c. A patient is experiencing a ruptured aneurysm.
d. A patient who has fibromyalgia requests pain medication.
e. A patient has back pain related to an accident that occurred last year.
f. A patient is experiencing pain from second-degree burns.: A, D, E
14. A patient complains of abdominal pain that is difficult to localize. The nursedocuments
this as which type of pain?
a. Cutaneous
b. Visceral
c. Superficial
d. Somatic: B
15. A female patient who is having a myocardial infarction complains of painthat is situated
in her jaw. The nurse documents this as what type of pain?
a. Transient pain
b. Superficial pain
c. Phantom pain
d. Referred pain: D
16. The three types of responses to pain are physiologic, behavioral, and af- fective. Which
are examples of behavioral responses to pain? Select all thatapply.
a. A patient cradles a wrist that was injured in a car accident.
b. A child is moaning and crying due to a stomachache.
c. A patient's pulse is increased following a myocardial infarction.
d. A patient in pain strikes out at a nurse who attempts to bathe him.
e. A patient who has chronic cancer pain is depressed and withdrawn.
f. A child pulls away from a nurse trying to give him an injection.: A, B, F
17. An elderly patient is confined to bedrest following cervical spine surgeryto treat nerve
pinching. The nurse is vigilant about turning the patient and assessing the patient regularly to
prevent the formation of pressure ulcers.What type of agent is the stimulus for pressure
ulcers?
a. Mechanical
1. A nurse observes some involuntary muscle jerking in a sleeping patient.The nurse
determines that the patient is most likely in which stage of sleep?
a. Stage I NREM sleep
b. Stage II NREM sleep
c. Stage IV NREM sleep
d. REM sleep: A
2. A nurse observes a slight increase in a patient's vital signs while he is sleeping during the
night. According to the patient's stage of sleep, the nurseexpects what conditions to be true?
Select all that apply.
a. He is aware of his surroundings at this point.
b. He is in delta sleep at this time.
c. It would be most difficult to awaken him at this time.
d. This is most likely an NREM stage.
e. This stage constitutes around 20% to 25% of total sleep.
f. The muscles are relaxed in this stage.: C, E
3. A nurse working the night shift at a hospital observes the developmentalfactors that may
affect sleep. Which statements accurately describe these variations? Select all that apply.
a. REM sleep constitutes much of the sleep cycle of a preschool child.
b. By the age of 8 years, most children no longer take naps.
c. Sleep needs usually decrease when physical growth peaks.
d. Many adolescents do not get enough sleep.
e. Total sleep decreases in adults with a decrease in stage IV sleep.
f. Sleep is less sound in older adults and stage IV sleep may be absent.: D, E,F
4. A nurse is discussing with an older female patient the factors that affectsleep. What fact
does the nurse teach her?
a. Drinking a cup of regular tea at night induces sleep.
b. Using alcohol moderately promotes a deep sleep.
c. Aging decreases the amount of REM sleep a person experiences.
d. Exercising decreases REM and NREM sleep.: C
5. A nurse is assessing patients in a skilled nursing facility for sleep deficits.Which patients
would be considered at a higher risk for having sleep distur- bances? Select all that apply.
,a. A patient who has uncontrolled hypothyroidism
b. A patient with coronary artery disease
c. A patient who has gastroesophageal reflux (GERD)
d. A patient who is HIV positive
e. A patient who is taking corticosteroids for arthritis
f. A patient with a urinary tract infection: A, B, C
6. A nurse is providing discharge teaching for patients regarding their med- ications. For
which patients would the nurse recommend actions to promotesleep? Select all that apply.
a. A patient who is taking iron supplements for anemia
b. A patient with Parkinson disease who is taking dopamine
c. An elderly patient taking diuretics for congestive heart failure
d. A patient who is taking antibiotics for an ear infection
e. A patient who is prescribed antidepressants
f. A patient who is taking low-dose aspirin prophylactically: B, C, E
7. A nurse working the night shift in a pediatric unit observes a 10-year-oldmale patient
walking the hallway in a sleep state. The child is unaware of his environment and doesn't
recall the incident in the morning. Which sleepdisorder would the nurse expect?
