Exam (elaborations)
HESI COMMUNITY HEALTH PROCTORED EXAM
- Module
- Dental nursing level 3
- Institution
- Dental Nursing Level 3
HESI COMMUNITY HEALTH PROCTORED EXAM
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HESI COMMUNITY HEALTH PROCTORED EXAM1. The nurse is completing a sleep assessment on a patient.
Which tool will the
nurse use to complete the assessment?
a. Visual analog scale
b. Cataplexy scale
c. Polysomnogram
d. RAS scale
ANS: A
The visual analog scale is utilized for assessing sleep quality. Cataplexy, or sudden
muscle weakness during intense emotions such as anger, sadness, or laughter,
occurs at any time during the day; there is no cataplexy scale for sleep
assessment. A polysomnogram involves the use of EEG, EMG, and EOG to
monitor stages of sleep and wakefulness during nighttime sleep; this is used in a
sleep laboratory study. Researchers believe that the ascending reticular
activating system (RAS) located in the upper brainstem contains special cells that
maintain alertness and wakefulness; however, there is no assessment tool called
the RAS scale.
2. The nurse is beginning a sleep assessment on a patient. Which question will be
most appropriate for the nurse to ask initially?
a. “What is going on?”
b. “How are you sleeping?”
c. “Are you taking any medications?”
d. “What did you have for dinner last night?”
, ANS: B
Sleep is a subjective experience. Only the patient is able to report whether or
not it is sufficient and restful. Asking patients how they are sleeping is an
introductory question. After this beginning question is asked, problems with
sleep such as the nature of the problem, signs and symptoms, onset and
duration of the issue, severity, predisposing factors, and the effect on the
patient can be assessed. What is going on is too broad and open ended for
information about sleep to be obtained specifically. Medications and food
intake can be part of the detailed assessment of sleep issues.
3. The nurse adds a nursing diagnosis of ineffective breathing pattern to a
patient’s care plan. Which sleep condition caused the nurse to assign this
nursing diagnosis?
a. Insomnia
b. Narcolepsy
c. Sleep deprivation
d. Obstructive sleep
apnea
ANS: D
Obstructive sleep apnea (OSA) occurs when the muscles or structures of the
oral cavity or throat relax during sleep. The upper airway becomes partially
or completely blocked, diminishing airflow or stopping it for as long as 30
seconds. The person still attempts to breathe because chest and abdominal
movements continue, resulting in snoring or snorting sounds. With
narcolepsy, the person feels an overwhelming wave of sleepiness and falls
asleep. Insomnia is characterized by chronic difficulty falling asleep. Sleep
deprivation is a condition caused by dyssomnia. OSA is the only one of these
conditions that results in blockage of the airway and impacts the ability to
breathe.
4. The nurse is caring for a postpartum patient. The patient’s labor has lasted
over 28 hours within the hospital; the patient has not slept and is
disoriented
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