Unit 10 Sleep

Front 1

collapse of the alveoli

Back 1

Atelectasis

Front 2

a wasting or diminished size because of disease or other influence

Back 2

Atrophy

Front 3

Body alignment

Back 3

- posture
- Developmental Changes- toddler different from older adult.
- Assess learning needs client with regard to posture.
- Identify any trauma muscle damage or nerve dysfunction

Front 4

Body mechanics

Back 4

- coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing ADL’s.
- Proper implementation reduces the risk for injury to the musculoskeletal system and facilitates body movements, allowing physical mobility w/out muscle strain or excessive use of muscle energy.

Front 5

BSR
Bulbar Synchronizing Region

Back 5

- located in pons and medulla
- secretes serotonin which quiets down the sensory stimuli to the RAS and takes over.
- If we get rid of stimuli such as going to a quiet area and turning off the lights, the RAS is quieted and we can sleep.

Front 6

Cataplexy

Back 6

sudden muscle weakness during intense emotions such as anger, sadness, or laughter

Front 7

Central Sleep Apnea

Back 7

dysfunction in brain’s respiratory control center.

Front 8

Disuse atrophy

Back 8

the pathological reduction in normal size of muscle fibers after prolonged inactivity from bed rest, trauma, casting, or local nerve damage

Front 9

Dyssomnias

Back 9

primary sleep disorders which have origins in different body systems

Front 10

Embolus

Back 10

a dislodged thrombus (clot)

Front 11

Foot drop

Back 11

when the foot is fixed in plantar flexation

Front 12

Genu valgum

Back 12

knock kneed, a condition where the legs are curved inward so the knees are together

Front 13

Genu varum

Back 13

bow legged, a condition where the legs are bent outward at the knees

Front 14

Hemiparesis

Back 14

one-sided weakness

Front 15

Hemiplegia

Back 15

one-sided paralysis

Front 16

Hypersomnolence

Back 16

inadequate quantity or quality of sleep

Front 17

Hypertonicity

Back 17

excessive tone or tension of muscles

Front 18

Hypertrophy

Back 18

enlarged muscles

Front 19

Infradian Rhythm

Back 19

More than 24 hours ex: period

Front 20

Isometric contraction

Back 20

a static contraction, causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle

Front 21

Isometric exercise

Back 21

- exercise that involves tightening or tensing muscles without moving body parts.
- Example: quad exercises and contraction of the gluteal muscles.
- Easily accomplished by someone on bed rest. Increases muscle mass, strength, and tone, increased circulation and osteoblastic activity.

Front 22

Isotonic contraction

Back 22

the tightening or tensing of muscle

Front 23

Isotonic exercise

Back 23

- exercise that causes muscular contraction and change in length
- ex: walking, swimming, aerobics, jogging, biking.
- Increases circulation and respiratory functioning, osteoblastic activity (bone forming), muscle tone, mass, and shape

Front 24

Kyphosis

Back 24

hunchback

Front 25

Lordosis

Back 25

swayback

Front 26

Narkolepsy

Back 26

a dysfunction of the mechanism in the brain which controls sleep and wake states

Front 27

Nonrapid eyemovement (NREM)

Back 27

- 4 stages in a 90 min. sleep cycle.
- The sleep becomes increasingly deep between 1-4.
- Contributes to body tissue restoration.
- Function such as HR, BP, and muscle tone slow down.
- Peripheral blood vessels dilate
- GI activity increases
- Dreams occur, but they are less vivid
- BMR decreases 10-30%

Front 28

Obstructive sleep apnea

Back 28

when muscles or structures of the oral cavity/throat relax during sleeping

Front 29

Parasomnias

Back 29

undesirable behaviors that occur during sleep. Sleep and wake disturbances.

