Chapter 42 Sleep & Rest

Physical activity/exercise effects on sleep:

:increases fatigue and promotes relaxation, UNLESS w/in 2 hours of bedtime, where it can hinder

Chronic insomnia:

:insomnia over 5 weeks to 6 months.

Parasomnias:

:patterns of waking behavior that appear during sleep.

motivation effect on sleep:

:situations arise where a person wants to stay up, and also not.

Somnambulism:

:sleepwalking.

REM rebound (def).:

:when deprived of REM sleep on successive nights, the person will have more REM sleep at a later time to make up for the loss.

9. New research indicates that to increase safety the nurse should instruct parents to do which of the following? 1. Provide a stuffed toy for comfort. 2. Cover the infant loosely with a blanket. 3. Place the infant on his or her back. 4. Use small pillows in the crib.

Place the infant on his or her back. Infants are usually placed on their backs to prevent suffocation or on their sides to prevent aspiration of stomach contents. To reduce the chance of suffocation, pillows, stuffed toys, or the ends of loose blankets should not be placed in cribs. Infants should not be covered loosely with a blanket because infants might pull them over their faces and suffocate. To reduce the chance of suffocation, pillows should not be placed in cribs.

40. A 73-year-old male client who normally sleeps on his right side recently underwent a right-side hip replacement surgery and now has trouble sleeping. One of the interventions that the nurse might try with this client is to: 1. Request medication to help the client sleep while in the hospital 2. Carefully prop the client on his operative side using pillows to support the hip 3. Schedule therapy for the evening to help the client become tired so he can sleep 4. Question the client to learn more about his normal sleep pattern

Question the client to learn more about his normal sleep pattern Knowing a client's usual, preferred sleep pattern allows a nurse to try to match sleeping conditions in a health care setting with those in the home.

Eyes darting back and forth quickly is indicative of which type of sleep?

REM sleep.

rest

decreased state of activity with the consequent feeling of being refreshed

Abnormally long sleep cycles can be the result of damage to the:

:hypothalamus.

development effects on sleep:

:age affects sleep time, ex., babies - 16-24hr; toddlers, 8-10,12; pre-schoolers, 9-16; school age, 8-10, adults, 8

Restless Leg Syndrome:

:creeping, crawling, tingling in legs. People with iron deficiency and end stage renal disease seem to have this, but others as well.

Culture effects on sleep:

:differences in bedtime rituals

31. A 70-year-old client is reporting to the nurse a concern over "taking longer to fall asleep and waking up three to four times during the night." The most therapeutic nursing response to the client's concern is: 1. "I think you need to mention your concerns to your health care provider." 2. "Older adults seem to need less sleep. Do you still feel rested in the morning?" 3. "I suggest that you plan for a nap in the afternoon to make up for that missed sleep." 4. "As we age, those kinds of problems seem more common. Does this disruption in your sleep cause you to be tired or irritable?"

"As we age, those kinds of problems seem more common. Does this disruption in your sleep cause you to be tired or irritable?" An older adult awakens more often during the night, and it takes more time for an older adult to fall asleep. The answer provides an opportunity for a discussion about the effect this problem may be creating.

28. The client asks the nurse, "How will I know if I'm really rested?" The nurse's most therapeutic response is: 1. "Everyone's definition of rested is different. How would you define rested?" 2. "When you aren't tired when you get up in the morning or after an afternoon nap." 3. "When you are mentally, physically, and emotionally ready to go about your daily activities." 4. "You are rested if you fall asleep easily and sleep uninterruptedly for at least 6 to 8 hours."

"When you are mentally, physically, and emotionally ready to go about your daily activities." When people are at rest they are in a state of mental, physical, and spiritual activity that leaves them feeling refreshed, rejuvenated, and ready to resume the activities of the day. The remaining options ask questions or provide a limited view on what rested means.

22. A client has reported to the nurse that his sprained ankle resulted from "a careless accident. I seem so clumsy and unfocused lately." Which of the following assessment questions is most likely to reveal information regarding the cause of these symptoms? 1. "How many accidents have you had lately?" 2. "Have the accidents resulted in serious injuries?" 3. "Have there been any changes in your daily routine lately?" 4. "Do you have any idea what is responsible for this lack of focus?"

"Do you have any idea what is responsible for this lack of focus?" A loss of REM sleep leads to feelings of confusion and suspicion. Various body functions (e.g., mood, motor performance, memory, and equilibrium) are altered when prolonged sleep loss occurs. Research estimates that traffic, home, and work-related accidents caused by falling asleep are often a result of sleep loss. This answer is the best question because it directly opens up the opportunity for the client to discuss possible sleep problems if they exist. The other questions are not inappropriate but are less likely to reveal the possible cause of the accidents.

