During an assessment to determine whether a client has a "good sleep" pattern, the nurse should be aware of a behaviorally defined assessment that includes which of the following?
1. Observation of alertness during sedentary, repetitive activities
2. Noting the ability to fall asleep within 1 hour
3. Noting the final awakening at the habitual sleeping time
4. Videotaping movement during sleep
1. Observation of alertness during sedentary, repetitive activities
Rationale:
Behavioral assessment includes observation of alertness during sedentary, repetitive activities. It notes the ability to fall asleep within 10–30 minutes, not 1 hour. It notes the final awakening at the habitual rising time, not sleepling time, and uses the photographic serializing of movement during sleep, not videotaping.
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The family of an older adult client is informed that the client has delirium. Which statement indicates that the family understands the diagnosis?
A) "Dad has always been so independent. He's lived alone for years since my mom died." B) "The changes in his behavior came on so quickly. He was fine when he woke up but didn't know the year or where he was by lunch time." C) "Dad has been becoming increasingly forgetful over the last several months." D) "Maybe it's just caused by aging. This usually happens when people get older."
The nurse is caring for a client who is diagnosed with benign prostatic hypertrophy (BPH). The client reports an increase in symptoms. Which of the following assessments would best determine the source of the increased symptoms?
A) use of over-the-counter saw palmetto B) decreased oral intake at night C) use of over-the-counter cold medication D) recent vasectomy
After spinal fusion surgery the nurse should check for signs of what?
a. Seizure activity b. Increased intracranial pressure c. Impaired color, sensitivity, and movement to the lower extremities d. Impaired pupillary response during neurologic checks
In planning for home care of a woman with preterm labor, which concern should be addressed?
a. The necessity of home health care providers coming into the home. b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor. c. Child and family care tasks are typically carried out by the woman. d. Nursing assessments will be different from those done in the hospital setting.