UNIT XIII - Rest, Sleep and Comfort

Question 1

What are the two types of sleep?

Answer 1

REM (Rapid Eye Movement) and NREM (Non-Rapid Eye Movement)

Question 2

What are the stages of NREM?

Answer 2

Stage I
Stage II
Stage III and IV

Question 9

Describe Stage 1 NREM of sleep.

Answer 9

• Very light sleep
• Only a few minutes long
• Vital signs and metabolism beginning to diminish
• Can be awaken easily
• Feels relaxed and drowsy

Question 10

Describe Stage 2 NREM of sleep.

Answer 10

• Deeper sleep
• 10 to 20 min in length
• Vital signs and metabolism continuing to diminish
• Requires slightly more stimulation to be awakened
• Increased relaxation

Question 11

MyNursingLab - Submodule 2.10 Activity

Which intervention would be aimed at promoting sleep in an infant?

A. Keeping room dimly lit
B. Providing a soft pillow
C. Opening a window nearby
D. Keeping room temperature at 80ºF

Answer 11

A. Keeping room dimly lit

Question 11

Describe Stage 3 NREM of sleep.

Answer 11

• Deep sleep
• 15 to 30 min in length
• Vital signs continuing to decrease
• Difficult to awaken
• Relaxation such that the person seldom moves

Question 12

Describe Stage 4 NREM of sleep.

Answer 12

• Called delta sleep
• Deepest sleep
• 15 to 30 min in length
• Vital signs very low as compared to when awake
• Very difficult to awaken
• Stage at which the body achieves physical rest and restoration
• Stage at which enuresis and talking and walking in one’s sleep occur
• Repair and renewal of tissue

Question 13

Describe Stage REM of sleep.

Answer 13

• Occurrence of dreams
• Usually begins about 90 min after falling asleep
• Length increases with each sleep cycle
• Average length is 20 minutes
• Varying vital signs
• Very difficult to awaken
• Stage at which mental rest and restoration occur.

Question 14

What is insomnia?

Answer 14

The inability to get an adequate amount of sleep and to feel rested. The person may have difficulty falling asleep; having the difficulty staying asleep, awaken too early.

Question 15

What is sleep apnea?

Answer 15

A disorder in which there are more than five apneic occurrences lasting longer than 10 seconds/hr during sleep

Question 16

What is narcolepsy?

Answer 16

A disorder of the sleep and wake mechanism. The person may lose the ability to stay awake.

Question 17

What is referred pain?

Answer 17

Appear to arise in different areas to other parts of the body.

Question 18

What is visceral pain?

Answer 18

Pain arising from organs or hollow viscera

Question 19

What is somatic pain?

Answer 19

Pain that originates in the skin, muscles, bone or connective tissues.

Question 20

What is pain threshold?

Answer 20

Is the least amount of stimuli that is in needed for a person to label a sensation as pain.

Question 21

What is Pain Tolerance?

Answer 21

Is the maximum amount of painful stimuli that a person is willing to withstand without seeking avoidance of avoidance of the pain

Question 22

Define Hyperalgesia (or hyperpathia).

Answer 22

Increased sensation of pain in response to a normally painful stimulus.

Question 23

Define Allodynia.

Answer 23

Sensation of pain from a stimulus that normally does not produce pain (e.g. light touch)

Question 24

Define dysethesia

Answer 24

An unpleasant abnormal sensation that can be either spontaneous or evoked.

Question 25

MyNursingLab - Submodule 2.10 Activity

The nurse notes that a resident is having trouble sleeping shortly after being admitted to a long-term care facility. Which action by the nurse might be most beneficial?

A. Allowing the resident to sleep for long periods during the day
B. Offering a sleeping medication
C. Finding out the client’s prior sleep habits
D. Moving the client’s room closer to the nurse’s station

Answer 25

C. Finding out the client’s prior sleep habits

Question 25

MyNursingLab - Submodule 2.10 Activity

The nurse finds a client up at 3 a.m. The nurse’s best approach would be to:

A. Talk to the client to see what factors are disturbing his or her sleep
B. Encourage the client to do some light exercise
C. Turn on the television for awhile
D. Give the client a hypnotic medication

Answer 25

A. Talk to the client to see what factors are disturbing his or her sleep

Question 25

Berman Workbook - Chapter 31

What position is good for resting and sleeping clients?

