A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply)
A. "H...
NUR 380 Proctored Exam 2 2024
A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt
tired during the day and cannot sleep at night." Which of the following responses should the
nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply)
A. "Have your working hours changed recently?"
B. "Do you feel confused in the late afternoon?"
C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?"
D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you
sleep?"
E. "Tell me about any personal stress you are experiencing." - A
C
D
E
A nurse is talking with a client about ways to help sleep and rest. Which of the following
recommendations should the nurse give to the client to promote sleep and rest? (Select all that
apply)
A. Practice muscle relaxation techniques
B. Exercise each morning
C. Take an afternoon nap
D. Alter the sleep environment for comfort
E. Limit fluid intake at least 2 hr before bedtime - A
B
D
E
A nurse is caring for a client who has been following the facility's routine and bathing in the
morning. However, at home, the client always takes a warm bath just before bedtime. Now the
client is having difficulty sleeping at night. Which of the following actions should the nurse take
first?
A. Rub the client's back for 15 min before bedtime
B. Offer the client warm milk and crackers at 2100
C. Allow the client to take a bath in the evening
D. Ask the provider for a sleeping medication - C
A nurse is preparing a presentation at a local community center about sleep hygiene. When
explaining rapid eye movement (REM) sleep, which of the following characteristics should the
nurse include? (Select all that apply)
A. REM sleep provides cognitive restoration
B. REM sleep lasts about 90 mins
C. It is difficult to awaken a person in REM sleep
,D. Sleepwalking occurs during REM sleep
E. Vivid dreams are common during REM sleep - A
C
E
A nurse is instructing a client who has narcolepsy about measures that might help with self-
management. Which of the following statements should the nurse identify as an indication that
the client understands the instruction?
A. "I'll add plenty of carbohydrates to my meals."
B. "I'll take a short nap whenever I feel a little sleepy."
C. "I'll make sure I stay warm when I am ay my desk at work."
D. "It's okay to drink alcohol as long as I limit it to one drink per day." - B
A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia.
Which of the following interventions should the nurse use to promote communication with this
client? (Select all that apply.)
A. Speak fast and loudly.
B. Minimize background noise.
C. Write down what the client does not understand.
D. Allow plenty of time for the client to respond.
E. Use brief sentences with simple words. - A. CORRECT: The client is not hearing impaired,
so speaking loudly will not promote communication.
B. CORRECT: Minimizing background noise provides a calming environment.
C. INCORRECT: Writing down what the client does not understand provides the same
information in a format the client can understand, provided he is literate.
D. INCORRECT: Allowing ample time for the client to respond helps enhance communication.
Rushing ahead to the next question would be demeaning and could cause frustration.
E. INCORRECT: Brief sentences with simple words are generally easy to understand.
A nurse is caring for a client who had an amphetamine overdose and has sensory overload.
Which of the following interventions should the nurse implement?
A. Immediately complete a thorough assessment.
B. Put the client in a room with a client who is hearing impaired.
C. Provide a private room, and limit stimulation.
D. Talk loudly to the client, and encourage ambulation. - C. CORRECT: Minimizing stimuli
helps clients who have sensory overload.
A. INCORRECT: Immediately completing a thorough assessment might overwhelm the client at
this time. Therefore, brief assessments during the course of the shift are better.
B. INCORRECT: Rooming with a client who is hearing impaired would increase environmental
stimuli.
D. INCORRECT: Talking loudly would increase environmental stimuli.
, A nurse is caring for a client who reports difficulty hearing. Which of the following assessment
findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.)
A. Weber test showing lateralization to the right ear
B. Light reflex at 10 o'clock in the left ear
C. No signs of obstruction in the left ear canal
D. Rinne test showing length of time is decreased for air and bone conduction
E. Rinne test showing air conduction less than bone conduction in the left ear - A. CORRECT:
With sensorineural hearing loss, the Weber test demonstrates lateralization to the unaffected ear.
D. CORRECT: With sensorineural hearing loss in the left ear, length of time is decreased for
both air and bone conduction.
B. INCORRECT: A light reflex at 10 o'clock in the left ear indicates that air or fluid has
displaced the tympanic membrane, but it does not indicate sensorineural hearing loss.
C. CORRECT: Signs of obstruction in the ear canal indicate conductive, not sensorineural,
hearing loss.
E. INCORRECT: With sensorineural hearing loss in the left ear, air conduction is greater than
bone conduction in the left ear.
A nurse is reviewing instructions with a client who is hearing impaired and has just started
wearing hearing aids. Which of the following statements by the client indicates understanding of
the instructions?
A. "I use a damp cloth to clean the outside part of my hearing aids."
B. "I clean the ear molds of my hearing aids with rubbing alcohol."
C. "I keep the volume of my hearing aids turned up so I can hear better."
D. "I take the batteries out of my hearing aids when I take them off at night." - D. CORRECT:
To conserve battery power, the client should turn off the hearing aids and remove the batteries
when not in use.
A. INCORRECT: The client should keep the hearing aids completely dry at all times.
B. INCORRECT: The client should clean the ear molds with mild soap and water.
C. INCORRECT: To avoid feedback noise, the client should keep the volume on the lowest
setting that allows her to hear.
A nurse is caring for a client who has several risk factors for hearing loss. As the nurse reviews
the client's medication history, which of the following medications the client takes should alert
the nurse to a further risk for ototoxicity? (Select all that apply.)
A. Furosemide (Lasix)
B. Ibuprofen (Advil)
C. Cimetidine (Tagamet)
D. Simvastatin (Zocor)
E. Amiodarone (Cordarone) - A. CORRECT: Furosemide, a loop diuretic, can cause hearing
loss as well as blurred vision.
B. CORRECT: Ibuprofen, a nonsteroidal anti-inflammatory agent, can cause hearing loss as well
as vision loss.
C. INCORRECT: Cimetidine, a medication
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