Fund 2 Welcome to your Pain Assessment Email 1. A nurse is assessing a client who had abdominal surgery 12 hours ago. Which of the following findings are relevant cues that indicate pain? Select all that apply. The client is guarding their abdomen during movement. The client’s vital signs are within normal limits The client refuses to eat and says, “I’m not hungry.” The client asks, “Is it time for my pain medicine yet?” The client reports pain as 5/10 on the numeric scale. Show Results 2. A nurse is assessing a client with advanced cancer who reports constant dull pain in the lower back, worsened by movement. Which assessment findings should be recognized as relevant cues? Select all that apply. Pain is described as “aching” and “deep.” Pain level reported as 7/10 despite around-the-clock medication. Facial grimacing during repositioning. Moist mucous membranes. Refusal to participate in physical therapy. Show Results 3. A nurse reviews the chart of a client prescribed hydrocodone for moderate pain. The client now reports increased pain and difficulty sleeping. Which cues should the nurse recognize as needing further exploration? Select all that apply. Client rating current pain as 8/10. Increased requests for PRN pain medication. Client states, “This pain med isn’t working anymore.” Client’s bowel sounds are hyperactive. Client is requesting to go home early. Show Results 4. A client with postoperative pain is rating their pain as 7/10, but their vital signs are stable, and they are not grimacing or guarding. What conclusions should the nurse draw based on these cues? Select all that apply. The client may be underreporting pain due to stoicism. The pain may be chronic, not acute. Pain is subjective, and self-report is the most reliable cue. The absence of nonverbal signs means the pain is exaggerated. The client may benefit from further pain control despite normal vitals. Show Results None 5. A nurse is caring for a client receiving morphine. The client states, “My pain was a 9 earlier, but now it’s about a 5.” However, the client appears drowsy and barely responsive to questions. What should the nurse infer from these observations? Select all that apply. The client’s sedation level may be too high. Respiratory depression is a potential concern. Pain management goals have been achieved. The opioid dose may need to be reduced. The client is likely experiencing a side effect of unrelieved pain. Show Results 6. A client with cancer reports aching pain in the hip that is constant and rated 8/10 despite scheduled opioids. What should the nurse consider when analyzing this situation? Select all that apply. The client may be experiencing breakthrough pain. Pain may be neuropathic and need adjuvant meds. The current opioid dose is likely adequate. The client is likely exaggerating due to opioid-seeking behavior. The scheduled dose may not be controlling persistent baseline pain. Show Results 7. A client with burning, tingling foot pain reports little relief from acetaminophen. They describe the pain as “shooting” and “electrical.” What can the nurse conclude? Select all that apply. The client likely has nociceptive pain. This pain is consistent with neuropathy. Acetaminophen is not the most effective choice. An adjuvant medication may be indicated. The pain is imaginary since there’s no visible injury. Show Results 8. A client recovering from abdominal surgery reports pain rated 8/10, and refuses to ambulate or use the incentive spirometer. The nurse also notes tachycardia and shallow respirations. Which of the following client problems should be prioritized? Select all that apply. Uncontrolled acute pain Risk for impaired gas exchange Opioid overdose Risk for postoperative complications (e.g., pneumonia) Ineffective coping Show Results 9. A client receiving hydromorphone IV for cancer pain has a respiratory rate of 8, is hard to arouse, and has pinpoint pupils. What is the nurse’s priority hypothesis? Select all that apply. The client is experiencing opioid toxicity. The client has developed a tolerance to the medication. The client is at risk for respiratory arrest. Pain management is currently effective. Naloxone administration may be required. Show Results None 10. A nurse is reviewing pain management for a client with diabetic neuropathy who continues to report burning foot pain despite acetaminophen. Which hypotheses should be prioritized? Select all that apply. Current medication regimen is not effective for neuropathic pain. Client may be experiencing a pain crisis and requires hospitalization. Client needs an adjuvant medication (e.g., gabapentin). Neuropathy is worsening and needs reassessment. The pain is likely psychosomatic. Show Results 11. A client reports persistent 6/10 pain post-hip surgery, despite around-the-clock non-opioid medication. The client avoids deep breathing and is hesitant to ambulate. What should be the nurse’s top priorities? Select all that apply. Consider breakthrough pain management. Advocate for a stronger opioid regimen. Encourage ambulation before adjusting meds. Assess for complications like DVT or pneumonia risk. Reassess the frequency and dosing schedule of current meds. Show Results None 12. A nurse is caring for a client with postoperative pain rated 7/10, who is due for acetaminophen and ibuprofen in 1 hour. The client is grimacing and guarding their incision. Which actions are most appropriate to include in the care plan right now? Select all that apply. Offer a warm compress and reposition the client. Assist with guided breathing exercises or distraction techniques. Contact the provider for a breakthrough opioid order. Administer the scheduled non-opioids immediately. Reinforce the importance of waiting until the scheduled dose. Show Results 13. A client receiving morphine IV reports itching, drowsiness, and mild nausea, but denies pain at this time. Which interventions