NR-226 Patient Care Fundamentals - Set 4 - Part 3

Correct Answer: Slowed dark adaptation makes this a fall risk

A smaller pupil and slower photopigment regeneration mean the aging eye needs extra time moving from bright light into darkness. This doorway transition is a known fall event, so night lights belong in the plan. Option a is incorrect because her vision is not lost, only slow to adjust. She sees perfectly well in the lit corridor, and an urgent referral would treat a universal age change as an emergency. Option b is incorrect because no eye disease is present in this client. A clouded lens produces glare, halos and gradual blurring across all conditions rather than a delay confined to a lighting change. Option c is incorrect because she reports her problem accurately and stops walking to stay safe, which is intact judgment. Labeling a sensory limit as confusion invites a sitter when a night light would solve it.

Correct Answer: Addiction is uncommon when opioids treat short-term surgical pain.

Addiction is a behavioral disease marked by compulsive use and craving, and it is uncommon when opioids are used appropriately for acute surgical pain. Correcting the misconception removes the barrier that leads to undertreatment. Option a is incorrect because it abandons an indicated analgesic instead of addressing the fear behind the refusal. Cold and other comfort measures are adjuncts that raise the effect of medication; they do not cover severe postoperative pain. Option c is incorrect because a rising dose requirement describes tolerance, a normal physiological adaptation. Labeling it addiction repeats the very error the client fears and would make him even less willing to accept relief. Option d is incorrect because severe pain is harder to control and ends up requiring larger total doses. Teaching a client to hold out until the pain peaks works directly against the goal of early, lower-dose relief.

Correct Answer: "Alcohol shortens onset but fragments the later night."

Alcohol is a central nervous system depressant, so it does shorten sleep latency. As it is metabolized it produces rebound arousal, suppresses dreaming sleep, worsens snoring and apnea, and causes nocturia. Option a is incorrect because denying the sedating effect contradicts what the client experiences and costs the nurse credibility. The teaching point is what alcohol does to the rest of the night, not to sleep onset. Option b is incorrect because even modest evening intake relaxes upper airway muscle, fragments the second half of the night and drives urine output. Endorsing a nightly glass leaves the underlying sleep problem untouched. Option c is incorrect because sedating antihistamines sold without prescription bring anticholinergic effects, next-day grogginess and rapid tolerance. Trading one poor sleep aid for another skips the behavioral changes this client needs.

Correct Answer: Cluster care to protect an uninterrupted block

Every arousal returns the sleeper to the lightest stage and restarts the descent, so hourly contacts prevent any complete cycle. Grouping care into fewer entries is the independent nursing action that restores architecture. Option a is incorrect because a hypnotic cannot overcome hourly interruptions and adds fall risk, next-day sedation and confusion. Medication belongs after the modifiable environmental causes have actually been removed, not before. Option c is incorrect because daytime sleeping discharges the homeostatic pressure that should be building toward night. Napping is a perpetuating behavior in hospital, and a long one also drags the client out of deep sleep. Option d is incorrect because the problem is fragmentation rather than insufficient opportunity. This client already has ample time in bed; lengthening it simply supplies more hours in which the same interruptions occur.

Correct Answer: Brain wave activity resembling the waking state

The findings describe REM sleep, which is called paradoxical because the electroencephalogram looks fast and awake-like while the body is atonic. Cerebral blood flow and brain metabolism rise toward waking levels. Option b is incorrect because delta waves are the signature of N3, the slow-wave stage that sits in the first third of the night. Muscle tone there is very relaxed but never paralyzed. Option c is incorrect because heart rate, blood pressure and temperature bottom out during deep NREM sleep. In the period described they swing unpredictably, since autonomic control becomes unstable once rapid eye movements begin. Option d is incorrect because spindles and K-complexes define N2 and act as sensory gates that shield a sleeper from minor noise. Eye movement has stopped by then, which the described recording contradicts.

