Sleep
A nurse is teaching a client about the stages of sleep. Which statement by the client indicates understanding of REM sleep?
A. "It’s the deepest stage of sleep where it’s hard to wake up."
B. "My heart rate and respirations slow down significantly during this stage."
C. "It’s the stage when I usually have vivid dreams."
D. "It’s the stage that occurs right after I fall asleep."
Correct Answer: C. "It’s the stage when I usually have vivid dreams."
Rationale:
Rapid Eye Movement (REM) sleep is characterized by vivid dreaming, increased brain activity, rapid eye movements, and irregular vital signs. Stage 3 (slow-wave sleep) is the deepest stage of sleep (A). Heart rate and respirations slow during NREM sleep (B), and REM occurs about 90 minutes after falling asleep, not immediately (D).
A nurse is assessing a client’s pain using the 0–10 numeric rating scale. The client reports a pain level of 8/10 but appears calm and is smiling. What is the most appropriate nursing action?
A. Document that the client’s pain is mild since they appear comfortable.
B. Reassess the pain after 30 minutes to see if the rating changes.
C. Believe the client’s report of pain and administer prescribed analgesics.
D. Ask the family if the client usually exaggerates pain.
Correct Answer: C. Believe the client’s report of pain and administer prescribed analgesics.
Rationale:
Pain is subjective, and the nurse must accept the client’s self-report as the most reliable indicator of pain. The client’s behavior or appearance may not reflect the intensity of pain. Reassessment should occur after pain relief interventions, not before (B). Questioning the client’s credibility (A, D) is nontherapeutic.
A nurse is teaching a group of older adults about normal age-related changes. Which statement by a participant indicates a need for further teaching?
A. "I may notice my skin becoming thinner and more fragile."
B. "My sense of thirst might decrease, so I should drink fluids regularly."
C. "I should expect my cognitive function to decline significantly with age."
D. "My bones may become weaker, so I need calcium and vitamin D."
Correct Answer: C. "I should expect my cognitive function to decline significantly with age."
Rationale:
Normal aging does not cause significant cognitive decline. Mild short-term memory loss is possible, but disorientation or confusion is pathological and may indicate dementia or delirium. The other statements accurately describe normal aging changes.
A nurse is caring for a client who has recently been diagnosed with a terminal illness. The client states, “There must be a mistake; I can’t be dying.” According to Kübler-Ross’s stages of grief, which stage is the client experiencing?
A. Anger
B. Bargaining
C. Denial
D. Depression
Correct Answer: C. Denial
Rationale:
Denial is the first stage of grief, characterized by disbelief and refusal to accept reality. The client’s statement reflects this stage. Anger involves frustration or blame; bargaining includes negotiating for more time; depression occurs when the person realizes the loss is inevitable.
A nurse is providing preoperative teaching to a client scheduled for abdominal surgery. Which statement by the client indicates understanding of the teaching?
A. “I will remove all jewelry and valuables before going to surgery.”
B. “I can eat a light meal the morning of surgery since I’m nervous.”
C. “I should stay in bed for several days after surgery to heal properly.”
D. “I won’t need to do any breathing exercises after surgery.”
Correct Answer: A. “I will remove all jewelry and valuables before going to surgery.”
Rationale:
Jewelry and valuables should be removed to prevent injury, burns, or loss. Clients must remain NPO before surgery to prevent aspiration (B). Early ambulation is encouraged postoperatively to prevent complications (C), and deep-breathing exercises are essential to prevent pneumonia (D).
A nurse is caring for an older adult client who reports frequent awakenings during the night. Which nursing intervention is most appropriate?
A. Encourage a glass of wine before bedtime.
B. Suggest avoiding naps during the day.
C. Recommend vigorous exercise before bed.
D. Advise taking a sleeping pill nightly.
Correct Answer: B. Suggest avoiding naps during the day.
Rationale:
Older adults may experience fragmented sleep. Encouraging consistent sleep-wake patterns and limiting daytime naps promotes nighttime sleep. Alcohol disrupts sleep architecture (A), exercise should be done at least 2–3 hours before bed (C), and sedatives should only be used under medical supervision due to risk of dependency (D).