should the nurse consider? Select all that apply. Administer an antiemetic as prescribed. Document this as effective pain control. Provide diphenhydramine for itching if ordered. Continue to monitor sedation and respiratory status. Discontinue the morphine immediately. Show Results 14. A nurse is planning care for a client with chronic lower back pain who is currently taking an opioid and a muscle relaxant. Which additional strategies should the nurse include in the plan of care? Select all that apply. Incorporate physical therapy and stretching as tolerated. Refer the client for cognitive-behavioral therapy. Encourage bedrest during peak pain episodes. Suggest heat application and guided meditation. Monitor for signs of constipation or sedation. Show Results 15. A client with diabetic neuropathy reports persistent burning pain in their feet. Which of the following nursing actions represent appropriate solutions? Select all that apply. Discuss with the provider the addition of gabapentin. Encourage the client to keep feet warm with a heating pad. Provide foot massage daily to improve circulation. Reinforce proper footwear and daily inspection. Educate on medication compliance even if pain relief is delayed. Show Results 16. A nurse receives an order for oxycodone 5 mg PO q4h PRN for moderate pain. The client reports pain 6/10 and requests medication. Which actions should the nurse take before administering the opioid? Select all that apply. Verify last time the PRN opioid was administered. Assess respiratory rate and level of sedation. Explain the expected effects and common side effects of the medication. Check for any history of substance misuse. Ask the UAP to administer the medication while the nurse prepares another task. Show Results 17. A nurse is caring for a post-op client who is due for pain meds. The client is on NPO status with an NG tube to suction and rates pain as 7/10. Which is the most appropriate nursing action? Select all that apply. Check if the prescribed medication is available in IV or IM form. Advocate for a new route of administration if current med is PO. Crush the oral med and administer via NG tube. Hold the med until the client is off NPO status. Reposition the client and use cold therapy until med route is clarified. Show Results 18. A client reports pain relief after receiving IV morphine. The nurse notes the client is now drowsy but arousable, with a respiratory rate of 10/min and oxygen saturation of 92% on room air. Which nursing actions are appropriate? Select all that apply. Place the client on continuous pulse oximetry. Stimulate the client periodically to assess level of consciousness. Notify the provider and prepare to administer naloxone. Elevate the head of the bed and continue to monitor. Document findings as expected side effects without concern. Show Results 19. A nurse is caring for a client with chronic pain who has a PCA pump delivering morphine. The family asks, “Can I push the button while they’re sleeping?” Which actions are appropriate for the nurse? Select all that apply. Educate that only the client should activate the PCA button. Reassure the family that the pump will not overdose the client. Instruct family not to press the button under any circumstance. Assess the client’s understanding of PCA usage. Set the lockout interval shorter if the client is still in pain. Show Results 20. A nurse administers hydromorphone to a client for post-op pain rated 8/10. Thirty minutes later, the client reports pain is now 3/10, appears relaxed, and is watching TV. Which actions should the nurse take? Select all that apply. Document the client’s pain level and response to intervention. Instruct the client to ambulate while the medication is active. Reassess pain again in 1–2 hours. Withhold future PRNs since the pain is now well managed. Encourage the client to report if pain returns or worsens. Show Results 21. A client with neuropathic pain started gabapentin three days ago. Today, they report slightly less tingling in their legs and improved sleep. Which conclusions can the nurse draw from this outcome? Select all that apply. The medication may be starting to take effect. Full benefit may take more time to develop. The plan of care is ineffective and should be changed. Adherence should be encouraged for continued results. The client may be developing tolerance and needs a higher dose. Show Results 22. A client receiving morphine IV for cancer pain is now confused, lethargic, and unable to participate in decision-making. RR is 9/min and oxygen sat is 91%. What should the nurse do in response to these outcomes? Select all that apply. Discontinue the morphine immediately. Administer naloxone as prescribed. Notify the provider and reassess vital signs frequently. Elevate HOB and apply supplemental oxygen. Re-educate the client about PCA pump use. Show Results 23. A client who received scheduled ibuprofen and acetaminophen reports pain as 2/10, is walking without grimacing, and participating in PT. Which outcomes indicate the current plan of care is effective? Select all that apply. Pain is mild and does not limit mobility. Client is actively participating in recovery. No breakthrough pain reported between doses. The plan of care should be escalated to opioid therapy. The nurse should request discontinuation of all medications. Show Result 24. A nurse is educating a patient about managing chronic pain. Which of the following strategies should the nurse include in the education? Focus solely on medication for pain relief Use pain relief strategies intermittently as needed Incorporate non-pharmacologic methods such as physical therapy and relaxation techniques Ignore the pain and continue normal activities without modifications None 25. A nurse is evaluating a patient who describes their pain as "sharp and sudden," and it began after a recent injury. What is the most appropriate