How can the nursing staff encourage sleep in long-term care facility residents? (Select all that apply.)
a. Using the minimum light necessary when making rounds
b. Making necessary sleep interruptions at the same time every night
c. Keeping conversational noise at the nursing station to a minimum
d. Answering call lights promptly
e. Providing heavy blankets for warmth
ANS: A, B, C, D
Heavy blankets may initially feel warm to the resident but eventually make the resident uncomfortable and unable to sleep. All other options listed will help diminish sleep interruptions.
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A patient has trouble shrugging his shoulders and turning his head from side to side against resistance. Which nerve should the nurse suspect to be involved?
A) Cranial nerve XI B) Cranial nerve XII C) Cranial nerve X D) Cranial nerve IX
A patient has been admitted with a tentative diagnosis of thrombocytopenia. Which patient statement would the nurse evaluate as significant to that disorder?
1. "I started taking cimetidine for heartburn about a month ago." 2. "My family and I just got back from a vacation in the mountains." 3. "I spend a lot of time working at my computer." 4. "I have been taking a new calcium supplement."
During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate?
1. "Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychologic approach to family bonding. 2. "Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on the stomach." 3. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." 4. "Cosleeping is not recommended; however, if you wish to do this, place your baby on a comforter, as opposed to directly on the mattress."
A nurse finds a client sitting alone and crying. The most appropriate way to document this is to state:
A. Client appears depressed. B. Client sitting alone and appears upset. C. Client sitting alone and crying in room, states "feels bad" when asked. D. Client not interacting with others, found obviously upset. Will refer client for evaluation and determination of problem.