Answer to Question 1
ANS: A
The patient is the source for evaluating outcomes. The patient is the only one who knows whether sleep problems have improved and what has been successful. Interventions may or may not need to be adjusted. Observations do provide needed data, but in the case of insomnia, the patient is the source for evaluating the restfulness of sleep. Sometimes, the nurse has to work with the patient to redefine sleep expectations associated with medical conditions.
Answer to Question 2
ANS: B
Asking patients how they are sleeping is an introductory question. After this beginning question is asked, problems with sleep such as the nature of the problem, signs and symptoms, onset and duration of the issue, severity, predisposing factors, and the effect on the patient can be assessed. What is going on is too broad and open ended for information about sleep to be obtained specifically. Medications and food intake can be part of the detailed assessment of sleep issues.
Examples of NANDA nursing diagnosis
Responsibilities of the nurse manager
Each patient is greeted by the receptionist.
Digital recording devices can be helpful when providing patient education to visually impaired ...
The correct beginning position for the patient’s feet and crutches (tripod position).
National Patient Safety Goals for Acute-Care Hospitals