The nurse assesses a client before bedtime. The spouse at bedside jokes about the client's snoring. Which assessment finding most concerns the nurse?
1. The client reports unrefreshing sleep.
2. Blood pressure 168/98 mmHg.
3. Choking sounds during sleep.
4. Oxygen saturation 88 percent during sleep.
2. Blood pressure 168/98 mmHg.
Explanation: 1. This report indicates to the nurse that the client likely has sleep apnea, rather than just snoring.
2. Sleep apnea results in hypertension. This blood pressure reading could indicate the client is experiencing adverse physiological effects from sleep apnea.
3. Sounds of choking during sleep occur when the client struggles to breathe during sleep due to apnea. This finding supports the nurse's suspicion that the client has sleep apnea.
4. A decreased oxygen saturation during sleep helps confirm the nurse's suspicion that the client has sleep apnea, particularly if the oxygen saturation returns to normal when the client is woken. This reading is not of most concern.
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