classification of this pain? Chronic pain Acute pain Neuropathic pain Breakthrough pain None 26. A nurse is caring for a patient who has just been admitted to the unit and has several issues including a high fever, pain at an infusion site, and slight confusion. What should the nurse address first? The patient’s high fever The pain at the infusion site The patient’s slight confusion Documentation of all symptoms None 27. A patient reports that their pain has been present for over six months and is affecting their daily life. What type of pain is this patient most likely experiencing? Acute pain Referred pain Chronic pain Neuropathic pain None 28. A nurse is using the Brief Pain Inventory (BPI) to assess a patient’s pain. What type of information does this tool primarily gather? The location and description of the pain The pain’s intensity and its impact on daily functioning The patient’s past medical history related to pain The effectiveness of pain medications used None 29. A nurse is comparing the acute pain associated with an exacerbation of rheumatoid arthritis to that of an acute gastrointestinal bleed. What is a key difference in the pain characteristics? Rheumatoid arthritis pain is often relieved by anti-inflammatory medications, while gastrointestinal bleed pain is not typically responsive to these medications Pain from a gastrointestinal bleed is usually described as a dull ache, while rheumatoid arthritis pain is sharp and intermittent Rheumatoid arthritis pain is usually constant and improves with activity, while gastrointestinal bleed pain is intermittent and worsens with movement Gastrointestinal bleed pain is often relieved by antacids, while rheumatoid arthritis pain improves with physical therapy None 30. A nurse is using the Wong-Baker FACES Pain Rating Scale to assess a child’s pain level. How should the nurse instruct the child to use this scale? Point to the face that best describes how much pain they feel, from "no pain" to "very much pain" Describe their pain intensity in words ranging from "mild" to "severe" Rate their pain on a scale from 1 to 10, where 10 is the worst pain Indicate if their pain is constant or intermittent None 31. A nurse is assessing pain in a non-verbal patient using the FLACC Pain Scale. What does the FLACC scale evaluate? Pain intensity through facial expressions and verbal descriptions Pain based on the patient’s heart rate and blood pressure Pain using behavioral and physiological indicators, including facial expression, leg movement, activity, cry, and consolability Pain through the patient’s ability to perform daily activities None 32. A nurse is using the NIPS (Neonatal Infant Pain Scale) to assess a neonate’s pain. Which of the following indicators does the NIPS include? Facial expression, crying, breathing pattern, leg movement, and posture Crying, facial expression, heart rate, blood pressure, and respiratory rate Facial expression, cry, sleep pattern, and physical activity Crying, facial expression, leg movement, and consolability None 33. A nurse is assessing pain in a patient using the Numeric Pain Rating Scale. What is the primary advantage of using this scale? It is suitable for patients who have difficulty understanding visual images It provides a quick, easy-to-understand measure of pain intensity It is effective for assessing pain in non-verbal patients It measures pain by assessing physiological changes None 34. A nurse is using the COMFORT Scale to evaluate pain in a pediatric patient who is non-verbal. What aspects does the COMFORT Scale assess? Pain based on the child’s ability to use a pain rating scale Pain through behavioral indicators including alertness, calmness, muscle tone, and physical activity Pain using facial expressions and physiological indicators like heart rate Pain by assessing the patient’s verbal descriptions and pain history None 35. A nurse is differentiating between acute pain due to a fracture and acute pain from a kidney stone. Which statement best describes the difference in the pain experienced? Fracture pain is usually intermittent, while kidney stone pain is constant Fracture pain is often described as sharp and localized, while kidney stone pain is typically described as colicky and may radiate from the flank to the groin Pain from a fracture is relieved by hydration, while kidney stone pain improves with rest Fracture pain is generally dull and achy, whereas kidney stone pain is sharp and localized None 36. A nurse is assessing a patient’s pain using the McGill Pain Questionnaire. What type of information does this tool provide? A numerical rating of pain intensity The patient’s verbal description of the pain and its characteristics A visual representation of pain using faces A comparison of pain before and after treatment None 37. A nurse is using the CRIES Pain Scale to evaluate a preterm infant’s pain. Which of the following is an indicator used on the CRIES scale? Vocalization Facial expression Activity level Respiratory rate None 38. A nurse is assessing a patient with acute pain. Which of the following characteristics is most likely to describe the patient’s pain? Persistent and lasting for months Associated with a specific injury or event Intensity that is generally stable over time Often described as dull or aching None 39. A nurse is documenting the results of a CRIES Pain Scale assessment for an infant who scored 10 out of 10. What does this score indicate? No pain is present Mild pain Moderate pain Severe pain None 40. A nurse is assessing an infant’s pain using the CRIES Pain Scale and notes that the infant’s heart rate is elevated, and they are crying intensely. How should these findings be interpreted according to the CRIES scale? The pain is likely minimal and not a concern The infant’s pain level is moderate to severe The elevated heart rate and crying indicate no pain The findings suggest that the infant