Front 30

Pigeon toes

Back 30

when the toes are pointed in

Front 31

Propioception

Back 31

the awareness of the position of the body and its parts

Front 32

Rapid eye movement (REM)

Back 32

- the end of each 90 minute sleep cycle
- Active dreaming occurs, & dreams are remembered
– the brain is very active
- The sleeper may be difficult to arouse or may wake spontaneously
- A few irregular muscle movements occur especially bursts of rapid eye movements
- Heart and respiratory rates are irregular
- Muscle tone is depressed

Front 33

Retricular activating System (RAS)

Back 33

- located in the upper brain stem
- controls alertness and wakefulness
- Sensitive to sensory stimuli (light and sound) and cerebral activity (thinking, worrying)
- Wakefulness results from neurons in the RAS that release catacholamines such as norepinephrine.
- Norepi. Stimulates you to stay awake.

Front 34

Sleep apnea

Back 34

a disorder characterized by a lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep

Front 35

Torticollis

Back 35

neck bent to the side (wry neck)

Front 36

Valsalva maneuver

Back 36

bearing down (in pain & holding in their breath), tell patients to breath out and give pain medication

Front 37

Physical changes of impaired mobility:

Back 37

1) Postural abnormalities- can cause pain, impair alignment or mobility (congenital or acquired)
2) Impaired muscular development- caused by injury of disease
3) Damage to the CNS- damage to voluntary movement centers
4) Direct trauma such as a fracture

Front 38

Changes in older adults which affect mobility:

Back 38

- Progressive loss of bone mass r/t decreased physical activity, hormonal changes, & bone reabsorption.
- Muscle mass reduced
- Posture changes
- Cardio respiratory changes- can’t get heart rate up high, lungs don’t expand as much
- Changes in activity tolerance
- Increased physical dependence

Front 39

Causes of immobility:

Back 39

- severe pain
- impairment of musculoskeletal system
- generalized weakness
- psychosocial problems
- infectious processes
- therapeutic restrictions
- unavoidable restrictions
- voluntary restrictions

Front 40

Factors the nurse should consider when assessing activity tolerance:

Back 40

1) Physiological factors (skeletal abnormalities, muscular impairments, decreased cardiac function
2) Emotional factors- anxiety, depression, motivation
3) Developmental factors- age, sex
4) Pregnancy

Front 41

Nursing measures that reduce the impact of immobility on body systems in the acute care setting:

Back 41

P-sychosocial
- encourage visitors
- re-orient frquently to date time place
- encourage hearing aids eyeglasses
- Interest in outside world
E-limination
- Turn and position, move, exercise
- Cough and deep breathe
- Chest physiotherapy
- Increase hydration
- High fiber diet

Front 42

Nursing measures that reduce the impact of immobility on body systems in the acute care setting:

Back 42

R-est and Activity
- body positioning
- weight bearing activity
- promote independence in ADL
- ROM
- ambulate
- promote execise
S-afety
- Assess skin integrity- lubricate skin
- Provide skin care lubricate
- Avoid trauma or injury to skin
- Positon
- Side rails
- ambulate with assistance
- Call bell

Front 43

Nursing measures that reduce the impact of immobility on body systems in the acute care setting:

Back 43

O-xygen
- Encourage deep breathe and coughing , use incentive Spirometer CPT
- Turn and positioning
- Apply TEDS , SCD (sequential compression device)
- Elevate legs
- Encourage movement ambulation
- Aviod valsalva
- Administer prophylactic anticoagulation therapy
N-utrition
- Increase protein intact
- Increase calories
- Increase fiber
- Vitamins and minerals
- Have patient sit up in bed during and after eating
- Encourage fluids

Front 44

Physiological & Psychosocial effects of immobility:

Back 44

1) Metabolic changes- such as metabolism, calcium resorption, and function of the GI system (difficulty passing stool)- client requires a high-protein, high calorie diet with vitamin B and C supplements
2) Respiratory changes- lack of movement and exercise could lead to alveoli collapse and the pooling of secretions, Hypostatic pneumonia. - preventing the stasis of pulmonary secretions
3) Cardiovascular changes- orthostatic hypotension, increased cardiac workload, and thrombus formation. - reduce orthostatic hypotension, reduce cardiac workload, prevent thrombus formation

