Online Practice Test 45

Your Results for: "NCLEX® Review"

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 45 > NCLEX® Review Date/Time Submitted: July 30, 2012 at 4:52 PM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		A client complains of inadequate sleep quantity and quality for the past month. The client wakes in the morning feeling tired. Which question provides the nurse with the best information about factors that may be contributing to this sleep problem? Your Answer: What are you currently doing to improve your sleep? Correct Answer: What brought this on?
		Objective: Identify factors that affect normal sleep. Rationale: Insomnia usually has an identifiable cause. What brought this on? addresses factors contributing to the problem. All of the incorrect responses do provide information about sleep, but do not directly address factors contributing to the problem. Nursing Process: Assessment Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		A client was sexually assaulted two days ago. She is afraid to go to sleep. The most appropriate nursing diagnosis related to the sleep problem is: Your Answer: Disturbed Sleep Pattern, difficulty falling asleep related to fear
		Objective: Identify factors that affect normal sleep. Rationale: Fear is the etiology of difficulty falling asleep. Insomnia is a type of sleep-pattern disturbance. The client does not complain of fatigue. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
3.		During a preschool screening, a parent asks how many hours of sleep a child of 3 years requires each night. What is the correct answer? Your Answer: 10-12 hours
		Objective: Describe variations in sleep patterns throughout the life span. Rationale: Growing children require more sleep than adults. Toddlers need 10-12 hours per day. About 20-30% is REM sleep. Children of this age usually spend about 50% or a little less sleeping at night. Bedtime is disliked, but is facilitated with rituals. Nursing Process: Planning Client Need: Health Maintenance and Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		The nurse knows that the client understands education about promoting restful sleep when the client says: Your Answer: "I bought some flannel sheets to help me stay warm at night."
		Objective: Describe interventions that promote normal sleep. Rationale: A comfortable, quiet, and calm environment induces sleep. Mental and physical exercise stimulate the mind and body, preventing sleep. Diuretics taken earlier in the day will prevent nocturia. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
5.		A hospitalized client complains of difficulty falling asleep because of worries associated with the diagnosis. What could the nurse provide for the client that would facilitate sleep? Your Answer: Back massage
		Objective: Describe interventions that promote normal sleep. Rationale: Relaxation facilitates sleep. Nonstrenuous activity can help one become sleepy, but execise can also increase alertness. Chocolate contains caffiene, a stimulant. Light snacks can help sleep, but a high-fat, heavy snack can disrupt sleep. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Decide what is the best action for client and situation.
6.		Parents ask a nurse, "Is sleepwalking something we need to be worried about with our 9-year-old?" The best response of the nurse is: Your Answer: "Somnambulism, or sleepwalking, commonly occurs one to two hours after falling asleep, but not regularly. Sleepwalkers may not notice dangers such as stairs or other obstacles, so you will need to protect your child from this kind of injury. What kind of dangers like this do you have in your home?"
		Objective: Describe common sleep disorders. Rationale: Somnambulism is sleepwalking. Grinding and clenching teeth while asleep is called bruxism. Nocturnal enuresis is bed-wetting. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Decide what is the best action for client and situation
7.		A client who has taken a barbiturate sleep medication for several months wants to discontinue the medication. What information would be important to give to the client about this medication? Your Answer: It is best to taper the medication dose gradually.
		Objective: Describe interventions that promote normal sleep. Rationale: When this medication is no longer needed, it is best tapered gradually with supervision. Abrupt cessation can lead to withdrawal symptoms. It is not best to continue taking the medicine if it is no longer needed. Barbiturate sleep medication is legal when prescribed. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		There are four adult clients who see the nurse for complaints of fatigue. The adult client at greatest risk is the one who gets:  Your Answer: 4.5 hours of sleep Correct Answer: 10 hours of sleep
		Objective: Explain the functions and the physiology of sleep Rationale: Data from over one million adult Americans revealed that the group that slept more than 8.5 hours each night had the greatest mortality. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		__________ is a type of massage consisting of long, slow, gliding strokes. Your Answer: Effleurage
		Objective: Describe interventions that promote normal sleep. Rationale: Effleurage is a type of massage consisting of long, slow, gliding strokes. Research demonstrates that back massage has the ability to elicit a relaxation response. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge of relaxation techniques that may promote sleep.
10.		REM sleep deprivation can be caused by (Select all that apply.): Your Answer: Barbiturates  Alcohol Correct Answers: Barbiturates  Alcohol Jet lag
		Objective: Identify factors that affect normal sleep. Rationale: A prolonged disturbance in amount, quality, and consistency of sleep can lead to sleep deprivation. REM deprivation can be caused by alcohol, barbiturates, shift work, jet lag, extended ICU hospitalization, morphine and meperidine hydrochloride. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge of sleep disorders. Objective: Identify factors that affect normal sleep. Rationale: A prolonged disturbance in amount, quality, and consistency of sleep can lead to sleep deprivation. REM deprivation can be caused by alcohol, barbiturates, shift work, jet lag, extended ICU hospitalization, morphine and meperidine hydrochloride. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge of sleep disorders.