is comfortable None 41. A nurse is evaluating a patient with acute pain and a patient with a myocardial infarction (MI). What is a key difference in how these two types of pain are commonly described? Both are described as sharp and localized Acute pain from an injury is often described as dull and pressure-like, while MI pain is usually sharp and radiates to the arm or jaw MI pain is typically described as a squeezing or pressure sensation, whereas acute pain from an injury is often sharp and localized Both types of pain are usually accompanied by significant changes in blood pressure None 42. A nurse is using the CRIES Pain Scale to assess pain in a postoperative infant. What does the CRIES scale primarily measure? Pain intensity based on a numeric rating Pain through facial expressions and physiological indicators Pain using visual analog scale images Pain by evaluating the patient’s verbal descriptions None 43. A client with diabetic neuropathy describes pain as “pins and needles” and says their feet feel on fire at night. Which of the following are clinical cues the nurse should recognize as neuropathic pain? Select all that apply. Shooting or burning sensations. No identifiable physical injury. History of diabetes mellitus. Pain relieved only by opioids. Tingling or numbness in extremities. Show Results None Time's up Welcome to your Basic Comfort Needs Email 1. A nurse enters the room of a client who is postoperative day 2 after hip surgery. The client has refused hygiene care for two consecutive days. Which of the following findings should the nurse recognize as most relevant? Facial grimacing when repositioned Oral mucosa is moist and pink The client reports feeling "too tired" to shower Bed linens are soiled and wrinkled The client states, "I'm fine, just don’t feel like it." Show Results 2. Which of the following are relevant clinical observations when preparing to assist a dependent client with a complete bed bath? Select all that apply. The client has limited range of motion in upper extremities The client uses dentures The client’s bed is in high Fowler’s position The client is on anticoagulant therapy The client’s skin is intact but fragile Show Results 3. A nurse is assessing an older adult client in a long-term care facility. Which findings should be recognized as age-related changes that can influence hygiene needs? Select all that apply. Thickened toenails Increased oil production in the skin Dry oral mucosa Increased ear hair Elevated perspiration levels Show Results 4. The nurse is reviewing hand-off report. Which of the following client conditions would be most important to assess further before performing oral hygiene? Select all that apply. Reduced gag reflex Reports of dry mouth NPO status with IV hydration History of frequent choking episodes Using a partial set of dentures Show Results 5. A nurse observes that an older adult client’s skin is dry and fragile, and their gown and sheets are damp with sweat. The client states they haven’t bathed in 3 days due to being “too tired” and “not feeling up to it.” Which of the following clinical inferences should the nurse consider? Select all that apply. The client may be experiencing fatigue or pain that is limiting hygiene. Damp linens increase risk of pressure injury and fungal infection. The client’s symptoms reflect normal aging; no further action needed. There is a risk of social withdrawal or depression. The client is likely refusing care to assert independence. Show Results 6. A client with diabetes is observed walking barefoot in the room. Upon assessment, the nurse notes dry heels, a small callus on the big toe, and no sensation to light touch on the sole. Which of the following clinical implications can be drawn from this data? Select all that apply. The client has impaired peripheral sensation and is at risk for foot injury. Foot inspection should be increased to every 48 hours. A podiatry consult may be indicated. The client is not following instructions and should be reported. The presence of a callus and neuropathy indicates potential for ulcer development. Show Results 7. A nurse notes that a 72-year-old client has redness and slight maceration in the perineal area after being incontinent of urine overnight. The client states it “hurts to be wiped down there.” What clinical conclusions should the nurse consider based on this data? Select all that apply. The client is experiencing early signs of moisture-associated skin damage (MASD). Barrier creams or skin protectants may be needed. This finding is expected and will resolve without intervention. Incontinence care frequency should be reassessed. Perineal pain could be a sign of a UTI or irritation. 8. During morning care, a client who is bedbound and recovering from a stroke is found with dried saliva around their lips, halitosis, and crust buildup on the tongue. What do these cues most likely indicate? Select all that apply. The client has impaired oral hygiene and possible dehydration. There may be a risk for aspiration or oral infection. The oral mucosa is functioning normally. The client likely needs assistance with oral care. These symptoms are unrelated to hygiene concerns. Show Results 9. A nurse is caring for an older adult client who has fragile skin, a history of deep vein thrombosis (DVT), and requires assistance with hygiene. The client is currently refusing morning care, stating, “I’m just not ready yet.” Which of the following hypotheses should the nurse prioritize? Select all that apply. The client may have unresolved pain or fatigue. There is a risk of skin breakdown due to delayed hygiene. The client is likely just being uncooperative. The client may be fearful or embarrassed about dependence. Postponing care could increase risk for clot formation. Show Result 10. A nurse is performing foot care on a client with diabetes mellitus. The nurse notes calluses, cracked