A client who has been receiving IV morphine for postoperative pain reports new-onset drowsiness and a respiratory rate of 8 breaths per minute. What is the nurse’s priority action?
A. Administer naloxone per protocol.
B. Document findings and continue to monitor.
C. Elevate the head of the bed.
D. Reduce the next morphine dose by half.
Correct Answer: A. Administer naloxone per protocol.
Rationale:
A respiratory rate below 10/min indicates opioid-induced respiratory depression, which is a medical emergency. Naloxone (Narcan) reverses opioid effects. The nurse should also notify the provider and continue close monitoring. Simply documenting or adjusting the next dose is unsafe.
An older adult client is prescribed several medications for chronic conditions. Which nursing intervention is most important to prevent medication errors?
A. Encourage the client to take all medications at the same time each day.
B. Ask the client to bring all medications, including over-the-counter drugs, to each visit.
C. Advise the client to stop taking any medication that causes side effects.
D. Suggest storing all medications together in one container for convenience.
Correct Answer: B. Ask the client to bring all medications, including over-the-counter drugs, to each visit.
Rationale:
This allows the nurse to perform medication reconciliation and assess for polypharmacy or drug interactions, which are common risks in older adults. Stopping meds without provider approval (C) is unsafe, and combining meds (A, D) increases error risk.
A client who recently lost a spouse says to the nurse, “I don’t think I can go on living without them.” What is the nurse’s best response?
A. “You’ll feel better soon. Time heals all wounds.”
B. “You seem very overwhelmed right now. Tell me more about what you’re feeling.”
C. “You should try to think about the good times you had together.”
D. “It’s important to stay strong for your family.”
Correct Answer: B. “You seem very overwhelmed right now. Tell me more about what you’re feeling.”
Rationale:
This response uses therapeutic communication by acknowledging the client’s emotions and inviting further discussion. Minimizing the client’s feelings (A, C, D) blocks communication and invalidates their grief experience.
efore surgery, the client states, “I don’t really understand what they’re going to do to me.” What is the nurse’s best action?
A. Explain the surgical procedure in detail.
B. Notify the surgeon immediately before obtaining the consent form.
C. Ask the client to sign the consent form now and discuss later.
D. Ask the family member to sign the consent form instead.
Correct Answer: B. Notify the surgeon immediately before obtaining the consent form.
Rationale:
It is the surgeon’s legal responsibility to explain the procedure, risks, and benefits. The nurse’s role is to witness the signature and verify understanding, not to provide new explanations (A). Signing without understanding (C) invalidates consent. Family members cannot sign unless they hold legal authority (D).
A client reports falling asleep suddenly during the day, even while talking. The nurse recognizes this as a sign of which sleep disorder?
A. Insomnia
B. Sleep apnea
C. Narcolepsy
D. Restless leg syndrome
Correct Answer: C. Narcolepsy
Rationale:
Narcolepsy is characterized by sudden, uncontrollable episodes of sleep during the day. Insomnia involves difficulty falling or staying asleep (A). Sleep apnea involves breathing interruptions during sleep (B). Restless leg syndrome causes unpleasant leg sensations that interrupt sleep (D).
A client with chronic back pain asks for ways to reduce pain without medication. Which nursing intervention is most appropriate?
A. Encourage bed rest to avoid pain triggers.
B. Teach relaxation and guided imagery techniques.
C. Recommend increasing caffeine intake for alertness.
D. Advise avoiding all physical activity.
Correct Answer: B. Teach relaxation and guided imagery techniques.
Rationale:
Nonpharmacologic interventions such as relaxation, guided imagery, and distraction can help manage chronic pain by promoting comfort and reducing anxiety. Prolonged inactivity (A, D) leads to muscle deconditioning and worsens pain. Caffeine (C) may increase anxiety and interfere with rest.
An older adult client is confused and disoriented after surgery. Which nursing action is most appropriate?
