Sleep & Sleep Disorders
A hospitalized client reports poor sleep for the last 2n nights and asks for a sleeping pill. What is the best initial nursing action?
Assess contributing factors first (pain, anxiety, environmental disruptions, medication timing) before immediately requesting medication.
A client with hearing impairment is receiving discharge instructions. What is the best nursing action?
Face the client, speak clearly, reduce background noise, and verify understanding.
Which client should the nurse assess first?
Answer:
Client with new confusion and fever of 103°F
A cient with cellulitis had pain, redness, and warmth this morning. Four hours later, the nurse notes new chills and increasing fatigue. What change is most concerning?
The development of systemic symptoms, suggesting the infection may no longer be just local.
A client reporting gradual cloudy vision and increasing difficulty driving at night. What eye disorder is most liekly?
Cataracts
A client says, "I've started drinking coffee in the evening so I can stay awake longer and then hopefully crash." Why is this poor sleep management?
Caffeine later in the day can worsen sleep onset and sleep quality, creating a cycle of fatigue and poor sleep.
A client with chronic pain says, “I don’t want to ask for pain medication because I don’t want to be a burden.”
What is the best nursing response?
Answer:
Acknowledge the concern and discuss pain goals/safe pain management, reinforcing that pain control is an important part of care.
Which client should the nurse see first?
Answer:
Client with sacral wound drainage, tachycardia, and new hypotension
A client with chronic pain reports pain 8/10 before medication and 6/10 after medication. The client is still awake, talking, and breathing normally. What is the best interpretation.
A client says, "It looks liek a curtain is coming over part of my vision." and reports seeing flashes of light and floaters. What should the nurse suspect?
Retinal detachment
A client reports chronic insomnia and says they drink coffee at dinner “because I’m tired and trying to stay awake until bedtime.”
What teaching is most important?
Avoid caffeine later in the day because it can worsen difficulty falling asleep and staying asleep.
A client newly prescribed an immunosuppressive medication asks what to watch for at home.
What is the priority teaching point?
Answer:
Report fever or signs of infection promptly
What is the question you should always ask yourself first when prioritizing patients?
Answer:
Who is unstable / what could kill the patient first?
A client with stage 1 pressure injury now has a blistered open area with partial thickness skin loss. What hcanged, and why does it matter?
The pressure injury has progressed from stage 1 to stage 2, meaning that skin integrity is worsening and the risk of complication is increasing.
A client reports severe eye pain, blurred vision, nausea, and halos around lights. What condition should the nurse suspect?
Acute angle-closure glaucoma
A nurse is rounding at bedtime. Which client should the nurse assess first?
Client who received a bedtime sedative and is now difficult to arouse
A client with rheumatoid arthritis has chronic pain and poor sleep.
What is the best nursing plan?
Answer:
Address pain control, cluster nighttime care, reduce sleep disruptions, and use both pharmacologic and nonpharmacologic comfort measures.
An older adult says they need brighter light to read. Another client has chronic pain and wants a warm blanket. Another client with a wound has fever, tachycardia, and increasing confusion.
Who is priority and why?
The client with wound + fever + tachycardia + confusion is priority because they may be developing systemic infection / sepsis.
A client with insomnia slept only 3 hours last night. This afternoon, the client becomes increasingly irritable, distracted, and says, "I can't focus on what you're saying." What should the nurse recognize?
Sleep deprivation is now affecting function, cognition, and ability to participate in care.
A client who had recent eye surgery reports sudeen increasing pain, decreased vision, and nausea. What is the nurse's priority action?
Sudden pain + decreased vision, and nausea
A postoperative client with known obstructive sleep apnea received opioid pain medication 30 minutes ago and is now very sleepy.
What is the priority nursing concern?
Respiratory depression / airway compromise
A postoperative client with myasthenia gravis reports increasing fatigue and difficulty swallowing.
What is the priority nursing action?
Answer:
Assess airway protection and respiratory status immediately
Why: Fatigue + swallowing difficulty in MG can become an airway issue.
A client with lupus on immunosuppressants reports chills and has a temp of 100.6°F. Another client has chronic insomnia. Another client wants PRN pain medication.
Who is priority and why?
The client with lupus on immunosuppressants and fever/chills — infection is the priority concern because immunosuppression increases risk for serious infection.
A client receiving opioid analgesia was awake and alert 15 minutes ago. Now the client is arousable only to repeated stimulation and is answering slowly. REspirations are 11/minute. What is the most important change?
The client's level of sedatio nis worsening, which may lead to mroe respiratory depression.
A client with glaucoma and a history of asthma is prescribed timolol opthalmic drops. What potential should the nurse monitor for?
Bronchspasm/worsening respirtory status