a. Bruxism
b. Cataplexy
c. Restless leg syndrome
d. Somnambulism: D
8. A nurse is performing a sleep assessment on a patient being treated for asleep disorder.
During the assessment, the patient falls asleep in the middle of a conversation. The nurse
would suspect which disorder?
a. REM behavior disorder
b. Narcolepsy
c. Enuresis
d. Sleep apnea: B
9. A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data
would the nurse have the patient document? Select all thatapply.
a. Daily mental activities
b. Daily physical activities
,c. Morning and evening body temperature
d. Daily measurement of fluid intake and output
e. Presence of anxiety or worries affecting sleep
f. Morning and evening blood pressure readings: A, B, E
10. To promote sleep in a patient, a nurse suggests what intervention?
a. Follow the usual bedtime routine if possible.
b. Drink two or three glasses of water at bedtime.
c. Have a large snack at bedtime.
d. Take a sedative-hypnotic every night at bedtime.: A
11. A nurse formulates the following diagnosis for an elderly patient who is having trouble
getting to sleep at night: Disturbed Sleep Pattern: Initiation ofSleep. Which of the following
nursing interventions would the nurse performrelated to this diagnosis? Select all that apply.
a. Arrange for assessment for depression and treatment.
b. Discourage napping during the day.
c. Decrease fluids during the evening.
d. Administer diuretics in the morning.
e. Encourage patient to engage in some type of physical activity.
f. Assess medication for side effects of sleep pattern disturbances.: A, B, E, F
12. A nurse instructor is teaching a class of student nurses about the nature of pain. Which
statements accurately describe this phenomenon? Select all thatapply.
a. Pain is whatever the physician treating the pain says it is.
b. Pain exists whenever the person experiencing it says it exists.
c. Pain is an emotional and sensory reaction to tissue damage.
d. Pain is a simple, universal, and easy-to-describe phenomenon.
e. Pain that occurs without a known cause is psychological in nature.
f. Pain is classified by duration, location, source, transmission, and etiology.-
: B, C, F
13. One of the most common distinctions of pain is whether it is acute orchronic. Which
examples describe chronic pain? Select all that apply.
, a. A patient is receiving chemotherapy for bladder cancer.
b. An adolescent is admitted to the hospital for an appendectomy.
c. A patient is experiencing a ruptured aneurysm.
d. A patient who has fibromyalgia requests pain medication.
e. A patient has back pain related to an accident that occurred last year.
f. A patient is experiencing pain from second-degree burns.: A, D, E
14. A patient complains of abdominal pain that is difficult to localize. The nursedocuments
this as which type of pain?
a. Cutaneous
b. Visceral
c. Superficial
d. Somatic: B
15. A female patient who is having a myocardial infarction complains of painthat is situated
in her jaw. The nurse documents this as what type of pain?
a. Transient pain
b. Superficial pain
c. Phantom pain
d. Referred pain: D
16. The three types of responses to pain are physiologic, behavioral, and af- fective. Which
are examples of behavioral responses to pain? Select all thatapply.
a. A patient cradles a wrist that was injured in a car accident.
b. A child is moaning and crying due to a stomachache.
c. A patient's pulse is increased following a myocardial infarction.
d. A patient in pain strikes out at a nurse who attempts to bathe him.
e. A patient who has chronic cancer pain is depressed and withdrawn.
f. A child pulls away from a nurse trying to give him an injection.: A, B, F
17. An elderly patient is confined to bedrest following cervical spine surgeryto treat nerve
pinching. The nurse is vigilant about turning the patient and assessing the patient regularly to
prevent the formation of pressure ulcers.What type of agent is the stimulus for pressure
ulcers?
a. Mechanical
