The nurse is caring for a patient who has not been able to sleep ...

[faduma]

The nurse is caring for a patient who has not been able to sleep well while in the hospital. The nurse recognizes that lack of sleep can manifest in which of the following signs and symptoms? (Select all that apply.)
 
  a. Changes in physiological function such as temperature
  b. Decreased appetite and weight loss
  c. Anxiety, irritability, and restlessness
  d. Impaired judgment
  e. Nausea, vomiting, and diarrhea
  f. Shortness of breath and chest pain

Question 2

Which one of the following actions should the nurse take in order to promote respiratory function in the immobilized client?
 
  a. Change the client's position q48h.
  b. Encourage deep breathing and coughing every hour.
  c. Use oxygen and nebulizer treatments regularly.
  d. Suction the client every hour.

[Jossy]

Answer to Question 1

A, B, C, D
The biological rhythm of sleep frequently becomes synchronized with other body functions. Changes in body temperature correlate with sleep pattern. When the sleep-wake cycle becomes disrupted, changes in physiological function such as temperature can occur. Patients can experience decreased appetite, loss of weight, anxiety, restlessness, irritability, and impaired judgment. Gastrointestinal and respiratory/cardiovascular symptoms such as shortness of breath and chest pain are not symptoms of a disrupted sleep cycle.

Answer to Question 2

B
The nurse should actively work with the immobilized client to deep breathe and cough every one to two hours to promote chest expansion.
The client's position should be changed every two hours to reduce stagnation of secretions.
The physician must order oxygen and nebulizer treatments. These interventions are used primarily to treat the client who is experiencing an impaired air exchange, not to promote respiratory function in the immobilized client.
The client should be suctioned as needed, not every hour.

[faduma]

TYSM

[Jossy]

Excellent