Front 45

Physiological & Psychosocial effects of immobility:

Back 45

4) Musculoskeletal changes- loss of endurance, strength, and muscle mass; contractures, disuse osteoporosis (when not using bones)- receive exercise to prevent excessive atrophy and joint contractures
5) Urinary elimination changes- difficult to expel urine, may get kidney stones (renal calculi)
6) Integument changes- pressure ulcer formation. - relieve pressure
7) Psychological effects- immobilization may lead to emotional and behavioral responses, sensory alterations, and changes in coping. The most common changes are depression, behavioral changes, sleep-wake disturbances, anxiety and impaired coping.

Front 46

4 objectives of therapeutic bed rest:

Back 46

1) Reducing physical activity and the oxygen needs of the body
2) Reducing pain and the need for large doses of analgesics
3) Allowing ill or debilitated clients to rest
4) Allowing exhausted clients the opportunity for uninterrupted rest

Front 47

Possible nursing diagnoses for the patient with impaired mobility &/or improper body mechanics:

Back 47

- Altered mobility
- Impaired Physical Mobility
- Ineffective Tissue Perfussion
- Impaired Skin Integrity
- Ineffective Airway Clearance

Front 48

Body functions that are affected by circadian rhythms (dependent on the maintenance of the 24hr circadian cycle):

Back 48

1) Body temp dec.
2) Heart rate dec.
3) Blood pressure dec.
4) Hormone secretion
5) Sensory acuity
6) Mood
7) peripheral blood vessels dilate
8) GI activity increases
9) skeletal muscles relax
10) BMS decrease

Front 49

4 stages of NREM:

Back 49

Stage 1- very light sleep, drowsy & relaxed. eyes roll from side to side. HR & resp rates drop slightly, easily awakened. Only lasts for a few minutes
Stage 2- sound sleep, but can still be easily awakened. Relaxation progresses and eyes are still. body processes continue to slow. HR & resp rates & temp drop slightly. lasts 10-20 min.
Stage 3- Deep sleep difficult to arouse. Skeletal muscles are very relaxed & is undisturbed by sensory stimuli. Vital signs decrease but are stable. rarely moves. Lasts 15-30 min.
Stage 4- The deepest sleep stage, very difficult to arouse. HR & resp. rates are 20%-30% below waking rates. extremely relaxed & rarely moves. Lasts 15-30 min

Front 50

REM sleep: Rapid eye movement

Back 50

- Begins 90 min. after falling asleep.
- Can last for 60 min
- Active vivid dreams and is difficult to arouse or wake spontaneously.
- Fluctuation in heart, resp. and BP rates.
- Gastric secretions and brain metabolism increase.
- Needed for brain tissue restoration
- Cognitive Restoration
- Associated with changes in cerebral blood flow, increased cortical activity
- May assist with memory storage and learning
- Loss of REM - confusion & suspicion

Front 51

pattern of sleep:

Back 51

Pre-sleep sleepiness
-NREM1
-NREM2
-NREM3
-NREM4
-REM sleep
-NREM2
-NREM3
-NREM2 is the door stage because it is the entrance/exit for REM sleep

Front 52

The functions of sleep:

Back 52

- Restores biological processes
- Protein synthesis and cell division for renewal of tissue
- Helps conserve energy
- Important for cognitive restoration
- “Healing & restoration”
- Psychological & Physiological restoration
- Conservation of energy

Front 53

Physiological Symptoms of sleep deprivation:

Back 53

– Ptosis- blurred vision
– Fine motor clumsiness
– Slowed response time/decreased reflexes
– Decreased reasoning/judgment
– Decreased auditory and visual alertness
– Cardiac arrhythmias

Front 54

Psychological Symptoms of sleep deprivation:

Back 54

-Confusion/disorientation
-Increased sensitivity to pain
-Irritable, withdrawn, apathetic
-Excessive sleepiness
-Hyperactivity
-Decreased motivation
- Agitation

Front 55

4 Factors that affect an older adult’s sleep pattern: - amount of sleep doesn’t change, but quality of sleep decreases.

Back 55

1) presence of chronic illness such as arthritis
2) increased daytime napping
3) changes in the CNS that affect sleep regulation
4) sensory impairment (may not maintain cues of circadian rhythm)

Front 56

The effects drugs have on sleep:

Back 56

- Hypnotics – Interfere with reaching deeper sleep stages. Provide only a temporary (about 1 week) increase in quality of sleep. Eventually have a “hangover” effect during the day- excess drowsiness, confusion, decreased energy. Can worsen sleep apnea in older adults
- Alcohol – Speeds onset of sleep, reduces REM sleep, and awakens person at night and causes difficulty falling back asleep.
- Caffeine – Prevents person from falling asleep. Awaken during night. Interferes with REM sleep.

Front 57

The effects drugs have on sleep:

Back 57

- Narcotics – Suppress REM sleep. Causes daytime drowsiness. Resp. rate increases causing sleep apnea
- Diuretics- Nighttime awakenings caused by nocturia. Have to wake up to pee.
- Antidepressants & Stimulants- Suppress REM sleep. Decreases total sleep time
- Beta-Adrenergic Blockers- Causes nightmares, insomnia, and awakening from sleep.
- Benzodiazepines- AltersREM sleep. Increases sleep time and daytime sleepiness.
- Anticonvulsants- Decreases REM sleep time. May cause daytime drowsiness.

Front 58

Nursing diagnoses appropriate for patients with sleep alterations:

Back 58

- Sleep deprivation
- Disturbed sleep pattern
- Fatigue
- Anxiety
- Ineffective coping
- Breathing attern ineffective
- Confusion acute
- Coping ineffective (self/family)
- Sensory/perceptual alteration
- Sleep pattern disturbance: insomnia, apnea

Front 59

Components of a sleep history:

Back 59

- Usual bedtime
- Bedtime rituals
- Use of medications
- Sleep environment
- Time normally wake up
- Changes in sleep patterns
- Physical Assessment

Front 60

Assessment of Mobility:

Back 60

- ROM- don’t go past what joint can take
- GAIT - walking, balance or pain, safety
- Exercise/Activity Tolerance- kind and amount of exercise/activity that can be performed.
- Body Alignment- posture. Are there problems/deformations?

Front 61

Assessment of immobility:

Back 61

- Identify the impact of underlying disease on the client’s mobility
- Determine the effects of medication on the clients mobility
- Observe the body systems for hazards of immobility
- Assess psychosocial factors influenced by the client’s immobility

Front 62

Nursing interventions for someone diagnosed with activity intolerance:

Back 62

1) develop a plan of exercise in order to achieve the benefits of exercise
2) Teach the client about the benefits of exercise to protect against the development of cardiovascular disease and other risk factors such as obesity and hypertension.

Front 63

Range of motion exercises to the joints prevents contractures. Specific conditions which can be prevented:

Back 63

- Neck- prevents flexation where the chin would be on chest and visual field becomes altered
- Shoulder- correctly positions the shoulder to prevent pain, joint dislocation, and changes in body alignment
- Elbow- a fixed elbow at full extension limits independence
- Forearm- when fixed, the use of the hand is limited (cant supinate or pronate)
- Wrist- when fixed, the grasp is weakened
- Fingers and thumb- can’t perform ADL’s if fixed
- Hip- if fixed, the client will limp, can fix to far in or out making leg long or short
- Knee- a fixed knee joint can prevent a person from walking without the assistance of walker or crutch
- Ankle and foot- impairs the ability to walk
- Toes- the foot doesn’t rest properly on the floor for walking

Front 64

Obese patient with a nursing diagnosis of activity tolerance:

Back 64

- Obesity
- Dyspnea with exertion
- Hypertension
- Edema of lower extremities
- Chest pain
- Dizziness

Front 65

Before delegating to a nurse’s aide the task of assisting the patient with ambulation, what factors should the nurse consider?