A. Supine
B. Prone
C. Fowler’s
D. Lateral

Answer 25

D. Lateral

Question 25

Berman Workbook - Chapter 31

What position should be used for unconscious clients to facilitate drainage from the mouth and prevent aspiration of fluids?

A. Sims’
B. Prone
C. Supine
D. Lateral

Answer 25

A. Sims’

Question 25

Berman Textbook - Chapter 31

A client has a history of sleep apnea. A priority nursing interview question is which of the following?

A. “Do you have a history of cardiac irregularities?”
B. “Do you have a history of any kind of nasal obstruction?”
C. “Have you had chest pain with or without activity?”
D. “Do you have difficulty with daytime sleepiness?”

Answer 25

D. “Do you have difficulty with daytime sleepiness?”

Question 25

ATI Fundamentals Book - Chapter 38 (Rest and Sleep)

A nurse is caring for a client who presents to the clinic reporting fatigue and an inability to sleep at night. Which of the following questions should the nurse ask when collecting data about the client’s difficulty sleeping? (Select all that apply.)

A. Does your lack of sleep interfere with your ability to function during the day?
B. Do you experience confusion in the late afternoon?
C. Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?
D. Has anyone ever told you that you seem to stop breathing for a few seconds while are asleep?
E. Tell me about any personal stress you are experiencing.

Answer 25

A. Does your lack of sleep interfere with your ability to function during the day?
C. Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?
D. Has anyone ever told you that you seem to stop breathing for a few seconds while are asleep?
E. Tell me about any personal stress you are experiencing.

Question 26

ATI Fundamentals Book - Chapter 38 (Rest and Sleep)

Which of the following recommendations should a nurse give to a client to promote sleep and rest? (Select all that apply.)

A. Avoid all caffeinated beverages
B. Participate in regular exercise each morning.
C. Take an afternoon nap.
D. Practice relaxation exercises before bedtime.
E. Limit fluid intake at least 2 hr before bedtime.

Answer 26

B. Participate in regular exercise each morning.
D. Practice relaxation exercises before bedtime.
E. Limit fluid intake at least 2 hr before bedtime.

Question 27

ATI Fundamentals Book - Chapter 38 (Rest and Sleep)

A nurse is caring for an older adult client who has been bating in the morning following the facility’s routine. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following interventions should the nurse take first?

A. Rub her back for 15 min before bedtime.
B. Offer her warm milk and crackers at 2100.
C. Allow her to take a bath in the evening.
D. Ask her provider for a sleeping medication.

Answer 27

C. Allow her to take a bath in the evening.

Question 28

MyNursingLab - Submodule 2.15 Pain

On admission, the client gives a history of severe pain for the past year. The nurse correctly documents this as:

A. Intractable pain
B. Cutaneous pain
C. Chronic pain
D. Acute pain

Answer 28

C. Chronic pain

Question 29

MyNursingLab - Submodule 2.15 Pain

Which of the following interventions by the nurse will help reduce the client’s pain?

A. Providing ambulation
B. Providing comfort measures
C. Tell the client that everything will be alright
D. Offering sympathy

Answer 29

B. Providing comfort measures

Question 30

MyNursingLab - Submodule 2.15 Pain

Which of the following findings can be a result of severe long-term pain?

A. Hyperactive bowel sound
B. Euphoria
C. Depression
D. Increased activity

Answer 30

C. Depression

Question 31

MyNursingLab - Submodule 2.15 Pain

The doctors are discussing a client’s pain and classify the pain as visceral. The LPN understands that the pain:

A. is in the muscles
B. comes from the bone
C. is located deep in the internal organs
D. comes from the peripheral nerves

Answer 31

C. is located deep in the internal organs

Question 32

MyNursingLab - Submodule 2.15 Pain

The nurse records that the client’s pain is referred because it is:

A. the result of removal of a limb
B. originating in the mind
C. experienced at a distance from the site of origin
D. Radiating beyond its origin

Answer 32

C. experienced at a distance from the site of origin

Question 33

MyNursingLab - Submodule 2.15 Pain

An 80-year-old client is admitted with first degree burns sustained during his morning bath. The nurse instructs the client to use a thermometer to check water temperature because:

A. The older client is less able to perceive pain
B. Someone is obviously abusing the client
C. The client may not know how hot the water should be
D. The older client is probably experiencing senility and needs to be careful

Answer 33

A. The older client is less able to perceive pain

Question 34

MyNursingLab - Submodule 2.15 Pain

The nurse would expect an order for medication for a client with severe pain to read:

A. Aspirin
B. Tylenol
C. Morphine
D. Motrin

Answer 34

C. Morphine

Question 35

MyNursingLab - Submodule 2.15 Pain

What non pharmacological measure can the nurse implement to reduce the client’s pain?