heels, and decreased sensation to touch. Which hypotheses should be prioritized based on these cues? Select all that apply. The client is at high risk for foot ulcers. Foot care should be referred to a podiatrist. The findings are normal and not clinically significant. There is a risk for delayed wound healing. Sensory loss could indicate progression of neuropathy. Show Result 11. You are caring for a bedbound client who is incontinent and has perineal redness and pain. The client’s caregiver mentions they’ve noticed a “rash that won’t go away.” Which client concerns should be prioritized at this time? Select all that apply. The client may be developing incontinence-associated dermatitis (IAD). Risk of pressure injury should be reassessed. Nutritional support must be added to the care plan. A focused skin and hygiene routine is urgently needed. The client is likely exaggerating their symptoms. Show Result 12. A 76-year-old client with dry mucous membranes, cracked lips, and difficulty swallowing pills is observed during oral hygiene. The client is currently taking diuretics and antihypertensives. Which hypotheses should the nurse explore and prioritize? Select all that apply. The client may be experiencing xerostomia (dry mouth) related to medications. Dehydration is a potential concern. The client may be noncompliant with medication due to swallowing difficulty. The client’s oral status is age-appropriate and not a concern. Poor oral hygiene may lead to systemic infection. Show Result 13. A nurse is planning hygiene care for a client who has fragile skin, limited mobility, and is easily fatigued. Which of the following strategies are appropriate to include in the client’s care plan? Select all that apply. Provide a full bed bath using long, firm strokes. Schedule bathing at a time when the client is most alert. Offer rest periods between different portions of care. Use light pressure and soft washcloths during bathing. Perform hygiene care rapidly to reduce fatigue. Show Results 14. A nurse is creating a care plan for a client with oral dryness, who is on diuretics and antihypertensive medications, and is reluctant to participate in brushing their teeth. Which of the following evidence-based interventions should the nurse include? Select all that apply. Offer frequent sips of water or oral rinses unless contraindicated. Encourage the use of alcohol-based mouthwash to kill bacteria. Provide a soft-bristled toothbrush and assist with brushing as needed. Use a glycerin swab to stimulate saliva. Offer oral care after meals and at bedtime. Show Result 15. The nurse is developing a plan for a client with diabetes mellitus who needs foot care assistance. Which nursing actions should be included in the plan of care? Select all that apply. Soak the client’s feet in warm water for 20 minutes before trimming nails. File the nails straight across with an emery board. Apply lotion between the toes to prevent cracking. Inspect the feet daily and especially the area between the toes. Check the client’s shoes for rough seams or debris before use. Show Result 16. A nurse is planning hygiene care for a client who is bedbound, has incontinence, and has a history of pressure injuries. Which nursing actions should be implemented to reduce skin breakdown and discomfort? Select all that apply. Use a moisture barrier cream after each incontinence episode. Perform perineal care every 8 hours during shift changes Reposition the client every 2 hours and after each episode of incontinence. Use incontinence briefs and minimize moisture-wicking surfaces. Document skin condition and client tolerance after hygiene. Show Results 17. The nurse is preparing to delegate a partial bed bath for a stable older adult client to an experienced unlicensed assistive personnel (UAP). Which instructions should the nurse provide to ensure safe and effective care? Select all that apply. Avoid using excessive soap or friction on the client’s lower legs. Report any redness, rashes, or open areas on the client’s skin. Ensure water temperature is between 100°F and 105°F. Start with the feet and work upwards toward the face. Allow the client to participate in care as much as they’re able. Show Results 18. A nurse is providing oral care to an unconscious client. Which of the following actions are appropriate and safe? Select all that apply. Position the client on their side with the head turned toward the mattress. Use foam swabs dipped in water to clean the oral cavity. Suction oral secretions as needed during care. Place two fingers in the client’s mouth to open it fully. Document the appearance of the mucosa and any abnormal findings. Show Results 19. A nurse is caring for a client with anticoagulant therapy and notices the client needs shaving and nail care. Which actions should the nurse take? Select all that apply. Use an electric razor instead of a straight razor. Cut the client’s toenails using clean nail clippers. File the fingernails with a soft emery board. Delay nail trimming and request a podiatry consult. Shave the face using warm water, skin taut, and short downward strokes. Show Results 20. A nurse is preparing to perform perineal care for a female client who is incontinent of urine. Which of the following techniques demonstrate proper infection control and comfort? Select all that apply. Cleanse from front to back using a new portion of the cloth for each wipe. Retract labia to cleanse folds thoroughly. Use circular motions around the perineal area and rectum. Dry thoroughly after cleansing to prevent moisture buildup. Perform care only at the end of the shift to reduce discomfort. 