15. The nurse is completing an assessment of the client's sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is: 1. "How easily do you fall asleep?" 2. "Do you have vivid, lifelike dreams?" 3. "Do you ever experience loss of muscle control or falling?" 4. "Do you snore loudly or experience headaches?"

"Do you snore loudly or experience headaches?" To assess for sleep apnea (unlike assessing for narcolepsy or insomnia), the nurse may ask, "Do you snore loudly?" and "Do you experience headaches after awakening?" A positive response may indicate the client experiences sleep apnea.

17. A client is concerned that her habit of sleeping during the day and being awake at night is not "healthy or normal." The nurse's most therapeutic response to the client's concern is: 1. "What makes you think that sleeping during the day and being up at night is unhealthy or abnormal?" 2. "Many people share your sleep habits. As long as you feel all right, I don't think there is anything to worry about." 3. "Are you interested in changing your sleep habits for any particular reason? Is sleeping during the day a problem for you?" 4. "Everyone has a different biological clock that controls his or her sleep cycle. As long as you are sleeping and functioning well, your habit isn't abnormal or unhealthy."

"Everyone has a different biological clock that controls his or her sleep cycle. As long as you are sleeping and functioning well, your habit isn't abnormal or unhealthy." All persons have biological clocks that synchronize their sleep cycles. If the sleep pattern does not adversely affect the client's health or ability to function, it is not problematic.

18. A client is discussing his recent restlessness and increased irritability. Which of the following assessment questions is likely to be most helping in determining the cause of these complaints? 1. "When did you start noticing these changes?" 2. "Has anything caused you to change your usual routine lately?" 3. "Do you have any idea what might be causing these problems?" 4. "What makes you think that you are more irritable than is normal for you?"

"Has anything caused you to change your usual routine lately?" When the sleep-wake cycle becomes disrupted (e.g., by working rotating shifts), other physiological functions usually change as well. For example, the person experiences a decreased appetite and loses weight. Anxiety, restlessness, irritability, and impaired judgment are other common symptoms of sleep cycle disturbances. Failure to maintain the individual's usual sleep-wake cycle negatively influences the client's overall health. Although the other options are not inappropriate, they are not as directly aimed at determining the cause of the changes.

32. The nurse and the parents of a 3-year-old are discussing their child's sleep habits. They share a concern over the child's tendency to wake up several times during the night crying out loudly but not really being awake. The nurse addresses the parents' concern most therapeutically by responding: 1. "Have you ever tried reading a bedtime story before putting her to bed?" 2. "If she does that only a few times a week, I wouldn't be too overly concerned." 3. "Children her age often become poor sleepers. Have you discussed this with her pediatrician?" 4. "It is common for children to have trouble relaxing, and this behavior is the result. It's usually temporary."

"It is common for children to have trouble relaxing, and this behavior is the result. It's usually temporary." The preschooler usually has difficulty relaxing or quieting down after long, active days and has problems with bedtime fears, waking during the night, or nightmares. Partial wakening followed by normal return to sleep is frequent. In the waking period, the child exhibits brief crying, walking around, unintelligible speech, sleepwalking, or bed-wetting. The other options either ask questions or provide possible tactics for preventing the problems.

34. A 22-year-old male client shares with the nurse that he is always tired. In assessing the client's sleep pattern to determine the quantity of sleep the client is getting, the nurse should ask: 1. "On a scale from 0 to 10, how much sleep to you think you get each night?" 2. "What time do you usually go to bed?" 3. "What time do you usually get up?" 4. "Do you have a bedtime ritual?"

"On a scale from 0 to 10, how much sleep to you think you get each night?" This question helps quantify the length of sleep that the client receives. A brief subjective method to assess sleep is a numeric scale with a 0 to 10 sleep rating. Ask individuals to separately rate their quantity and quality of sleep on the scale. Instruct clients to indicate with a number between 0 and 10 their sleep quantity then their quality of sleep with 0 being the worst sleep and 10 being the best sleep

27. The nurse is discussing child care strategies with a mother of a newborn. The mother asks the nurse, "What causes sudden infant death syndrome (SIDS)?" Which of the following responses is most likely to answer the mother's question therapeutically? 1. "SIDS is a common fear for new mothers. The best advice is to put your baby to sleep on her back." 2. "We aren't sure exactly, but it may have something to do with undetected cardiac or oxygen problems." 3. "Research is inconclusive, but it's thought to be a result of a nervous system problem that occurs when the baby is asleep." 4. "Your pediatrician wants you to put your baby to sleep on her back because research has shown that more stomach sleepers are victims."

