NCLEX - W6 - Sleep, Rest, Mobility

Question 1

Sleep and Rest
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Question: A nurse is caring for a client who reports difficulty sleeping. Which of the following actions should the nurse take first?
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A. Administer a prescribed sleep medication.
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B. Ask the client about their usual sleep patterns and rituals.
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C. Encourage the client to exercise 1 hour before bedtime.
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D. Teach the client about the importance of limiting caffeine intake.
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Answer 1

Answer: B
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Rationale: Before implementing any interventions, the nurse must first assess the client’s usual sleep patterns and rituals to understand their specific needs and identify potential factors contributing to their sleep difficulties.

Question 2

Question: A client is admitted to the hospital for a sleep study. Which of the following diagnostic tests is most commonly used to diagnose sleep apnea?
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A. Electrocardiogram (ECG)
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B. Polysomnography
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C. Electroencephalogram (EEG)
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D. Electromyography (EMG)
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Answer 2

Answer: B
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Rationale: Polysomnography is the most common sleep study used to diagnose sleep apnea, as it records various physiological parameters during sleep, including brain-wave activity, eye movement, oxygen and carbon dioxide levels, vital signs, and body movements.

Question 3

Question: A nurse is caring for a client diagnosed with narcolepsy. Which of the following medications would the nurse expect to be prescribed for this client?
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A. Zolpidem (Ambien)
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B. Methylphenidate (Ritalin)
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C. Temazepam (Restoril)
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D. Diphenhydramine (Benadryl)
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Answer 3

Answer: B
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Rationale: Narcolepsy is a chronic sleep disorder characterized by excessive daytime sleepiness and sudden, uncontrollable sleep attacks. Central nervous system stimulants like methylphenidate are used to manage narcolepsy by promoting wakefulness.

Question 4

Question: A client with chronic insomnia asks the nurse about using over-the-counter (OTC) sleep medications. What is the most important information for the nurse to provide?
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A. OTC sleep medications are generally safe for long-term use.
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B. Check the ingredient label to see if the medication contains an antihistamine.
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C. It is best to take the medication right before going to bed.
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D. OTC sleep medications are more effective than prescription medications.
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Answer 4

Answer: B
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Rationale: Many OTC sleep aids contain antihistamines, which can cause side effects such as constipation, urinary retention, and memory impairment, especially with prolonged use. The nurse should advise the client to check the label and consult with their prescriber or pharmacist before using OTC sleep medications.

Question 5

Question: A nurse is assessing a client who reports feeling tired despite sleeping for 8 hours each night. Which of the following factors could be contributing to the client’s fatigue? Select all that apply.
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A. Use of alcohol before bedtime
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B. Strenuous exercise right before bedtime
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C. A dark, quiet sleep environment
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D. A consistent sleep-wake schedule
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E. Chronic pain
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Answer: A, B, E
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Rationale: Alcohol consumption before bed can disrupt sleep, particularly REM sleep, leading to fatigue. Exercise too close to bedtime can make it difficult to fall asleep. Chronic pain can interfere with sleep quality and quantity, causing fatigue even after a seemingly adequate amount of sleep.

Answer 5

Answer: A, B, E
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Rationale: Alcohol consumption before bed can disrupt sleep, particularly REM sleep, leading to fatigue. Exercise too close to bedtime can make it difficult to fall asleep. Chronic pain can interfere with sleep quality and quantity, causing fatigue even after a seemingly adequate amount of sleep.

Question 6

Question: A nurse is developing a care plan for a hospitalized client with obstructive sleep apnea (OSA). Which of the following interventions should the nurse include in the plan?
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A. Encourage the client to sleep in the supine position.
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B. Administer a sedative medication at bedtime.
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C. Elevate the head of the bed.
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D. Restrict fluids in the evening.
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Answer 6

Answer: C
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Rationale: Elevating the head of the bed can help improve airflow and reduce snoring and apneic episodes in clients with OSA.