21. A nurse assisted a client with fragile skin in taking a complete bed bath this morning. Two hours later, the client states, “I feel clean and more relaxed. Thank you for letting me help with the arms.” Which of the following conclusions can the nurse make from this outcome? Select all that apply. The client experienced both physical and emotional benefit from the bath. The nurse should increase frequency of full baths for the client. Allowing the client to participate preserved dignity and independence. The client’s response indicates successful hygiene care delivery. The care plan should be modified to restrict all hygiene to nursing staff. 22. A nurse implemented a new oral hygiene routine for a client with dry mouth, including assisted brushing, mouth swabs, and increased fluids. On reassessment, the client's lips are less cracked, and the client states, “My mouth isn’t as dry anymore.” What can be inferred from this outcome? Select all that apply. The oral care plan is effective and improving mucosal condition. The client's report and findings suggest symptom relief. Oral hygiene no longer needs to be performed. The care plan can be continued as is, with ongoing monitoring. Oral care products should be discontinued to avoid overhydration. 23. After receiving foot care education, a client with diabetes begins inspecting their feet daily and avoids walking barefoot. Two weeks later, the nurse observes intact skin and proper footwear use. Which of the following statements are accurate evaluations of the intervention? Select all that apply. The client is demonstrating understanding and compliance. There is a reduced risk of diabetic foot injury. The teaching was not effective and should be repeated. The intervention has been successful and can be documented as resolved. Further teaching is not required unless new risks arise. 24. nurse re-evaluates a client who has been receiving perineal care twice per shift due to incontinence. Despite interventions, the client’s skin remains red and moist. Which nursing responses are appropriate based on this outcome? Select all that apply. Continue current routine and reassess in 48 hours. Notify the provider of continued perineal breakdown. Apply barrier cream more frequently and reassess product effectiveness. Evaluate if the client is being turned/repositioned consistently. Reduce hygiene frequency to avoid further irritation. 1 out of 24 Time's up Welcome to your Sleep Health Email Which of the following would be important cues for a nurse to gather when assessing a client with suspected sleep apnea? Select all that apply. Reports of daytime sleepiness Loud snoring at night reported by partner Episodes of breathing cessation while asleep Falling asleep after lunch each day Weight loss of 10 lbs in the past month See Results A nurse is caring for a client who reports waking up multiple times during the night and feeling groggy in the morning. Which of the following observations should the nurse consider relevant to this client’s sleep concern? Select all that apply. Client drinks coffee at 8 p.m. Client shares a room with a loud roommate Client uses melatonin each night Client has frequent nighttime urination Client reports falling asleep easily but waking at 3 a.m. Show Results A nurse is reviewing intake information for a client who reports difficulty falling asleep. Which of the following findings should be recognized as potential contributing factors? Select all that apply. The client exercises vigorously at 9 p.m. The client reads in bed for 30 minutes before sleeping The client eats a large meal at 10 p.m. The client reports anxiety related to work The client drinks warm milk before bed Show Results A nurse is completing an admission assessment on a client with narcolepsy. Which statements from the client should be considered key cues associated with this condition? Select all that apply. “I feel refreshed after a short nap.” “I fall asleep during meetings without warning.” “I take long walks every evening.” “Sometimes my legs go limp when I laugh.” “I drink alcohol at night to help me stay awake.” Show Results A client tells the nurse, “Even though I sleep 7 hours, I still wake up feeling exhausted.” The nurse observes frequent yawning, lack of focus, and the client dozing off during morning vitals. Which clinical concerns should the nurse consider based on these cues? Select all that apply. The client may have a sleep disorder affecting sleep quality. The client could be experiencing nonrestorative sleep. The client is likely faking fatigue to avoid morning activities. There is a potential disruption in the REM sleep cycle. The client needs more total hours of sleep. Show Results A client who works night shifts reports trouble sleeping during the day, waking every hour, and never feeling rested. The room has bright sunlight, and family members talk loudly in the living room. Which of the following conclusions should the nurse draw? Select all that apply. The client may have circadian rhythm disruption. Environmental factors are impairing daytime sleep. The client is adjusting normally to shift work. Nonpharmacologic sleep strategies are needed. The client's sleep concerns are likely psychological. Show Results A client reports difficulty staying awake during the day, and the nurse notes the client struggles to stay focused during teaching. The client denies caffeine use and has a regular bedtime. Which of the following clinical possibilities should be explored further? Select all that apply The client may have hypersomnolence disorder. The client might be experiencing medication side effects. The client has insomnia due to a circadian rhythm issue. The client could have undiagnosed sleep apnea. The client is demonstrating normal post-op fatigue. Show Results A nurse is assessing a client who reports feeling exhausted during the day despite sleeping 8 hours at night. The client wakes frequently, snores, and has morning headaches. Which of the following hypotheses should the nurse prioritize? Select all that apply. The client is experiencing symptoms of obstructive sleep apnea. The client is likely experiencing stress-related