"Research is inconclusive, but it's thought to be a result of a nervous system problem that occurs when the baby is asleep." Some have hypothesized that sudden infant death syndrome (SIDS) is caused by abnormalities in the autonomic nervous system that are manifested during sleep, resulting in apnea, hypoxia, and/or cardiac dysrhythmias. This answer provides the most thorough answer to the mother's question, whereas the remaining options stress preventive measures.

6. An 11-year-old boy in middle school is currently experiencing sleep-related fatigue during classes. Which of the following is the most appropriate response by the school nurse when counseling the child's parents regarding this assessment? 1. "What are the child's usual sleep patterns?" 2. "Establish bedtimes for the child, and withhold his allowance whenever those times are not adhered to." 3. "We need to explore other health-related problems, because sleep problems are not likely the cause of his fatigue." 4. "The bulbar synchronizing region of the child's central nervous system is causing these insomniac problems."

"What are the child's usual sleep patterns?" A school-age child will be tired the following day if allowed to stay up later than usual. The nurse should ask a question to assess the child's usual sleep patterns. The nurse should first assess the child's usual sleep pattern to determine if the child is adhering to a bedtime. A sleep problem is often the cause of fatigue.

10. A 74-year-old client has been having sleeping difficulties. To have a better idea of the client's problem, the nurse should respond: 1. "What do you do just before going to bed?" 2. "Let's make sure that your bedroom is completely darkened at night." 3. "Why don't you try napping more during the daytime?" 4. "Do you eat a small snack before going to bed?"

"What do you do just before going to bed?" To assess the client's sleeping problem, the nurse should inquire about predisposing factors, such as by asking "What do you do just before going to bed?" Assessment is aimed at understanding the characteristics of any sleep problem and the client's usual sleep habits so that ways for promoting sleep can be incorporated into nursing care. Older adults sleep best in softly lit rooms. Napping more during the daytime is often not the best solution. The nurse should first assess the client's sleeping problem. The client does not always have to eat something before going to bed.

19. The nurse and a client are discussing possible behaviors that might be interfering with the client's ability to fall asleep. Which of the following assessment questions is most likely to identify possible problems with the client's sleep routine that possibly are contributing to the difficulty? 1. "When do you usually retire for the night?" 2. "What do you do to help yourself fall asleep?" 3. "How much time does it usually take for you to fall asleep?" 4. "Have you changed anything about your presleep ritual lately?"

"What do you do to help yourself fall asleep?" As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem. Although the other questions are not inappropriate, they are not as directed toward the cause of the problem.

REM sleep consumes ____% of sleep time.

20-25

21. A 9-year-old client asks the nurse, "Why do I need to sleep?" The nurse's most age-appropriate, informative response is: 1. "Everyone needs to sleep to feel rested." 2. "It gives your body a chance to really rest." 3. "You'll be able to do so much better in school if you're rested." 4. "Your body needs to rest in order to grow and be really healthy."

"Your body needs to rest in order to grow and be really healthy." Sleep contributes to physiological and psychological restoration, maintenance, and growth of the body at any age. The remaining options are not as effective at providing a thorough answer to the child's question. The body needs sleep to routinely restore biological processes.

25. A client shares with the nurse that "My wife complains about my snoring, and I never really feel rested." Which of the following responses best attempts to explain the cause of the problem to the client? 1. "Sleep disturbances can really affect all aspects of your life. How long have you been experiencing this problem?" 2. "You need to get help to breathe more effortlessly at night so both you and your wife can get sufficient deep stage sleep." 3. "Something is interfering with your ability to breathe while you are asleep. Have you talked with your health care provider about the problem?" 4. "Your upper airway is blocked, and that is making it difficult for you to breathe effectively, so you are spending most of the night in the light sleep stage."

"Your upper airway is blocked, and that is making it difficult for you to breathe effectively, so you are spending most of the night in the light sleep stage." The upper airway becomes partially or completely blocked, and diminished nasal airflow (hypopnea) can result for as long as 30 seconds. The person attempts to breathe, which often results in loud snoring and snorting sounds. The effort to breathe during sleep results in arousals from deep sleep, often to the stage 2 cycle, causing interference with deep sleep and thus the client's not feeling rested. The remaining options are not inappropriate, but they are not as directed at explaining the problem to the client.

Hypersomnia:

:excessive sleep.

NREM sleep deprivation is characterized by:

:fatigue, lethargy, depression, and difficulty with ADLs.

When 'Disturbed Sleep' is the problem, it receives either of two etiologies -

- 'Disturbed Sleep Pattern' is the problem is time-limited, or 'Sleep Deprivation' if the problem is prolonged.

When 'Disturbed Sleep' is the etiology, there are many diagnoses that are manifested from it, like -

- *Anxiety related to inability to fall asleep, *Activity intolerance, *Ineffective coping related to insomnia, (list on p. 1095)

Characteristics of REM sleep:

:Respirations are irregular and sometimes interspersed with apnea; Metabolism and body temp increase; It constitutes about 20-25% of sleep.