Question 7

Question: Which of the following statements by a client indicates an understanding of sleep hygiene practices?
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A. “I should drink coffee right before bed to help me relax.”
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B. “I will go to bed and wake up around the same time each day.”
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C. “I will make sure to take a long nap every afternoon.”
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D. “I should watch television in bed to help me fall asleep.”
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Answer 7

Answer: B
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Rationale: Maintaining a consistent sleep-wake schedule helps regulate the body’s circadian rhythm, promoting better sleep.

Question 8

Question: A nurse is caring for an older adult client who is experiencing sleep disturbances. Which of the following age-related changes is most likely contributing to the client’s sleep problem?
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A. Increased REM sleep
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B. Decreased sleep latency
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C. Advanced sleep phase syndrome
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D. Increased total sleep time
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Answer 8

Answer: C
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Rationale: Older adults often experience advanced sleep phase syndrome, which causes them to feel sleepy earlier in the evening and wake up earlier in the morning.

Question 9

Question: Which of the following symptoms are characteristic of sleep deprivation? Select all that apply.
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A. Decreased reaction time
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B. Improved concentration
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C. Increased energy levels
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D. Irritability
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E. Impaired cognitive function
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Answer 9

Answer: A, D, E
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Rationale: Sleep deprivation can lead to slowed reaction time, irritability, and difficulty processing information, making decisions, and problem-solving.

Question 10

Question: Which of the following statements about rest and sleep is accurate?
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A. Rest is more restorative than sleep.
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B. Sleep is a passive state with minimal brain activity.
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C. Rest without sleep is sufficient for physical and mental recovery.
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D. Sleep helps reduce stress and anxiety.
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Answer 10

Answer: D
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Rationale: Sleep plays a role in reducing stress and anxiety, contributing to improved coping and focus on daily activities.

Question 11

Question: A nurse is assisting a client with ambulation after surgery. Which of the following actions by the nurse demonstrates proper body mechanics?
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A. Bending at the waist to lift the client.
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B. Keeping the client at arm’s length while walking.
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C. Maintaining a wide base of support with feet apart.
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D. Twisting the torso to position the client.
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Answer 11

Answer: C
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Rationale: Maintaining a wide base of support by keeping the feet apart provides stability and balance, reducing the risk of injury when assisting with ambulation.

Question 12

Question: A client is prescribed crutches for ambulation after a leg injury. Which of the following crutch gaits would be most appropriate for a client who is allowed to bear weight on both legs?
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A. Two-point gait
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B. Three-point gait
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C. Four-point gait
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D. Swing-to gait
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Answer 12

Answer: A
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Rationale: The two-point gait is used when the client can bear partial weight on both legs. It involves moving the opposite crutch and leg forward simultaneously, mimicking a natural walking pattern.

Question 13

Question: A nurse is caring for a client with prolonged immobility. Which of the following interventions should the nurse implement to prevent deep vein thrombosis (DVT)?
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A. Encourage active range-of-motion (ROM) exercises.
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B. Apply sequential compression devices (SCDs).
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C. Limit fluid intake.
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D. Massage the client’s calves.
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Answer 13

Answer: B
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Rationale: SCDs promote venous return by applying intermittent pressure to the legs, reducing the risk of DVT formation in immobile clients.

Question 14

Question: A nurse is planning care for a client with impaired physical mobility. Which of the following is a priority nursing diagnosis for this client?
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A. Risk for Imbalanced Nutrition: Less Than Body Requirements
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B. Risk for Impaired Skin Integrity
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C. Ineffective Coping
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D. Social Isolation
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Answer 14

Answer: B
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Rationale: Immobile clients are at high risk for pressure ulcers and skin breakdown due to prolonged pressure on bony prominences. Preventing skin integrity issues is a priority for clients with impaired mobility.