A. Apply physical restraints for safety.
B. Increase environmental stimulation to improve orientation.
C. Assess for possible causes such as infection or medication effects.
D. Assume this confusion is normal aging.
Correct Answer: C. Assess for possible causes such as infection or medication effects.
Rationale:
Acute confusion in older adults often indicates delirium, which is usually secondary to another problem (e.g., infection, medication toxicity, metabolic imbalance). Delirium is reversible if the cause is treated. Confusing it with dementia (D) delays care. Restraints (A) and excessive stimulation (B) can worsen agitation.
The nurse is assessing a client who lost a child one year ago. Which finding suggests complicated (maladaptive) grief?
A. Expressing sadness when discussing the loss
B. Talking to the deceased child when feeling lonely
C. Refusing to leave the child’s room untouched or participate in usual activities
D. Crying occasionally on anniversaries of the child’s death
Correct Answer: C. Refusing to leave the child’s room untouched or participate in usual activities
Rationale:
Complicated grief involves prolonged, disabling emotional responses that interfere with normal functioning (e.g., social withdrawal, inability to resume daily activities). The other behaviors (A, B, D) can be normal coping mechanisms during the grieving process.
During surgery, a nurse in the operating room notices that the client’s arm is hanging off the side of the table. What should the nurse do first?
A. Continue assisting with the procedure to avoid contamination.
B. Reposition and pad the client’s arm on the table.
C. Report the incident after the surgery is complete.
D. Document that the client’s arm was not secured properly.
Correct Answer: B. Reposition and pad the client’s arm on the table.
Rationale:
During surgery, the nurse must ensure proper positioning and padding to prevent nerve damage or injury. Safety takes priority. The nurse should intervene immediately (B). Documentation and reporting (C, D) occur after client safety is ensured.
The nurse is teaching a client about improving sleep hygiene. Which instruction should be included?
A. Go to bed only when feeling sleepy.
B. Drink caffeinated beverages in the evening to relax.
C. Watch TV in bed to promote relaxation.
D. Take long daytime naps to make up for lost sleep.
Correct Answer: A. Go to bed only when feeling sleepy.
Rationale:
Going to bed only when sleepy helps condition the body to associate the bed with sleep. Caffeine interferes with sleep (B). Watching TV in bed disrupts the sleep environment (C). Long naps can reduce nighttime sleep drive (D).
A postoperative client is using a patient-controlled analgesia (PCA) pump with morphine. Which nursing action is most appropriate?
A. Instruct family members to press the button when the client appears in pain.
B. Assess the client’s pain level and sedation frequently.
C. Turn off the PCA at night so the client can rest.
D. Increase the dose if the client continues to report pain.
Correct Answer: B. Assess the client’s pain level and sedation frequently.
Rationale:
With PCA, only the client should press the button (A) to prevent overdose. The nurse must frequently assess pain, sedation, and respiratory status to ensure safety. The PCA should remain on continuously (C), and dose changes (D) require a provider’s order.
A nurse is developing a plan of care to prevent falls for an older adult in a long-term care facility. Which intervention should the nurse include?
A. Keep the bed in a high position for easy access.
B. Encourage the client to wear socks when ambulating.
C. Ensure the client’s call light is within easy reach.
D. Dim the hallway lights at night to promote rest.
Correct Answer: C. Ensure the client’s call light is within easy reach.
Rationale:
Falls are a major safety risk for older adults. Keeping the call light accessible allows clients to request assistance safely. The bed should be low (A), clients should wear non-slip footwear (B), and adequate lighting (not dim) prevents falls (D).
A hospice nurse is caring for a dying client who says, “I’m afraid of being alone when I die.” Which is the most appropriate nursing action?
A. Tell the client that staff will check on them frequently.
B. Ask the family to visit more often.
C. Stay with the client and offer to hold their hand.
D. Change the subject to a more comforting topic.
Correct Answer: C. Stay with the client and offer to hold their hand.
Rationale:
Providing presence and touch communicates compassion and support, reducing fear and loneliness. Frequent checks (A) are not the same as being present. Asking the family to visit (B) is helpful but doesn’t address immediate fear. Changing the subject (D) avoids the client’s feelings.