Back 65

- Cannot be delegated if there is spinal cord trauma, otherwise it may be delegated. Caution the aide about proper body mechanics, technique, actions should the patient become dizzy or faint. Assess the patient’s mobility and any factors which might interfere with it (such as drowsiness meds, confused, visual impairment, sensory impairment)
- The RN assesses the patient, not the aide. We must assess whether the patient should be walking or not. The nurse should be there for the first time walking such as post operative.

Front 66

Sleep Disorders Dyssomnias

Back 66

– Insomnia
– Sleep Apnea
– Narcolepsy
– Sleep Deprivation

Front 67

Sleep Disorders Parasomnias

Back 67

- Sleepwalking, tooth grinding, bed-wetting
- Disorders associated with medical/psychiatric problems
- Proposed sleep disorders

Front 68

Sleep requirements/patterns:

Back 68

- Young adult- an average of 6 - 8½ hours a night 20% in REM sleep
- Middle adult- a decrease in the time spent sleeping at night, the amount of stage 4 sleep begins fall, a decline that continues with age. Sleep disturbances caused by anxiety, stress, depression, and physical ailments.
- Older adults- the total amount of sleep doesn’t change as age increases, but he quality of sleep deteriorates. REM sleep shortens and there is a progressive shortening of stage 3&4 sleep. Some have almost no stage 4 or deep sleep.

Front 69

You are administering a benzodiazepine to your patient for sleep…

Back 69

A) What is the desired outcome? To cause relaxation, antianxiety, and hypnotic effects (induce sleep) by depressing the CNS responsiveness to stimuli thus reducing the level of arousal.
B) What might be some undesirable outcomes? In pregnant women, they can cause congenital anomalies. In older adults they can cause changes in metabolism. Not useful for children or infants.
C) What patient assessments should the nurse make before and after administration? The nurse should make sure the patient is not taking more than the prescribed dose especially if the med appears to be less effective after the initial dose. Change in status of a patient’s continence, alertness, or impaired mobility, the drug should be considered as a cause. Monitor the response to the sleep medication

Front 70

isometric contraction

Back 70

increased muscle tension without muscles shortening

Front 71

isotonic contraction

Back 71

increased muscle tension resulting in muscle contraction and muscle shortening

Front 72

The nurse and the unlicensed assistive personnel (UAP) are about to move a 200-pound client up in bed. Before lifting this client, the nurse instructs the UAP to do which of the following? (Select all that apply.)
A. Bend slightly (30 degrees) at the waist toward the client.
B. Stand as close to the bed as possible.
C. Place feet close together, about 6 inches apart.
D. Face in the direction of the head of the bed.
E. Bend at the knees.

Back 72

b, d, and e. Standing close to the bed allows the weight to be lifted to be as close to the body as possible. This places the weight in the same plane as the lifter and close to the center of gravity for balance. By facing in the direction one is pulling the client, twisting is avoided. Bending of the knees helps to maintain the nurse's center of gravity and lets the leg muscle do the work instead of the back muscles.

Front 73

To validate the suspicion that a married male client has sleep apnea the nurse first:
A. Asks the client if he experiences apnea in the middle of the night
B. Questions the spouse if she is awakened by her husband’s snoring
C. Places the client on a continuous positive airway pressure (CPAP) device
D. Schedules the client for a sleep test

Back 73

B
a. The client would not know this information.
c. This is a treatment for sleep apnea.
d. Although this is a diagnostic tool, the first thing the nurse would do is question the spouse. This may lead to determining whether more tests are needed.