insomnia. The client may be receiving nonrestorative sleep due to breathing interruptions. The client’s sleep hygiene habits are poor. The client needs a referral for a sleep study. Show Results A nurse is planning care for a client with chronic insomnia. The client reports difficulty falling asleep, ruminating thoughts at bedtime, and stressful work demands. Which of the following hypotheses are most appropriate to prioritize? Select all that apply. The client may benefit from cognitive-behavioral therapy for insomnia. The client is showing signs of a circadian rhythm disorder. The insomnia may be rooted in anxiety or psychological stress. The client likely needs sleep medication as the first-line intervention. The client’s symptoms reflect short-term adjustment insomnia. Show Results A client with narcolepsy reports episodes of sudden muscle weakness when laughing and uncontrollable sleep attacks during the day. Which clinical priorities should the nurse focus on for this client? Select all that apply. Safety risk due to sudden loss of muscle tone Diagnosing obstructive sleep apnea Injury prevention during daily activities Exploring stimulant medication options Encouraging naps when drowsiness occurs Show Results A client has been experiencing daytime drowsiness, difficulty focusing, and irritability. The nurse notes the client has been waking at 3 a.m. nightly and has multiple stressors at home. Which of the following issues should the nurse consider the highest priority for planning care? Select all that apply. Disrupted sleep continuity related to emotional stress Signs of early morning awakening, a common feature in depression Substance-induced insomnia Noncompliance with sleep recommendations High risk for decreased cognitive performance and emotional instability Show Results A client in the hospital is having trouble falling asleep due to stress and environmental noise. Which nursing interventions are appropriate to help this client improve sleep quality? Select all that apply. Offer a warm blanket and dim the room lights. Provide a back massage before bedtime. Turn on the overhead fluorescent light for reading. Cluster nighttime care activities to limit disruptions. Offer warm caffeinated tea as a comfort measure. Show Results A nurse is planning discharge education for a client with chronic insomnia who reports anxiety, inconsistent sleep times, and difficulty falling asleep. Which of the following interventions should be included in the teaching? Select all that apply. Go to bed and wake up at the same time each day, even on weekends. Avoid napping during the day if possible. Use the bed only for sleep and intimacy. Watch stimulating TV shows in bed to unwind. Perform muscle relaxation exercises before bedtime. Show Results A client with sleep apnea is being treated with CPAP therapy but reports removing the mask in their sleep and still feeling tired in the morning. Which of the following should the nurse consider as potential interventions? Select all that apply. Reassess mask fit and comfort. Provide education on the importance of CPAP use. Refer to respiratory therapy for mask trial/fitting. Ask the provider to increase CPAP pressure. Explore alternate options like mandibular advancement devices. Show Results A client newly diagnosed with narcolepsy asks for strategies to reduce the risk of injury and improve quality of life. Which responses by the nurse are appropriate? Select all that apply. Take short scheduled naps during the day. Avoid driving or operating machinery when drowsy. Eat large high-carbohydrate meals before work. Keep the room warm and dim to promote restfulness at work. Use prescribed stimulants as directed. Show Results A nurse is caring for a hospitalized client who has trouble falling asleep due to hospital noise and frequent interruptions. What are the most appropriate nursing actions? Select all that apply. Bundle vital signs, medication administration, and care into fewer interruptions. Close the door or curtain to reduce environmental noise. Offer television to help distract the client before bed. Administer prescribed zolpidem without assessing readiness for sleep. Provide a quiet activity or relaxation technique such as soft music. Show Results The nurse is caring for a client with insomnia and has included progressive muscle relaxation and sleep journaling in the care plan. Which of the following demonstrates appropriate nursing action? Select all that apply. Teach the client to tense and relax muscle groups from head to toe. Provide a sample template to document sleep/wake times and disturbances. Encourage the client to journal before sleep to identify stress triggers. Ask the client to use the journal only if medication doesn't work. Practice the muscle relaxation technique with the client during the day. Show Results A nurse receives an order for zolpidem (Ambien) 5 mg at bedtime PRN for sleep. What actions should the nurse take before administration? Select all that apply. Confirm the client is in bed or ready for sleep. Dim the lights and reduce external stimulation. Encourage the client to watch TV until they feel tired. Assess the client's history of sleep aid use or adverse reactions. Confirm that no other CNS depressants have been administered recently. Show Results A client with hypersomnolence disorder is starting daytime stimulant therapy and expresses concern about driving to work safely. What nursing actions are appropriate at this stage? Select all that apply. Reinforce that the client should not drive until the medication regimen is stable. Discuss adjusting the client's work schedule if fatigue persists. Recommend alcohol at night to deepen nighttime sleep. Educate the client on the importance of medication timing and adherence Schedule a follow-up to evaluate response to treatment and safety concerns. Show Results A client with acute insomnia began practicing