Question 15

Question: A client is being discharged home after a hip replacement. Which of the following instructions should the nurse provide to prevent hip dislocation?
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A. Keep the hip flexed at a 90-degree angle.
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B. Avoid crossing the legs.
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C. Sleep on the affected side.
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D. Sit in low chairs.
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Answer 15

Answer: B
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Rationale: Clients should avoid adduction and internal rotation of the hip after hip replacement surgery. Crossing the legs can lead to hip dislocation.

Question 16

Question: Which of the following exercises are classified as isometric?
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A. Lifting weights
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B. Swimming laps
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C. Holding a plank position
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D. Cycling on a stationary bike
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Answer 16

Answer: C
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Rationale: Isometric exercises involve muscle contraction without joint movement, such as holding a static position like a plank.

Question 17

Question: A nurse is teaching a client about the benefits of regular exercise. Which of the following statements by the client indicates a need for further teaching?
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A. “Exercise can help me control my blood sugar.”
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B. “Exercise can increase my risk of heart disease.”
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C. “Exercise can improve my mood.”
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D. “Exercise can strengthen my bones.”
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Answer 17

Answer: B
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Rationale: Regular exercise has been shown to reduce the risk of heart disease, not increase it.

Question 18

Question: A nurse is assessing an older adult client’s risk for falls. Which of the following factors increases the client’s risk?
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A. Use of a walker
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B. History of falls
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C. Regular exercise routine
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D. Adequate lighting in the home
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Answer 18

Answer: B
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Rationale: A history of previous falls is a significant risk factor for future falls in older adults

Question 19

Question: A client with limited mobility is being discharged home. Which of the following assistive devices would be most appropriate for the client to use when transferring from bed to chair?
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A. Cane
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B. Crutches
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C. Walker
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D. Transfer board
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Answer 19

Answer: D
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Rationale: A transfer board provides a smooth, stable surface for clients with limited mobility to slide across when moving between surfaces, such as bed to chair.

Question 20

Question: Which of the following physiological changes can occur as a result of prolonged immobility?
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A. Increased bone density
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B. Increased muscle mass
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C. Decreased lung capacity
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D. Improved circulation
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Answer 20

Answer: C
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Rationale: Immobility can lead to decreased lung expansion and atelectasis, resulting in reduced lung capacity and increased risk of respiratory complications.

Question 21

Question: Which of the following positions is most appropriate for a client with difficulty breathing?
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A. Supine
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B. Prone
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C. Fowler’s
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D. Sims’
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Answer 21

Answer: C
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Rationale: Fowler’s position, with the head of the bed elevated, promotes lung expansion and improves ventilation, making it beneficial for clients with respiratory distress.

Question 22

Question: A nurse is caring for a client with a fractured hip. Which of the following devices is commonly used to prevent external rotation of the hip?
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A. Trochanter roll
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B. Foot cradle
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C. Hand splint
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D. Abduction pillow
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Answer 22

Answer: A
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Rationale: Trochanter rolls are positioned alongside the hips to prevent external rotation, which is important for clients with hip fractures or after hip surgery

Question 23

Question: Which of the following actions should the nurse take when assisting a client with ambulation who is using a walker?
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A. Walk behind the client, holding onto the walker.
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B. Encourage the client to take small, shuffling steps.
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C. Have the client lift the walker and move it forward, then step into it.
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D. Advise the client to look down at their feet while walking.
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Answer 23

Answer: C
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Rationale: When using a walker, the client should lift the walker and move it forward a short distance, then step into the walker while maintaining balance and stability

Question 24

Question: A nurse is caring for a client who has been on bedrest for an extended period. Which of the following nursing diagnoses is most appropriate for this client?
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A. Impaired Physical Mobility
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B. Risk for Falls
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C. Activity Intolerance
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D. Ineffective Airway Clearance
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Answer 24

Answer: A
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Rationale: Impaired Physical Mobility specifically addresses the client’s limited ability to move purposefully and independently due to the prolonged bedrest.