Front 74

When analgesics are ordered for a client with obstructive sleep apnea (OSA) following surgery, the nurse is most concerned about:
A. Nonsteroidal antiinflammatory drugs (NSAIDs)
B. Opioids
C. Anticonvulsants
D. Antidepressants
E. Adjuvants

Back 74

b. Clients with obstructive sleep apnea are particularly sensitive to opioids. Thus the risk of respiratory depression is increased. The nurse must recognize that clients with OSA should start out receiving very low doses of opioids.
a, c, d, and e. These have not been shown to increase the risk of respiratory depression in clients with OSA.

Front 75

The nurse finds a client sleep walking down the unit hallway. An appropriate intervention the nurse implements is:
A. Asking the client what he or she is doing and call for help
B. Quietly approaching the client and then loudly calling his or her name
C. Lightly tapping the client on the shoulder and leading him or her back to bed
D. Blocking the hallway with chairs and seating the client

Back 75

c. The nurse should not startle the client but should gently awaken the client and lead him or her back to bed.
a. Sleepwalkers are unaware of their surroundings. Asking them this question is fruitless. The nurse may or may not need assistance.
b. Startling the client may result in injury.
d. Blocking the walkway with chairs may result in injury.

Front 76

Which of the following medications are the safest to administer to adults needing assistance in falling asleep?
A. Sedatives
B. Hypnotics
C. Benzodiazepines
D. Antianxiety agents

Back 76

c. The group of drugs that are the safest are the benzodiazepines. They facilitate the action of the neurons in the central nervous system (CNS) that suppress responsiveness to stimulation, therefore decreasing levels of arousal.
a, b, and d. These can be used, but long-term use of antianxiety, sedative, or hypnotic agents can disrupt sleep and lead to more serious problems.

Front 77

The older adult client asks the nurse if taking nonprescription over-the-counter sleeping medications is advisable. The nurse responds by saying ___________:

Back 77

No, because of the risks involved with these medications, which include confusion, increased risk for falls, dependency, and further sleep disruption. Older adults are more vulnerable to the side effects of sleeping pills.

Front 78

Strategies that the nurse suggests to parents to help their young preschool children to sleep include

Back 78

establishing a bedtime ritual such as reading the child a bedtime story, rocking the child, or playing a quiet game with the child. Bedtime routines and consistent bedtime environments have been shown to assist the child in falling asleep.

Front 79

The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply):
A. Extended time to fall asleep
B. Falling asleep at inappropriate times
C. Difficulty staying asleep
D. Feeling tired after a night's sleep

Back 79

a, c, and d. These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.
b. Falling asleep at inappropriate times is indicative of narcolepsy.

Front 80

The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply):
A. Prone
B. Side lying
C. Supine
D. Fowler's

Back 80

b and c. Research demonstrates that the occurrence of SIDS is reduced with these two positions.
a and d. These have not been shown to influence the incidence of SIDS.

Front 81

The nurse suspects the client is at risk for falling. Which of the following statements made by the client would most alert the nurse to this risk?
A. “I recently began taking medication for high blood pressure.”
B. “I no longer have pain in my knee after physical therapy treatment.”
C. “I have lost 20 pounds during the past 6 months.”
D. “My cancer has been in remission for 5 years.”

Back 81

a. The ability to balance can be impaired by dizziness, which is a side effect of high blood pressure medication.
b. The ability to balance can be compromised by pain.
c. The force of an object is directed downward, which can increase the risk of falling.
d. The ability to balance can be compromised by disease.

Front 82

Fibrous tissues that bind joints together, connecting bone and cartilage are known as:
A. Ligaments
B. Tendons
C. Cartilaginous tissues
D. Skeletal muscles

Back 82

a. Ligaments are elastic and allow joint flexibility and support.
b. Tendons are fibrous bands of tissue that connect muscle to bone.
c. Cartilaginous tissue is nonvascular supporting connective tissue located in joints, thorax, trachea, larynx, nose, and ear.
d. Skeletal muscle involves the working elements of movement.