sleep hygiene techniques 3 days ago. Today, they report falling asleep within 30 minutes, waking only once, and feeling more alert in the morning. Which conclusions should the nurse draw? Select all that apply. The client is demonstrating improved sleep initiation and continuity. The current interventions are effective and should be continued. The client should now begin pharmacological therapy. Sleep hygiene education has led to behavior change. The care plan needs to be revised due to lack of improvement. Show Results A client with sleep apnea started using a CPAP device one week ago. They report feeling more rested, and their spouse says snoring has stopped. Which of the following statements best evaluate this outcome? Select all that apply. CPAP therapy is effective and should be maintained. Further intervention is needed due to lack of improvement. Client’s adherence to treatment appears high. The plan of care can be discontinued. The nurse should reinforce the importance of ongoing use. Show Results After implementing a relaxation routine before bedtime, a client reports still taking over an hour to fall asleep, waking frequently, and feeling anxious at night. Which of the following should the nurse do based on this outcome? Select all that apply. Consider escalating to pharmacologic sleep aids temporarily. Reassess the client’s stress levels and coping mechanisms. Discontinue the relaxation exercises. Encourage consistency and allow more time for nonpharmacologic strategies to work. Refer to a provider for further evaluation, possibly for cognitive behavioral therapy for insomnia (CBT-I). Show Results A nurse provides sleep hygiene education to a client. At follow-up, the client says: “I’ve started dimming the lights, turning off my phone, and going to bed at the same time every night. I still wake up once or twice, but I fall back asleep quickly.” What does this response suggest? Select all that apply. The client has adopted multiple effective behaviors. The intervention is showing partial success. The care plan should be abandoned due to persistent waking. The nurse should encourage continued adherence. Additional support may be needed if sleep does not improve further. Show Result A client reports frequent awakenings, dry mouth, and being told they snore loudly. Which of the following conditions should the nurse suspect based on these cues? Select all that apply. Insomnia Obstructive sleep apnea Central sleep apnea Restless leg syndrome Poor sleep hygiene Show Results An adolescent patient reports trouble falling asleep at night. Which of the following factors may be contributing to the patient’s sleep difficulties? Deselect Answer Drinking a small amount of water before bed Playing video games and using electronic devices before bedtime Eating a small protein snack with a complex carbohydrate before sleep Engaging in light exercise 2 hours before bedtime None The nurse is performing an assessment on an older adult client (age 68) with the following vital signs: heart rate 70 bpm, respiratory rate 16 breaths per minute, blood pressure 128/80 mmHg, oxygen saturation 97%, and temperature 36.6°C (97.9°F). The client reports difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? Deselect Answer "I swim three times a week for exercise." "I quit smoking cigars five years ago." "I drink hot chocolate before bedtime to help keep me warm." "I read for about 40 minutes before bed to relax." None A middle-aged patient works night shifts and reports difficulty staying awake during work and feeling overly tired during the day. The nurse suspects a circadian rhythm sleep-wake disorder. Which of the following is a characteristic of this disorder? Deselect Answer Excessive daytime sleepiness due to the misalignment between internal circadian rhythm and the desired sleep-wake schedule Difficulty falling asleep due to increased physical activity Frequent nightmares and nighttime arousals A temporary disruption of sleep patterns lasting less than a week None An older adult patient with end-stage renal disease (ESRD) reports persistent sleep disturbances. The nurse knows that which of the following factors is most likely contributing to the patient's sleep problems? Deselect Answer Increased production of melatonin in patients with ESRD Changes in metabolic waste levels affecting sleep patterns Improved sleep architecture due to dialysis treatments Increased REM sleep in patients with chronic illness None A nurse is caring for a newborn in the hospital with the following vital signs: heart rate 130 bpm, respiratory rate 40 breaths per minute, blood pressure 60/40 mmHg, oxygen saturation 98%, and temperature 37.2°C (99°F). The nurse notices that the newborn has been averaging 16 hours of sleep per day. What should be the nurse's next intervention? Deselect Answer This is a normal finding, continue to monitor. Call the doctor immediately. Wake the newborn up. Give the mother of the newborn a call. None A nurse is discussing sleep patterns with an older adult patient. Which statement reflects the typical sleep changes in older adults? Deselect Answer "Older adults require less sleep, so 5-6 hours per night is sufficient." "It’s common for older adults to spend more time in deep sleep (NREM stages III and IV)." "Older adults may experience a decrease in REM sleep and spend more time in lighter stages of sleep." "As people age, sleep patterns remain relatively stable, with no significant changes in sleep architecture." None A nurse is educating the parents of a school-age child about the importance of sleep for growth and development. Which of the following is an effect of insufficient sleep in children? Deselect Answer Enhanced cognitive development Increased risk for obesity Improved emotional regulation Increased physical growth None 1 out of 31 Time's up Post navigation Previous Previous post: Fund 1Next Next post: Fund 3