4. Which of the following client statements made by young adults suggest a risk factor for sleep disturbance problems? (Select all that apply.) 1. "I have a job that requires my attention 110% of the time." 2. "I really enjoy fishing; I wish we lived closer to a river or pond." 3. "My wife just found out she is pregnant for the third time in 5 years." 4. "My father recently suffered a heart attack, and Mom is so very worried about him." 5. "The kids are so active in after-school things that we never have an evening at home." 6. "Gardening always gave me such a sense of accomplishment, but I don't have much free time now."

1. "I have a job that requires my attention 110% of the time." 3. "My wife just found out she is pregnant for the third time in 5 years." 4. "My father recently suffered a heart attack, and Mom is so very worried about him." 5. "The kids are so active in after-school things that we never have an evening at home." It is common for the stresses of jobs, family relationships, and social activities to lead frequently to insomnia and the use of medication for sleep. The remaining options reflect a sense of loss but not necessarily of stress.

2. Although the most common effect of obstructive sleep apnea is a disrupted sleep pattern, the condition can cause a serious decline in arterial oxygen levels that may result in: (Select all that apply.) 1. Hypertension 2. Angina attacks 3. Alzheimer's disease 4. Cardiac dysrhythmias 5. Cerebral vascular accidents 6. Type 2 diabetes

1. Hypertension 2. Angina attacks 4. Cardiac dysrhythmias 5. Cerebral vascular accidents Obstructive apnea causes a serious decline in arterial oxygen saturation level. Clients are at risk for cardiac dysrhythmias, right-sided heart failure, pulmonary hypertension, angina attacks, stroke, and hypertension. The other options are not directly related to a diminished supply of arterial oxygen.

1. The nurse and a client are discussing the importance of an effective 24-hour sleep cycle. Which of the following responses by the client may be a direct result of an inadequate sleep pattern? (Select all that apply.) 1. Gaining weight 2. Usually feeling cold 3. Always feeling "tired" 4. A heart that beats "really fast" 5. Often feeling "blue" or depressed 6. Feeling dizzy when getting up from a chair

2. Usually feeling cold 3. Always feeling "tired" 4. A heart that beats "really fast" 5. Often feeling "blue" or depressed 6. Feeling dizzy when getting up from a chair The predictable changing of body temperature, heart rate, blood pressure, hormone secretion, sensory acuity, and mood depend on the maintenance of the 24-hour circadian cycle. Weight gain is not typically a result of poor sleep patterns.

4. A new mother is concerned that her 2-week-old daughter is not sleeping through the night. The nurse should respond that infants usually develop a nighttime pattern of sleep by: 1. 1 month 2. 2 months 3. 3 months 4. 6 months

3 months Infants usually develop a nighttime pattern of sleep by 3 months of age.

3. The nurse is preparing to discuss the management of the sleeping disorder narcolepsy. In addition to the prescription of stimulants and antidepressants, which of the following nonpharmaceutical strategies should be included and shared with the client? (Select all that apply.) 1. Wine with meals 2. Regular use of a sauna 3. Light but high-protein meals 4. Regular use of chewing gum 5. Adoption of a regular exercise routine 6. Brief daytime naps of 20 minutes or less

3. Light but high-protein meals 4. Regular use of chewing gum 5. Adoption of a regular exercise routine 6. Brief daytime naps of 20 minutes or less Narcoleptics may be helped by brief daytime naps no longer than 20 minutes, a regular exercise program, avoiding shifts in sleep, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins. Clients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol, heavy meals, exhausting activities, long-distance driving, and long periods of sitting in hot, stuffy rooms).

URGE diagnosis for restless leg:

:U - urge to move legs, R - rest-induced, G - gets better with activity, E - evening symptoms more severe.

Sleep apnea:

:absence of breathing (apnea) or diminished breathing (hypopnea)

What amount of sleep in hours is generally considered adequate for adults?

5-7 hours of sleep.

Etiologies for 'Disturbed Sleep' (common ones):

: *Physical discomfort or pain, *Emotional discomfort or pain, *Changes in bedtime rituals, *Disruption of circadian rhythm, * Exercise before sleep, (list is on p. 1095)

Sleep deprivation:

: Debilitating lack of sleep. Causes stress. Life shortening

Stress and sleep:

: High stress, low sleep.

Diet effects on sleep:

: alcohol = sleep, lots of alcohol = bad sleep, caffeine, smoking = hinders sleep

Factors affecting sleep:

: culture, development, lifestyle/habits, motivation, environment, psychological stress, illness, medication

Environment effects on sleep:

: home is best. Noisy, big city, small city. What's around you effects how you sleep and if you have adapted to it or not.