Question 25

Question: A client is experiencing fatigue related to chronic pain and immobility. Which of the following interventions should the nurse prioritize?
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A. Encourage the client to push through the fatigue and exercise.
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B. Promote a balance of rest and activity.
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C. Administer a stimulant medication.
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D. Refer the client to physical therapy.
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Answer 25

Answer: B
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Rationale: For clients with fatigue related to pain and immobility, finding a balance between rest and activity is essential to avoid overexertion while gradually increasing their tolerance for activity.

Question 26

Question: A nurse is providing care to a client who is postoperative day 1 following abdominal surgery. The client is hesitant to get out of bed due to pain and fear of pulling on the incision. What should the nurse do first?
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A. Reassure the client that it is important to start moving early to prevent complications.
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B. Administer pain medication as prescribed and allow time for it to take effect.
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C. Explain the benefits of early ambulation, such as improved circulation and reduced risk of pneumonia.
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D. Ask a colleague to assist with moving the client to reduce strain on the nurse’s back.
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Answer 26

Answer: B
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Rationale: Addressing the client’s pain is essential before encouraging them to move. By administering pain medication and allowing time for it to take effect, the nurse can ensure the client’s comfort and cooperation during mobilization.

Question 27

Question: A nurse is caring for an older adult client who has experienced a decline in mobility and activity tolerance following a recent illness. What should the nurse do to promote the client’s independence and prevent further functional decline?
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A. Encourage the client to participate in activities they enjoy and are physically able to do.
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B. Assist the client with all aspects of personal care to minimize their exertion.
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C. Focus on passive range-of-motion exercises to maintain joint flexibility.
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D. Limit social interaction to prevent the client from becoming fatigued.
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Answer 27

Answer: A
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Rationale: Engaging the client in activities they enjoy and can perform safely promotes a sense of purpose, improves mood, and encourages physical activity, helping to maintain their independence and prevent further decline.

Question 28

Question: A nurse is caring for a client who is prescribed bedrest following a spinal injury. What safety measures should the nurse implement to minimize the client’s risk of injury while in bed? Select all that apply.
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A. Keep the bed in the lowest position.
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B. Engage the bed alarm when the client is unattended.
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C. Place the call light within easy reach.
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D. Keep the side rails raised at all times.
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E. Provide regular repositioning and skin assessments.
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Answer 28

Answer: A, B, C, E
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Rationale: Lowering the bed, using a bed alarm, ensuring easy access to the call light, and providing regular repositioning and skin assessments are crucial safety measures to protect clients on bedrest from falls, pressure ulcers, and other complications. While side rails can be helpful for some clients, raising them at all times can pose a risk of entrapment and may be considered a restraint, requiring careful consideration and adherence to facility policy.

Question 29

Question: A client is prescribed a continuous passive motion (CPM) machine following knee replacement surgery. What is the primary purpose of this device?
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A. To strengthen the surrounding muscles.
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B. To improve range of motion and prevent joint stiffness.
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C. To relieve pain and inflammation.
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D. To promote circulation and reduce swelling.
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Answer 29

Answer: B
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Rationale: CPM machines are designed to passively move the joint through a controlled range of motion, promoting flexibility, preventing contractures, and facilitating healing after surgery.

Question 30

Question: A nurse is providing discharge teaching to a client who will be using crutches at home. What instructions should the nurse include to ensure the client’s safety?
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A. Measure the crutches so that the handgrips are level with the client’s waist.
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B. Advise the client to lean on the crutches for support when standing or walking.
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C. Instruct the client to keep their elbows straight when using the crutches.
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D. Teach the client to position the crutches about 6 inches in front of their feet with each step.
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Answer 30

Answer: D
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Rationale: Clients should position their crutches slightly ahead of their feet with each step to maintain balance and prevent falls. The handgrips should be level with the wrists, elbows should be slightly bent, and clients should not lean on the crutches for support, as this can put pressure on the armpits and nerves.