Author Question: The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling ... (Read 56 times)

xroflmao · **on:** Jul 22, 2018

The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate?

a. Close the door to decrease noise from unit activities.
b. Adjust temperature in the patient's room to 21 C (70 F).
c. Ensure that the night-light in the patient's room is working.
d. Encourage the discontinuation of a soda and chocolate nightly snack.

Question 2

Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep?

a. Eyes closed, lying quietly, respirations 12, heart rate 60
b. Eyes closed, tossing in bed, respirations 18, heart rate 80
c. Eyes closed, mumbling to self, respirations 16, heart rate 68
d. Eyes closed, lying supine in bed, respirations 22, heart rate 66

bpool94 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: D
Discontinuing the soda and chocolate nightly snack will be most beneficial for this patient since it has two factors that will cause difficulty falling asleep. Coffee, tea, colas, and chocolate act as stimulants, causing a person to stay awake or to awaken throughout the night. Personal preference influences the temperature of the room, as well as the lighting of the room. Noise can be a factor in the unit and can awaken the patient, but caffeine can make it difficult to fall asleep.

Answer to Question 2

ANS: A
During NREM sleep, biological functions slow. During sleep, the heart rate decreases to 60 beats/min or less. The patient experiences decreased respirations, blood pressure, and muscle tone. Heart rates above 60 are too high and respirations of 22 are too high to indicate comfortable NREM sleep.