Acute insomnia:

: insomnia 4 weeks or less.

Sleep hygiene:

: non-pharm steps to get better sleep. (Examples on p. 1088)

Dyssomnias:

: sleep disorders characterized by insomnia or excessive sleepiness.

Sleep architecture:

: the term coined for the alternating between NREM and REM cycles

Narcolepsy:

: uncontrollable desire to sleep.

An individual's sleep cycle is fully developed by age:

:2-3years.

Enuresis:

:Bedwetting

Illness and sleep:

:Certain illnesses disturb certain stages. (p. 1087)

Medications and sleep:

:Drugs that decrease REM - barbiturates, amphetamines, anti-depressants. Diuretics, anti-hypertensives, steroids, decongestants cause problems. zoloft and ambien assist in sleep.

Parasomnias:

:Patterns of waking that occur during REM and NREM

24. Which of the following clients experiencing disrupted sleep patterns is most at risk for obstructive sleep apnea (OSA)? 1. A 15-year-old boy with type 1 diabetes 2. A 22-year-old diagnosed with Crohn's disease 3. A 49-year-old man who is an avid cross-county runner 4. A 58-year-old woman diagnosed with chronic depression

A 58-year-old woman diagnosed with chronic depression Many think OSA affects middle-age men more frequently, particularly when they are obese. However, obstructive sleep apnea is also common in postmenopausal women, younger women, and children. Although the clients in all of the options may experience OSA, the postmenopausal woman has the greatest risk.

23. Which of the following clients is most likely to experience difficulty returning to sleep? 1. A 60-year-old with benign hypertropic prostatic disease 2. A 15-year-old with type 1 diabetes 3. A 35-year-old diagnosed with hypothyroidism 4. A 55-year-old diagnosed with hypertension

A 60-year-old with benign hypertropic prostatic disease Nocturia, or urination during the night, disrupts sleep and the sleep cycle. This condition is most common in older people with reduced bladder tone or persons with cardiac disease, diabetes, urethritis, or prostatic disease. After a person awakens repeatedly to urinate, returning to sleep is difficult. Although all the clients may have difficulty falling back to sleep when awakened, the answer represents the client with the greatest tendency to be awakened during the night.

Q: How many cycles do people go through on an average night?

A: 4-5 cycles

Which patients admitted to a healthcare agency should have a sleep history taken?

All patients.

14. It is determined that the client will need pharmacological treatment to assist with the client's sleep patterns. The nurse anticipates that treatment with an anxiety-reducing, relaxation-promoting medication will include the use of: 1. Barbiturates 2. Amphetamines 3. Benzodiazepines 4. Tricyclic antidepressants

Benzodiazepines The benzodiazepines cause relaxation, antianxiety, and hypnotic effects by facilitating the action of neurons in the central nervous system (CNS) that suppress responsiveness to stimulation, therefore decreasing levels of arousal. Withdrawal from CNS depressants, such as barbiturates, can cause insomnia and must be managed carefully. Barbiturates can cause tolerance and dependence. Central nervous system stimulants, such as amphetamines, should be used sparingly and under medical management. Amphetamine sulfate may be used to treat narcolepsy. Prolonged use may cause drug dependence. Tricyclic antidepressants can cause insomnia when withdrawn and should be managed carefully. They are used primarily to treat depression.

3. Which of the following symptoms should the nurse assess with a client who is deprived of sleep? 1. Elevated blood pressure and confusion 2. Confusion and irritability 3. Inappropriateness and rapid respirations 4. Decreased temperature and talkativeness

Confusion and irritability Psychological symptoms of sleep deprivation include confusion and irritability. Elevated blood pressure is not a symptom of sleep deprivation. Rapid respirations are not a symptom of sleep deprivation. There may be a decreased ability of reasoning and judgment that could lead to inappropriateness. Decreased temperature is not a symptom of sleep deprivation. The client with sleep deprivation is often withdrawn, not talkative.

39. A female client describes the most elaborate dreams to the nurse. She states that she could see colors, hear music, and even had the sensation of flying. The nurse replies to the client that her dreams indicate that she must be: 1. Depressed 2. Pragmatic 3. Creative 4. Mentally ill

Creative Personality influences the quality of dreams; for example, a creative person has elaborate and complex dreams, whereas a depressed person dreams of helplessness. Most people dream about immediate concerns such as an argument with a spouse or worries over work. Sometimes a person is unaware of fears represented in bizarre dreams.

What is the name of the medical instrument that receives and records electrical currents from the brain?

Electroencephalograph.

