The patient has been in the critical care unit for 3 weeks and has been on the intraaortic balloon pump for the past 3 days. The patient's condition has been serious, and hourly assessments and vital signs have been necessary
The nursing staff has noted that the patient has been unable to achieve sleep for more than 30 minutes at a time. The patient has been given diazepam (Valium) prn. Which techniques may assist in assessing the patient's sleep pattern? a. Correlating sleep time with vital signs
b. Documenting sleep periods of more than 90 minutes
c. Assessing degree of arousal on hourly checks
d. Observing the length of NREM sleep periods
B
Keeping a sleep chart for 48 to 72 hours and documenting sleep periods greater than 90 minutes, the number and length of awakenings, and the total possible sleep time can help assess sleep patterns in the critical care unit.
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A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.)
a. Attend hand-off rounds to coach and mentor. b. Conduct audits of staff using a new template. c. Create a template of topics to include in report. d. Encourage staff to ask questions during hand-off. e. Give raises based on compliance with reporting.
An older adult client with chronic heart failure is found to have cardiomegaly. The client asks you to explain what has caused this problem. Which of the following would be most accurate?
1. Damage from bacteria collecting on heart valves 2. Being too sedentary or immobile for years 3. Decreased elasticity of the arteries and veins 4. Elevated cholesterol and triglyceride levels
A nurse is conducting a health assessment for an African American client. What should the nurse consider in terms of cultural sensitivity?
A) All individuals, regardless of culture, have the same anatomy and physiology. B) Asking specific questions about race during the health history C) Cultural risk factors for alterations in health and normal racial variations D) Differences in emotional, social, and spiritual basic human needs
The client's health care provider prescribed dantrolene sodium (Dantrium) 25 mg daily for the treatment of neck spasms secondary to spinal cord injury
The client reports that the medication is "not working," even though it has been 45 days since the medication was started. What changes in this client's plan of care would the nurse anticipate? Standard Text: Select all that apply. 1. Increase in the dosage frequency to twice a day 2. Discontinuation of the medication 3. Increase in the frequency of hepatic function tests 4. Change to a different medication 5. Addition of succinylcholine (Anectine) to the client's medications