A client has been in the intensive care unit for a week receiving various procedures throughout the day and night. Currently the client, 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?
Standard Text: Select all that apply.
1. Check the client's oxygen status.
2. Request an order for sleep medication.
3. Assess the client'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.
Correct Answer: 2,4,5
Rationale 1: The client is physiologically stable.
Rationale 2: Since it is important for the client to get rest, an order for sleep medication would be appropriate.
Rationale 3: It is not necessary to assess the client's vital signs, since the client is physiologically stable.
Rationale 4: 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.
Rationale 5: When deprived of REM sleep, people experience a sleep debt and become frightened, irritable, paranoid, and even emotionally disturbed. It is important to institute measures that promote restful sleep, which would include scheduling tests and procedures so as to not disturb the client's sleep.
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