A patient has been in the intensive care unit for a week receiving various procedures throughout the day and night. Currently the patient, though physiologically stable, is irritable and paranoid and complains of vivid dreams when dozing off to sleep. What are the best actions for the nurse to take at this time? Note: Credit will be given only if all correct choices and no incorrect choices are
selected. Standard Text: Select all that apply.
1. Check the patient's oxygen status.
2. Request an order for sleep medication.
3. Assess the patient's vital signs.
4. Turn down the lights at night and reduce noise to a minimum.
5. Schedule all tests and procedures before 9 p.m. or after 7 a.m.
2,4,5
Rationale 1: The patient is physiologically stable.
Rationale 2: Since it is important for the patient to get rest, an order for sleep medication would be appropriate.
Rationale 3: It is not necessary to assess the patient's vital signs, since the patient is physiologically stable.
Rationale 4: Turning down the lights and reducing noises will help support sleep.
Rationale 5: Scheduling tests and procedures so as to not disturb the patient's sleep is indicated.
Global Rationale: Since it is important for the patient to get rest, an order for sleep medication would be appropriate. When deprived of REM sleep, people experience a sleep debt and become frightened, irritable, paranoid, and even emotionally disturbed. It is speculated that to make up for their lack of dreaming, these persons experience far more daydreaming and fantasizing throughout the day. It is important to institute measures that promote restful sleep. Turning down the lights and reducing noises will help support sleep. It is not necessary to assess the patient's vital signs or oxygenation status, since the patient is physiologically stable.
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