Answer to Question 1
ANS: 2
As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem. Although the other questions are not inappropriate, they are not as directed toward the cause of the problem.
Answer to Question 2
ANS: 3
To promote sleep, daytime naps should be eliminated. If naps are used, they should be limited to 20 minutes or less twice a day. Alcohol should be limited in the late afternoon and evening be-cause it has an insomnia-producing effect. The use of nonprescription sleeping medications is not advisable. Over the long term, these drugs can lead to further sleep disruption even when they initially seemed to be effective. Following a bedtime routine should be consistent, not necessarily going to bed. The client should engage in quiet activities that promote relaxation and then may go to bed. If the client has not fallen asleep in 30 minutes, the client should get up out of bed and do some quiet activity until feeling sleepy enough to go back to bed.
The patient and his family meet with the nurse to discuss progress on the patient care plan.
The nurse assists the patient in reflecting on his feelings
Testing Visual Fields by Confrontation: The nurse and patient should be approximately at an eye to e
A nurse adjusts the rate of a client’s IV.
To check pupillary reflexes the nurse first holds the penlight
Testing the Achilles tendon reflex with client in a sitting position