A 68-year-old patient has been in the intensive care unit for 4 ...

[sammy]

A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?
 
  a. Administer prescribed sedatives or opioids at bedtime to promote sleep.
  b. Cluster nursing activities so that the patient has uninterrupted rest periods.
  c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
  d. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.

Question 2

During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)?
 
  a. Sleep disturbances
  b. Multiple tender points
  c. Cardiac palpitations and dizziness
  d. Multijoint pain with inflammation and swelling
  e. Widespread bilateral, burning musculoskeletal pain

[shoemake]

Answer to Question 1

ANS: B
Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night.

Answer to Question 2

ANS: A, B, E
These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia.

[sammy]

Thank you

[shoemake]

No problemo