Front 83

The hip joint is classified as what type of joint?
A. Synostotic
B. Cartilaginous
C. Fibrous
D. Synovial

Back 83

d. The hip joint is a synovial joint, which is a ball-and-socket joint freely moving.
a. This refers to bone jointed by bone.
b. This refers to a synchondrodial joint, which involves little movement.
c. This refers to a syndesmodial joint, which unites two bony surfaces by a ligament.

Front 84

When a client is immobilized, which of the following positions is preferred to prevent skin breakdown?
A. Side-lying with knees flexed
B. Semi-Fowler’s position
C. Supine with lower extremities extended
D. Prone with upper extremities flexed

Back 84

b. This is the preferred position because head of bed is elevated 30 degrees.
a. This position will put pressure on the greater trochanter area.
c. This puts pressure on scapula, buttocks, calf, and heels.
d. This puts pressure on anterior pelvis, knees, and elbows.

Front 85

An immobilized client is at risk for:
A. Hypercalcemia
B. Hypocalcemia
C. Hypernatremia
D. Hyponatremia

Back 85

a. Immobility leads to calcium being released from bone and going into the bloodstream.
b. This is a calcium deficiency and not a result of immobility.
c. This is an elevated sodium level and not a result of immobility.
d. This is a sodium deficiency and not a result of immobility.

Front 86

The most significant hazard of restricted mobility is:
A. Orthostatic hypotension
B. Tachycardia
C. Foot drop
D. Deep vein thrombosis

Back 86

d. An embolus may develop from a dislodged venous thrombus.
a. This is a lowered blood pressure when moving from supine to sitting or standing.
b. Recumbent position leads to an increase in cardiac workload, resulting in tachycardia.
c. This is a common debilitating contracture.

Front 87

Which of the following is the highest priority nursing diagnosis in an immobilized client? Risk for:
A. Ineffective peripheral tissue perfusion
B. Disuse syndrome
C. Deficient fluid volume
D. Ineffective airway clearance

Back 87

d. Airway is always the highest priority.
a. Circulation is not a priority over airway.
b. Disuse syndrome is not a priority over airway.
c. Deficient fluid volume is not a priority over airway.

Front 88

What type of diet is most important for an immobilized client?
A. High protein, high calorie
B. Low sodium
C. Heart healthy
D. Restricted carbohydrates

Back 88

a. This provides fuel to meet metabolic needs and replace subcutaneous tissues.
b. This will not provide adequate fuel or help in building tissues.
c. This will not provide adequate fuel or help in building tissues.
d. Restricting carbohydrates will not provide adequate fuel to meet metabolic needs.

Front 89

The immobilized client should be instructed to:
A. Take in a minimum of 2000 ml/day
B. Deep breathe and cough every 2 to 4 hours
C. Eat a restricted-calorie diet
D. Quickly resume walking exercises when able

Back 89

a. This amount of fluid helps keep mucociliary clearance normal.
b. The client should cough and deep breathe every 2 hours
c. A restricted-calorie diet will not help meet metabolic needs.
d. Exercises should always be resumed gradually.

Front 90

Antagonistic muscles bring about movement at the

Back 90

muscle

Front 91

proprioception is

Back 91

awereness of the position of the body

Front 92

balance is controlled by the nervous system, specifically by the

Back 92

cerebellum and inner ear

Front 93

a client with a right sided cerebral hemorrhage will have

Back 93

left-sided hemiplegia

Front 94

the greatest change in and impact on the maturational process is observed in

Back 94

childhood and old-age

Front 95

clients are more open to developing an exercise program if they

Back 95

are ata stage of readiness to change their behavior

Front 96

a principle of good body mechanics includes

Back 96

maintaining a wide base of support and bending at the knees.

Front 97

when assessing a clinet for obstructive sleep apnea, the nurse understands the most common symptom is

Back 97

excessive daytime sleepiness

Front 98

a client taking a beta-adrenergic blocker for hypertension can experience interference with sleep patterns such as

Back 98

increased daytime sleepniness