Correct Answer: Assess for pain, retention and low oxygen saturation

Delirium demands a search for the physiological cause, and undertreated pain, urinary retention and hypoxia are among the most common and most correctable. Treating the cause resolves the agitation that restraints and sedation only mask. Option a is incorrect because restraints escalate agitation, cause injury, and deepen the immobility that prolongs delirium. They are a last resort after the cause has been sought and safer measures have failed. Option b is incorrect because benzodiazepines worsen delirium in older adults and are reserved for alcohol or benzodiazepine withdrawal. Sedating this client would quiet the noise while the untreated cause continues doing damage. Option d is incorrect because closer observation improves surveillance without changing what is driving the confusion. Relocation also strips away whatever familiarity his room offered, which can deepen disorientation in a client already losing his bearings.

Correct Answer: Dilute and give small increments every few minutes

In an opioid tolerant client, naloxone is diluted and given in small increments titrated to adequate respiratory effort rather than full wakefulness. Abrupt complete reversal causes severe withdrawal, uncontrolled pain, hypertension and arrhythmia. Option a is incorrect because a full undiluted bolus strips every receptor at once. That produces acute withdrawal, a return of the original pain in full force, and rarely noncardiogenic pulmonary edema. Option b is incorrect because the endpoint is breathing, not alertness. Chasing full wakefulness pushes past the dose needed for safe ventilation and hands the client agitation, tachycardia and uncontrolled pain for nothing. Option c is incorrect because intramuscular absorption takes several minutes and cannot be titrated once injected. When ventilation is failing, the intravenous route is preferred precisely because each small increment can be judged before the next.

Correct Answer: Request added analgesia beyond the maintenance methadone dose

Maintenance methadone covers the opioid use disorder, not the fracture. This client needs the baseline requirement met plus additional analgesia, and tolerance means the added dose is often higher than an opioid naive client would need. Option a is incorrect because a substance use history never justifies leaving indicated analgesia out of the plan. Untreated pain is itself a relapse trigger, so withholding the drug works against recovery as well as comfort. Option b is incorrect because nalbuphine is an agonist antagonist, and giving one to a client maintained on methadone precipitates acute withdrawal. Agents of that class are avoided entirely in this population. Option d is incorrect because the maintenance dose treats dependence on a daily schedule and does not rise or fall with a broken bone. Waiting for it leaves a client with severe pain untreated for hours.

Correct Answer: Obtain an electrocardiogram and notify the provider

Dyspnea with diaphoresis and nausea is how myocardial infarction commonly presents in an older adult, and a normal rate on a beta blocker reassures no one. An electrocardiogram and provider notification cannot wait. Option a is incorrect because epigastric symptoms in this age group are a recognized anginal equivalent. Treating them as indigestion and waiting an hour is exactly how an infarction goes unrecognized until the damage is done. Option c is incorrect because charting a negative finding is accurate and useless here. The absence of chest pain does not remove acute coronary syndrome from consideration, since a third or more of older adults infarct painlessly. Option d is incorrect because comfort positioning treats anxiety, and nothing here suggests anxiety is the problem. Breathing coaching may accompany care, yet it delays the diagnostic step that decides whether this heart is infarcting.

Correct Answer: Drink on a schedule rather than waiting for thirst

Osmoreceptor sensitivity declines, so an older adult does not feel thirsty until dehydration is well advanced. Scheduled sips through the day replace an unreliable signal, and a toileting plan addresses the leaking she fears. Option b is incorrect because it endorses the very restriction that is drying her out. Fluids can be shifted earlier in the day, but the answer to leaking is a toileting schedule and easy bathroom access. Option c is incorrect because aged skin tents whether or not the person is dry. Elasticity is lost with age, making turgor on the hand useless here; weight, urine color and mental status track hydration better. Option d is incorrect because no supplement supplies water. Vitamins address specific nutrient gaps, and offering one here would let her keep restricting fluid while her kidneys lose the ability to conserve it.