A postoperative client who had abdominal surgery complains of sudden shortness of breath and chest pain. Which is the priority action by the nurse?
A. Check the client’s surgical dressing for bleeding.
B. Raise the head of the bed and apply oxygen.
C. Administer prescribed pain medication.
D. Notify the provider after completing all vital signs.
Correct Answer: B. Raise the head of the bed and apply oxygen.
Rationale:
The symptoms indicate a possible pulmonary embolism, a life-threatening emergency. The nurse should elevate the head of the bed and apply oxygen to improve oxygenation, then notify the provider. Checking the incision (A) or administering pain medication (C) delays urgent treatment.
A hospitalized client reports difficulty sleeping due to frequent noise on the unit. Which nursing action best promotes rest?
A. Administer a prescribed sedative-hypnotic medication.
B. Keep the client’s room lights on for safety.
C. Cluster nursing care activities during the night.
D. Encourage visitors to stay late to reduce anxiety.
Correct Answer: C. Cluster nursing care activities during the night.
Rationale:
Clustering care (e.g., combining vital signs, medications, and toileting) minimizes disturbances and promotes rest. Sedatives should not be first-line interventions (A). Keeping lights on (B) interferes with the body’s circadian rhythm. Late visitors may increase stimulation (D).
A nurse notes that a client from a cultural background that discourages verbal expression of pain denies pain but grimaces during movement. What is the best nursing response?
A. Accept the client’s statement and provide no analgesics.
B. Encourage the client to express pain more openly.
C. Use nonverbal cues along with assessment tools to evaluate pain.
D. Assume the client has no pain since they deny it.
Correct Answer: C. Use nonverbal cues along with assessment tools to evaluate pain.
Rationale:
Cultural beliefs may influence pain expression. Nurses must use both verbal and nonverbal cues (facial expressions, guarding, vital signs) to assess pain accurately. Ignoring pain (A, D) is unsafe. Pressuring the client to express pain differently (B) disregards cultural sensitivity.
Correct Answer: C. Ensure the client’s call light is within easy reach.
Rationale:
Falls are a major safety risk for older adults. Keeping the call light accessible allows clients to request assistance safely. The bed should be low (A), clients should wear non-slip footwear (B), and adequate lighting (not dim) prevents falls (D).
Correct Answer: C. Eat small, frequent meals rich in nutrients.
Rationale:
Older adults may experience decreased appetite due to reduced metabolism and taste changes. Small, frequent, nutrient-dense meals promote adequate intake. Excess salt (B) increases risk for hypertension. Large meals (A) may reduce appetite, and limiting fluids (D) risks dehydration.
A nurse is supporting a client whose spouse recently died. Which statement by the client indicates effective coping?
A. “I can’t stop crying, so I’ve been drinking to fall asleep.”
B. “I joined a local grief support group to help me talk about my feelings.”
C. “I don’t want to talk about my spouse or their death.”
D. “I’ve been avoiding family because they make me think of the loss.”
Correct Answer: B. “I joined a local grief support group to help me talk about my feelings.”
Rationale:
Joining a support group demonstrates adaptive coping by seeking help and expressing emotions constructively. Substance use (A), avoidance (C), and social withdrawal (D) are maladaptive coping mechanisms that can complicate grief.
The nurse is caring for a client on the first postoperative day after abdominal surgery. Which nursing intervention best promotes prevention of venous thromboembolism (VTE)?
A. Encourage the client to stay in bed to avoid pain.
B. Teach the client to perform leg exercises while in bed.
C. Keep the client’s legs elevated on two pillows.
D. Limit oral fluids until the client is fully ambulating.
Correct Answer: B. Teach the client to perform leg exercises while in bed.
Rationale:
Leg exercises, early ambulation, and compression devices help prevent venous stasis and VTE. Bed rest (A) increases risk. Leg elevation (C) alone is insufficient for prevention. Adequate hydration (D) should be maintained to prevent clot formation.