16. Which of the following may improve the sleep of an older adult client? 1. Drinking an alcoholic beverage before bedtime 2. Using an over-the-counter sleeping agent 3. Eliminating naps during the day 4. Going to bed at a consistent time even if not feeling sleepy

Eliminating naps during the day To promote sleep, daytime naps should be eliminated. If naps are used, they should be limited to 20 minutes or less twice a day. Alcohol should be limited in the late afternoon and evening because it has an insomnia-producing effect. The use of nonprescription sleeping medications is not advisable. Over the long term, these drugs can lead to further sleep disruption even when they initially seemed to be effective. Following a bedtime routine should be consistent, not necessarily going to bed. The client should engage in quiet activities that promote relaxation and then may go to bed. If the client has not fallen asleep in 30 minutes, the client should get up out of bed and do some quiet activity until feeling sleepy enough to go back to bed.

11. Which of the following information provided by the client's bed partner is most associated with sleep apnea? 1. Restlessness 2. Talking during sleep 3. Somnambulism 4. Excessive snoring

Excessive snoring Partners of clients with sleep apnea often complain that the client's snoring disturbs their sleep. Restlessness is not most associated with sleep apnea. Sleep talking is associated with sleep-wake transition disorders; somnambulism is associated with parasomnias (specifically, arousal disorders and sleep-wake transition disorders).

13. The nurse knows that which of the following habits may interfere with a client's sleep? 1. Listening to classical music 2. Finishing office work 3. Reading novels 4. Drinking warm milk

Finishing office work At home a client should not try to finish office work or resolve family problems before bedtime. Noise should be kept to a minimum. Soft music may be used to mask noise if necessary. 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. A dairy product snack such as warm milk or cocoa that contains L-tryptophan may be helpful in promoting sleep.

7. The nurse recognizes that the sleep patterns of older adults differ and older adults generally: 1. Are more difficult to arouse 2. Require more sleep than middle-age adults 3. Take less time to fall asleep 4. Have a decline in stage 4 sleep

Have a decline in stage 4 sleep As people age, there is a progressive decrease in stages 3 and 4 NREM sleep; some older adults have almost no stage 4, or deep, sleep. Older people do not become more difficult to arouse, not do they require more sleep than the middle-age adult. An older adult awakens more often during the night, and it may take more time for an older adult to fall asleep.

5. The mother of a 2-year-old child is frustrated because the child does not want to go to bed at the scheduled bedtime. The nurse should suggest that the parent: 1. Offer the child a bedtime snack 2. Eliminate one of the naps during the day 3. Allow the child to sleep longer in the mornings 4. Maintain consistency in the same bedtime ritual

Maintain consistency in the same bedtime ritual The nurse should advise the parent to maintain a regular bedtime and wake-up schedule and to reinforce patterns of preparing for bedtime. A bedtime routine (e.g., same hour for bedtime, quiet activity) used consistently helps young children avoid delaying sleep. It is most important that the parent maintains a consistent bedtime routine. If a bedtime snack is already part of that routine, then this is allowable. If it is not, then the child may only use having a snack as a measure of procrastination. After 3 years of age the child may give up daytime naps. A bedtime routine used consistently will be more effective in helping the child who resists going to sleep. The same regular bedtime and wake-up schedule should be maintained.

The two major stages of sleep

Non rapid eye movement (NREM), rapid eye movement (REM)

2. The nurse understands that the client with which of the following conditions is at risk for obstructive sleep apnea? 1. Heart disease 2. Respiratory tract infections 3. Nasal polyps 4. Obesity

Nasal polyps Structural abnormalities, such as a deviated septum, nasal polyps, certain jaw configurations, or enlarged tonsils predispose a client to obstructive apnea. Individuals with mixed apnea often have signs and symptoms of right-sided heart failure. Respiratory tract infections do not predispose a client to obstructive sleep apnea. Clients with obstructive apnea are often middle-age, obese men. Obesity itself does not predispose a client to obstructive sleep apnea.

8. Teaching for a client who is currently taking a diuretic should include information that he or she may experience: 1. Nocturia 2. Nightmares 3. Increased daytime sleepiness 4. Reduced REM sleep

Nocturia For the client who is currently taking a diuretic, the nurse should inform the client that he or she might experience nighttime awakening caused by nocturia. Diuretic use does not cause nightmares or daytime sleepiness or reduce REM sleep.

38. The assistive nursing personnel reports that the heart rate of the sleeping 23-year-old athlete, who is hospitalized following complications of a tonsillectomy, is 56. The assistive nursing personnel states that this is 10 beats per minute slower than when she took it earlier in the evening. The nurse knows that this is considered: 1. Normal, and they will continue to monitor the vital signs as ordered 2. Abnormally slow, and the health care provider should be notified immediately 3. Abnormally slow, and the nurse will recheck the heart rate before taking any action 4. Abnormally slow, signaling that the client may be hemorrhaging

Normal, and they will continue to monitor the vital signs as ordered A healthy adult's normal heart rate throughout the day averages 70 to 80 beats per minute or less if the individual is in excellent physical condition. However, during sleep the heart rate falls to 60 beats per minute or less. This means that the heart beats 10 to 20 fewer times in each minute during sleep or 60 to 120 fewer times in each hour. If the client were hemorrhaging, the heart rate would initially be tachycardic as the body attempts to compensate for the lost blood volume.