A. Provide patient-controlled analgesia
B. Provide distraction to draw client’s attention away from the pain
C. Increase fluid intake
D. Put the joints through full active range of motion

Answer 35

B. Provide distraction to draw client’s attention away from the pain

Question 36

MyNursingLab - Submodule 2.15 Pain

Pain assessment is classified as a symptom that is:

A. Subjective
B. Holistic
C. Objective
D. Reasonable

Answer 36

A. Subjective

Question 37

MyNursingLab - Submodule 2.15 Pain

Which of the following factors does not influence the client’s response to pain?

A. Socioeconomic standing
B. Pain threshold
C. Level of anxiety
D. Cultural practices

Answer 37

A. Socioeconomic standing

Question 38

MyNursingLab - Submodule 2.15 Pain

The client in pain has received several high doses of analgesic but continues to report a pain level of 10/10. The nurse informs the primary nurse and documents this as:

A. Intractable pain
B. Visceral pain
C. Acute pain
D. Chronic pain

Answer 38

A. Intractable pain

Rationale:
Intractable pain is unresponsive to analgesics and is severe.

Question 39

Berman Book - Chapter 18 Pain Management

The nurse classifies pain, reported by the client as 6 on a scale of 1 to 10, as which of the following?

A. Mild pain
B. Mild to moderate pain
C. Moderate to severe pain
D. Severe pain

Answer 39

C. Moderate to severe pain

Question 40

Berman Book - Chapter 18 Pain Management

A client who had abdominal surgery 4 hours ago is receiving a continuous epidural infusion of an analgesic. Which of the following observations indicates the nurse should monitor the client closely?

A. Drowsy; drifts off to sleep before completing a sentence.
B. Respirations of 22/minute
C. Drowsy; arouses with simulation
D. Pain rating 4 on 1-10 scale

Answer 40

A. Drowsy; drifts off to sleep before completing a sentence.

Question 41

Berman Book - Chapter 18 Pain Management

During an admission nursing assessment, a client with diabetes describes his leg pain as a “dull, burning sensation.” The nurse recognizes this description to be characteristic of which type of pain?

A. Physiological
B. Somatic
C. Visceral
D. Neuropathic

Answer 41

D. Neuropathic

Rationale:
See page 477. Neuropathic pain is described as “burning, electric-shock,” and/or tingling, dull, and aching.

Question 42

Berman Book - Chapter 18 Pain Management

Which of the following interventions, when implemented by the nurse, would apply the gate control theory of pain? (Select all that apply)

A. Oral analgesics around the clock (ATC)
B. Massage
C. Patient-controlled analgesia (PCA)
D. Heat or cold application
E. Teaching

Answer 42

B. Massage
D. Heat or cold application
E. Teaching

Question 43

Berman Book - Chapter 18 Pain Management

Which statement best reflects the nurse’s assessment of the fifth vital sign?

A. “Do you have any complaints?”
B. “Are you experiencing any discomfort right now?”
C. “Is there anything I can do for you now?”
D. “Do you have any complaints of pain?”

Answer 43

B. “Are you experiencing any discomfort right now?”

Question 44

Berman Book - Chapter 18 Pain Management

When planning care for pain control of older clients, the nurse should apply which of the following principles? (Select all that apply.)

A. Pain is a natural outcome of the aging process.
B. Pain perception increases with age.
C. The client may deny pain.
D. The nurse should avoid use of narcotics.
E. The client may describe pain as an “ache” or “discomfort”.

Answer 44

C. The client may deny pain.

E. The client may describe pain as an “ache” or “discomfort”.

Question 45

Berman Book - Chapter 18 Pain Management

A client recovering from abdominal surgery refuses analgesia, saying that he is “fine”, as long as he doesn’t move.” Which of the following nursing diagnoses should be a priority?

A. Deficient knowledge (pain control measure)
B. Ineffective Health Maintenance
C. Risk for ineffective Airway Clearance
D. Impaired Physical Mobility

Answer 45

A. Deficient knowledge (pain control measure)

Question 46

Berman Workbook - Chapter 18 Pain Management

When should pain be evaluated?

