Practice Quiz Answers

Unit 12

Question 1

In describing the sleep patterns of older adults, the nurse recognizes that they:

A) Are more difficult to arouse

B) Require more sleep than middle-aged adults
C) Take less time to fall asleep
D) Have a decline in stage 4 sleep.

Correct Answer: D

Explanation: D: As people age, a progressive decrease occurs in stages 3 and 4 NREM sleep;
some older adults have almost no stage 4, or deep sleep.
A. As people age, they do not become more difficult to arouse.
B. The older adult does not require more sleep than the middle-aged adult.
C. An older adult awakens more often during the night, and it may take more time for an older
adult to fall asleep.

Question 2

While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The
nurse, alert to a syncopal episode, should first:

A) Support the client and walk quickly back to the room

B) Lean the client against the wall until the episode passes
C) Lower the client gently to the floor
D) Go for help

Correct Answer: C

Explanation: C: If the client has a syncopal episode or begins to fall, the nurse should assume a
wide base of support with one foot in front of the other, supporting the client’s weight, and then
extend the leg allowing the client to slide against the leg gently lowering the client to the floor and
protecting the client’s head.
A. The nurse should not attempt to walk the client quickly back to the room.
B. The nurse should not lean the client against a wall as he or she might fall.
D. The nurse should not leave the client alone and go for help.

Question 3

For a client who is currently taking a diuretic, the nurse should inform the client that he or she
may experience:

A) Nocturia
B) Nightmares
C) Increased daytime sleepiness
D) Reduced REM sleep

Correct Answer: A

Explanation: A: For the client who is currently taking a diuretic, the nurse should inform the client
that he or she might experience nighttime awakening because of nocturia.
B. Diuretic use does not cause nightmares.
C. Diuretics do not cause increased daytime sleepiness.
D. Diuretics do not reduce REM sleep.

Question 4

A nursing intervention to assist the client with a nursing diagnosis of “Sleep pattern disturbance
related to the loss of spouse and fear of nightmares” should be to:

A) Administer sleeping medication per order

B) Refer the client to a psychologist or psychotherapist
C) Have the client complete a detailed sleep-pattern assessment
D) Sit with the client and encourage verbalization of feelings

Correct Answer: D

Explanation: D: A nursing intervention to facilitate grief work is to offer the client encouragement
to explore and verbalize feelings of grief. This encouragement refocuses the client on current
needs and minimizes dysfunctional adaptation behaviors (e.g., not sleeping) by facilitating
resolution of grief through problem-solving skills.
A. Administering sleeping medication may help the client get to sleep, but does not resolve the
issue of grief. Without addressing the grief, the client may develop another dysfunctional
adaptation behavior.
B. It is not necessary to refer the client to a psychologist or psychotherapist at this time. The client
should first be encouraged to verbalize his or her feelings.
C. Having the client complete a detailed sleep-pattern assessment may help the nurse identify
the number of hours of sleep the client is obtaining, but it does not address the issue causing the
sleep disturbance, which is grief from the loss of the spouse.

Question 5

Nurses must implement appropriate body mechanics to prevent injury to themselves and clients.
Which principle of body mechanics should the nurse incorporate into client care?

A) Flex the knees, and keep the feet wide apart

B) Assume a position far enough away from the client
C) Twist the body in the direction of movement
D) Use the strong back muscles for lifting or moving

Correct Answer: A

Explanation: A: Flexing the knees and keeping the feet wide apart provides a broad base of
support and increases stability.
B. The nurse should position himself or herself close to the client or object being lifted to minimize
the force (10 pounds held at waist height close to the body is equal to 100 pounds held at arms’
length). Having the client or object close to the center of gravity also helps maintain balance.
C. Twisting should be avoided, as it increases the risk of back injury.
D. The leg muscles should be used for lifting or moving. They are stronger, larger muscles
capable of greater work without injury.

Question 6

The nurse is assessing the body alignment of an alert and mobile client. The first action that the
nurse should take is to:

A) Observe gait
B) Put the client at ease
C) Determine activity tolerance
D) Determine range of joint motion

Correct Answer: B

Explanation: B: The first step in assessing body alignment is to put the client at ease so that
unnatural or rigid positions are not assumed.
A. When assessing body alignment, the nurse’s first action is to put the client at ease. Later the
nurse may assess the client’s gait to observe the client’s balance, posture, and ability to walk
without assistance.
C. Activity tolerance is the kind and amount of exercise or activity a person is able to perform. It is
not the first step in assessing a client’s body alignment.
D. Assessing ROM is one of the first assessment techniques used to determine the degree of
damage or injury to a joint. It is not the first step in assessing a client’s body alignment.

Question 7

When a client is deprived of sleep, the nurse might assess such symptoms as:

A) Elevated blood pressure and confusion

B) Confusion and irritability
C) Inappropriateness and rapid respirations
D) Decreased temperature and talkativeness

Correct Answer: B

Explanation: B: Psychological symptoms of sleep deprivation include confusion and irritability.

A. Elevated blood pressure is not a symptom of sleep deprivation.
C. Rapid respirations are not a symptom of sleep deprivation. A decreased ability of reasoning
and judgment could lead to inappropriateness.
D. Decreased temperature is not a symptom of sleep deprivation. The client with sleep
deprivation is often withdrawn, not talkative.

Question 8
A client has been on bed rest for a prolonged period. Which of the following is an example of
isometric exercise the nurse would suggest to prevent the complications of bed rest?

A) Quadriceps setting
B) Deep breathing exercises
C) Moving the arms and legs in circles
D) Pushing against a footboard

Correct Answer: A

Explanation: A. Quadriceps setting is an example of an isometric exercise.

B. Deep breathing is important to preventing complications of bedrest but it is not an isometric

exercise.
C. Moving the arms and legs in a circle is an example of isotonic exercise.

D: Resistive isometric exercises are those in which the individual contracts the muscle while
pushing against a stationary object or resisting the movement of an object. An example of a
resistive isometric exercise is pushing against a footboard.

Question 9

The nurse is discussing sleep habits with the client in the sleep-assessment clinic. Of the
following activities performed before sleeping, the nurse is alert to the one that may be interfering
with the client’s sleep, which is:

A) Listening to classical music

B) Finishing office work
C) Reading novels
D) Drinking warm milk

Correct Answer: B

Explanation: B: At home a client should not try to finish office work or resolve family problems
before bedtime.
A. Noise should be kept to a minimum. Soft music may be used to mask noise if necessary.
C. Reading a light novel, watching an enjoyable television program, or listening to music helps a
person to relax. Relaxation exercises can be useful at bedtime.
D. A dairy-product snack such as warm milk or cocoa that contains L-tryptophan may be helpful
in promoting sleep.

Question 10

In teaching methods to promote positive sleep habits at home, the nurse instructs the client to:

A) Use the bedroom only for sleep or sexual activity

B) Eat a large meal 1 to 2 hours before bedtime
C) Exercise vigorously before bedtime
D) Stay in bed if sleep does not come after 1/2 hour

Correct Answer: A

Explanation: A: The nurse should explain that if possible, the bedroom should not be used for
intensive studying, snacking, TV watching, or other nonsleep activity, besides sex.
B. The nurse should instruct the client to avoid heavy meals for 3 hours before bedtime; a light
snack may help.
C. The nurse should instruct the client to try to exercise daily, preferably in morning or afternoon,
and to avoid vigorous exercise in the evening within 2 hours of bedtime.
D. The nurse should advise the client to get out of bed and do some quiet activity until feeling
sleepy enough to go back to bed if the client does not fall asleep within 30 minutes of going to
bed.

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