30. A 63-year-old client is discussing the recent problem the client is experiencing with falling asleep. The nurse is discussing strategies to minimize this problem. Which of the following bedtime snacks would be the most likely to induce sleep? 1. One slice of cheese on four wheat crackers and a glass of skim milk 2. Two cups of air-popped popcorn and a glass of fruit juice 3. Two fig cookies and a cup of decaffeinated tea 4. One small pear and a glass of soymilk

One slice of cheese on four wheat crackers and a glass of skim milk One substance that promotes sleep in many people is L-tryptophan, a natural protein found in foods such as milk, cheese, and meats.

Insomnia therapies include:

Sleep hygiene, cognitive behavioral therapy, and stimulus control.

36. The night nurse goes quietly into the sleeping client's room to assess him. The client wakes up as soon as the nurse is in the room. The nurse knows that the client was most likely in which stage of sleep? 1. Stage 1: NREM 2. Stage 2: NREM 3. Stage 3: NREM 4. Stage 4: NREM

Stage 1: NREM Stage 1 NREM includes the lightest level of sleep. Sensory stimuli such as noise easily arouses the person. The stage lasts a few minutes. Decreased physiological activity begins with gradual fall in vital signs and metabolism. Awakened, person feels as though daydreaming has occurred. Stage 2 NREM is a period of sound sleep. Stage 3 NREM involves initial stages of deep sleep. Stage 4 NREM is the deepest stage of sleep. It is very difficult to arouse the sleeper.

20. An older adult client diagnosed as being in the early stage of Alzheimer's disease shares with the nurse that her sleep is interrupted by "the noises I hear all through the night." The nurse explains that the most likely reason for this problem is: 1. The client's age 2. A lack of presleep relaxation 3. The amount of noise entering into the client's environment 4. A manifestation of the disease process causing the brain disorder

The client's age With aging, sleep becomes more fragmented, and a person spends more time in lighter stages that are easily disturbed by noise. The remaining options may be a factor but not to the degree of normal aging.

37. A 25-year-old client's wife complains to the nurse that he sleepwalks during the night. The nurse knows that this behavior normally occurs in which stage of sleep? 1. Stage 2: NREM 2. Stage 3: NREM 3. Stage 4: NREM 4. REM

Stage 4: NREM Stage 4 NREM sleep is the deepest stage of sleep. It is very difficult to arouse the sleeper. If sleep loss has occurred, the sleeper will spend a considerable portion of the night in this stage. Vital signs are significantly lower than during waking hours. The stage lasts approximately 15 to 30 minutes. Sleepwalking and enuresis (bed-wetting) sometimes occur. Stage 2 NREM is a period of sound sleep. Stage 3 NREM involves initial stages of deep sleep. REM sleep involves vivid, full-color dreaming. Loss of skeletal muscle tone occurs. It is very difficult to arouse the sleeper. Less vivid dreaming occurs in other stages. The stage is typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure.

Light sleep, where a person can be roused easily, is:

Stage l and Stage ll of NREM sleep.

29. The nurse is caring for a 35-year-old father of three young children who has experienced a compound fractured femur as a result of a work-related incident. He has expressed great concern over both his physical recovery and his long-term ability to work again. This has affected both his emotional status and his sleeping patterns. The nurse's most immediate concern is that: 1. The client needs medication to prevent depression 2. The lack of appropriate rest will affect his healing process 3. An occupational therapy consult should be ordered to help him regain his ability to return to his job 4. A psychiatric consult should be ordered to help the client deal with his various emotional concerns

The lack of appropriate rest will affect his healing process You must always be aware of the client's need for rest. A lack of rest for long periods causes illness or worsening of existing illness. Although the other options are appropriate concerns, they are not as immediate in nature as is the sleep problem.

35. On a 2-week follow-up visit to the health care provider, a 64-year-old female postoperative client shares with the nurse that she is having difficulty sleeping and has never had a history of sleeping problems. The nurse shares with the client that: 1. Because of her age, the client should expect to begin having some problems sleeping 2. It may take a while to get used to sleeping in her bed at home after getting used to sleeping on a hospital bed 3. The medications used for anesthesia can disturb sleep cycles for several weeks following surgery 4. She may not be sleeping as well with her partner after being in a bed by herself while being hospitalized

The medications used for anesthesia can disturb sleep cycles for several weeks following surgery If the client has recently had surgery, expect the client to experience some disturbance in sleep. Clients usually awaken frequently during the first night after surgery and receive little deep or REM sleep. Depending on the type of surgery, it takes several days to months for a normal sleep cycle to return.