A. When the client complains of pain
B. When the client grimaces
C. When vital signs are taken
D. At least once q8h.

Answer 46

C. When vital signs are taken

Question 47

Berman Workbook - Chapter 18 Pain Management

Pain felt in one area of the body may be caused by another site. For example, pain to the right shoulder could be from the gallbladder. What is this called?

A. Chronic pain
B. Acute pain
C. Referred pain
D. Visceral pain

Answer 47

C. Referred pain

Question 48

Berman Workbook - Chapter 18 Pain Management

What form of pain originates in the skin, muscles, bone, or connective tissue?

A. Visceral pain
B. Somatic pain
C. Referred pain
D. Acute pain

Answer 48

B. Somatic pain

Question 49

Berman Workbook - Chapter 18 Pain Management

What type of pain is experienced by people who have damaged or malfunctioning nerves?

A. Referred pain
B. Visceral pain
C. Somatic pain
D. Neuropathic pain

Answer 49

D. Neuropathic pain

Question 50

Berman Workbook - Chapter 18 Pain Management

The nurse is attempting to manage a client’s chronic pain without success and learns from a review of the literature that evidence suggests this pain results from inadequate treatment during the perioperative period. What type of pain does this client have?

A. Somatic pain
B. Referred pain
C. Neuropathic pain
D. Chronic pain

Answer 50

C. Neuropathic pain

Rationale:
See Page 477, Berman Textbook.

Question 51

Berman Workbook - Chapter 18 Pain Management

What is the maximum amount of painful stimuli that a person is willing to withstand without seeking avoidance of the pain or relief?

A. Pain threshold
B. Pain acceptance
C. Pain tolerance
D. Neuropath

Answer 51

C. Pain tolerance

Question 52

Berman Workbook - Chapter 18 Pain Management

A nurse making rounds on a young client noticed he was laughing and having a good time with his visitors. The nurse interrupted and did a set of vitals on the client and asked him to rate his pain. He rated his pain at 6, which did not seem to match his demeanor. What should the nurse do?

A. Wait until after the visitors leave and ask him again.
B. Medicate him because the client should always be believed.
C. Explain the rating system to the client.
D. Medicate him with Tylenol and not the Percocet that was ordered.

Answer 52

B. Medicate him because the client should always be believed.

Question 53

Berman Workbook - Chapter 18 Pain Management

How can nurses accurately evaluate pain?

A. Ask the client.
B. Use the Wong Baker Faces chart.
C. Use numerical pain intensity scales.
D. Evaluate the client through activities.

Answer 53

D. Evaluate the client through activities.

Question 54

Berman Workbook - Chapter 18 Pain Management

Physiologic indicators may vary in infants, so how can pain be determined?

A. Ask them.
B. Observe their behavior.
C. Evaluate the shrillness of their cry.
D. Observe how they respond to holding.

Answer 54

B. Observe their behavior.

Question 55

Berman Workbook - Chapter 18 Pain Management

How does having a support system affect pain?

A. A person without a support network may perceive pain as severe.
B. The person who has supportive people around may perceive less pain.
C. A support system helps to alleviate pain.
D. Friends help to take a person’s mind off pain.

Answer 55

A. A person without a support network may perceive pain as severe.

Question 56

Berman Workbook - Chapter 18 Pain Management

What are coanalgesics beneficial for?

A. Reduce the side effects of analgesics
B. Counteract effects of opioids
C. Potentiate pain medications
D. Manage neuropathic pain

Answer 56

D. Manage neuropathic pain

Question 57

ATI Textbook - Chapter 41 Pain Management

A nurse is assessing the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client if he was experienced nausea and vomiting. The nurse is assessing which of the following?

A. Presence of associated symptoms
B. Location of the pain
C. Pain quality
D. Aggravating and relieving factors

Answer 57

A. Presence of associated symptoms

Question 58

ATI Textbook - Chapter 41 Pain Management

Frequent pain assessment includes quantifying the intensity of the pain. A nurse can best assess the intensity of a client’s pain by

A. asking what precipitates the pain.
B. questioning the client about the location of the pain.
C. offering the client a pain scale to measure his pain.
D. using open-ended questions to identify the sensation.

Answer 58

C. offering the client a pain scale to measure his pain.

Question 59

ATI Textbook - Chapter 41 Pain Management

Which of the following statements are true regarding pain? (Select all that apply.)

A. All cultures have the same attitudes regarding pain.
B. Pain can cause feelings of anger and guilt.
C. It may be difficult to assess pain adequately in a client who is cognitively impaired.
D. A client who is sleeping could not be experiencing pain.
E. It is best to wait until pain is severe before administering analgesics.

Answer 59

B. Pain can cause feelings of anger and guilt.

C. It may be difficult to assess pain adequately in a client who is cognitively impaired.

Question 60

ATI Textbook - Chapter 41 Pain Management

A nurse obtaining a history from a client who has pain knows that

A. most clients exaggerate their level of pain
B. pain must have an identifiable source to justify the use opioids.
C. objective data are essential in assessing pain.
D. pain is whatever the client says it is.

Answer 60

D. pain is whatever the client says it is.

Question 61

ATI - Pain Module

During a pain assessment, the nurse asks questions about the quality of an adult patient’s pain. Which of the following statements by the patient refers to pain quality?

A. “The pain in my abdomen began last night and has gotten worse and worse.”
B. “My pain is at a 9 on a scale of 0 to 10.”
C. “My pain feels like I’m being stabbed by a knife.”
D. “The pain is worse when I bend over at my waist.”

Answer 61

C. “My pain feels like I’m being stabbed by a knife.”

Question 62

ATI - Pain Module

A nurse is caring for a patient just transferred from the PACU following an abdominal hysterectomy. the patient is receiving PCA with IV morphine sulfate 2 mg q15 min with a 30 mg/4hr lockout. One hour after the patient has returned to the unit, the patient tells the nurse that her pain is still unbearable. The nurse checks the PCA monitor and determines that the patient has made six attempts within the last hour. Which of the following actions should the nurse take after performing a pain assessment?

A. Check the IV site and PCA pump for proper functioning.
B. Teach the patient proper use of the PCA system.
C. Ask the provider to increase the morphine dose and shorten the interval between doses.
D. Encourage family members to “push the pain button” when the patient is in too much pain to do it herself.

Answer 62

A. Check the IV site and PCA pump for proper functioning.

Question 63

ATI - Pain Module

A nurse is about to use the Wong-Baker FACES pain scale to assist a patient in assessing his pain level. Which of the following should the nurse know in order to use the pain scale?

A. Face #10 is chosen when the patient is crying because of severe pain.
B. Face #0 is chosen when the pain “hurts a little bit.”
C. This scale is useful for adult patients who have cognitive impairments.
D. The nurse matches a face on the scale with that of the patient’s face when he is in pain.

Answer 63

C. This scale is useful for adult patients who have cognitive impairments.

Question 64

ATI - Pain Module

A nurse is caring for a patient admitted to the emergency department with severe pain following a fall from a ladder. The initial assessment reveals long-term use of opioids for chronic pain. Which of the following provider prescriptions for initial pain relief should the nurse question?

A. Morphine sulfate
B. Pentazocine (Talwin)
C. Meperidine (Demerol)
D. Hydromorphone (Dilaudid)

Answer 64

B. Pentazocine (Talwin)

Question 65

ATI - Pain Module

A nurse is caring for two patients of different cultural backgrounds. Both patients returned from the same type of surgery 2 hr ago. Which of the following should the nurse expect to be the same for both patients?

A. Patient perception of the intensity of postoperative pain
B. Class of medication used to treat acute postoperative pain
C. Goal of pain management for each patient.
D. Level of pain indicated by each patient on a numeric pain scale.

Answer 65

B. Class of medication used to treat acute postoperative pain

Question 66

ATI - Pain Module

A nurse is planning to administer a dose of intravenous morphine sulfate for a postoperative patient. Which of the following is a pain management protocol that should be used by the nurse in this situation?

A. Withhold this medications for a respiratory rate of less than 14/min.
B. Perform the intravenous injection over 1 min.
C. Avoid administering opioid agonists on a fixed schedule.
D. Have an opioid antagonist available during the administration.

Answer 66

D. Have an opioid antagonist available during the administration.

Question 67

ATI - Pain Module

A patient who has been experiencing frequent, severe migraine headaches tells the nurse she has heard that biofeedback is effective in treating migraines. The patient asks the nurse to describe how this pain-relief method wrks. The nurse should reply that biofeedback involves

A. measuring skin tension and using learned techniques to relieve pain.
B. relating soothing visual images identified by the patient to promote relaxation.
C. Listening to an increasing volume of music until the pain subsides.
D. stimulating the skin with a mild electric current when pain occurs.

Answer 67

A. measuring skin tension and using learned techniques to relieve pain.