1. The physiology of sleep is complex. Which of the following is the most appropriate statement in regard to this process? 1. Ultradian rhythms occur in a cycle longer than 24 hours. 2. Nonrapid eye movement (NREM) refers to the cycle that most clients experience when in a high-stimulus environment. 3. The reticular activating system is partly responsible for the level of consciousness of a person. 4. The bulbar synchronizing region (BSR) causes the rapid eye movement (REM) sleep in most normal adults.

The reticular activating system is partly responsible for the level of consciousness of a person. The ascending reticular activating system (RAS) located in the upper brain stem is believed to contain special cells that maintain alertness and wakefulness. Infradian rhythms, not ultradian rhythms, occur in a cycle longer than 24 hours. Nonrapid eye movement refers to the sleep cycle that most clients experience in a low-stimulus environment. The bulbar synchronizing region is the area of the brain where serotonin is released to produce sleep. It is not responsible for REM sleep.

33. A 44-year-old female client shares with the nurse that she is having difficulty falling asleep at night, even though she is exhausted. The nurse knows that which of the following could be causing the sleeplessness? 1. Two cups of hot cocoa every evening 2. Vegetarian diet 3. Afternoon exercise program 4. Hot bath in the evening

Two cups of hot cocoa every evening Caffeine is a stimulant and can cause difficulty in falling asleep. There is about 30 mg of caffeine in two cups of hot cocoa.

26. A client hospitalized for a myocardial infarction in a cardiac critical care unit (CCU) is most likely to experience sleep deprivation as a result of: 1. A drug-disrupted circadian sleep pattern 2. Generally diminished cardiac output 3. Unfamiliar environmental stimuli 4. Increased emotional stressors

Unfamiliar environmental stimuli Hospitalization, especially in intensive care units, makes clients particularly vulnerable to the extrinsic and circadian sleep disorders that cause the "ICU syndrome of sleep deprivation." Constant environmental stimuli within the intensive care unit (ICU), such as strange noises from equipment, the frequent monitoring and care given by nurses, and ever-present lights, confuse clients and lead to sleep deprivation. Although the other options may be contributing factors, they are not as directly responsible.

12. The nurse should instruct the client to do which of the following to promote good sleep hygiene at home? 1. Use the bedroom only for sleep or sexual activity. 2. Eat a large meal 1 to 2 hours before bedtime. 3. Exercise vigorously before bedtime. 4. Stay in bed if sleep does not come after 1/2 hour.

Use the bedroom only for sleep or sexual activity. 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. The nurse should instruct the client to avoid heavy meals for 3 hours before bedtime; a light snack may help. The nurse should also 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. Getting out of bed and doing 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 may also help.

Sleep cycle (p.1082, fig. 34-2) -

Wake --> NREM l --> NREM 2 --> NREM 3 --> NREM 4 --> NREM 3 --> NREM 2 --> REM --> NREM 2

Circadian synchronization -

When an individual's sleep-wake patterns follow the inner biologic clock.

It is more difficult to arouse a person during___sleep

_REM_

Insomnias usually last for___

___ a few weeks

Approximately___suffer from chronic insomnia

___10%__

Newborns sleep an average of___hours per day

___16__

75 percent of sleep is____

___NREM sleep.

12 hours is the average___

___amount of sleep needed by preschoolers.

The parasympathetic nervous system___

___dominates NREM sleep.

During REM sleep____DECREASES

___general skeletal muscle and deep tendon reflexes___

A light protein and carbohydrate snack before bedtime____

___promotes sleep.

Ten percent of total sleep time is spent in___

___stage lll and stage lV of NREM sleep.

Deep sleep occurs more at the___of the night

__beginning__

Stage lll and Stage lV of NREM is also called___sleep.

__delta__

During sleep the RAS experiences__

__few stimuli from the cerebral cortex and the periphery of the body.

Non rapid eye movement sleep has___stages

__four__

The Arousal Threshold is usually the greatest in Stage ____ of NREM sleep.

__lV__

During REM sleep_____INCREASES

__pulse, resp, BP, metabolism, temp__

The Cerebral cortex and peripheral sensory organs stimulate the ________to bring about wakefulness.

__reticular activating system__

The reticular activation system extends___

__upward toward the medulla, the pons, and the midbrain, into the hypothalamus.

sleep

state of rest accompanied by altered consciousness

circadian rhythm

the biological clock; regular bodily rhythms that occur on a 24-hour cycle