Exam 4 RCCNURSE11

What are some nursing interventions for patients with decreased hearing? (T.43)

1. Make sure using hearing assistive devices 2. Use lower tone when speaking to patient 3. Speak so that patient can see mouth

State behavioral manifestations of alters sensory functions? (T.43)

1. Physical behaviors - drowsiness, excessive yawning 2. Escape behaviors - eating, exercising, sleeping, rushing away to escape the deprived environment 3. Change in cognitive perception 4. Change in affective behavior - crying, increased irritability and annoyance over small matters, confusion, panic and depression

What are some nursing interventions for patient with decreased sense of touch? (T.43)

1. Protect patient's skin from temperature extremes 2. Assess for skin breakdown, blisters, drainage, or open wounds 3. Ensure patient is ambulating with assistive devices

List effective interventions for sensory overload (T. 43)

1. Provide consistent stimuli over environment 2. Offer simple explanations of procedures, tests and examination 3. Establishing a schedule with the patient for routine care such as eating, bathing, turning, positioning, coughing and exercising

What are some nursing interventions for patients with decreased in vision? (T.43)

1. make sure wear glasses, contacts 2. Provide adequate lighting 3. Provide enlarge fonts 4. Encourage patient to visit eye doctor regularly 5. Administer medication that enhance vision

What is Restless leg syndrome? (T.33)

RLS - cannot lie still an report unpleasant creeping, crawling, or tingling sensations in the legs

Stage IV NREM sleep describes the patient how? (T.33)

Reaches greatest depth (delta sleep) Arousal from sleep is difficult Physiologic changes in body include: pulse, RR, bp all decreases, metabolism slows and body temperature is low, slow brain activity 10% of sleep

What are nursing teaching for older adults regarding sleep pattern? (T.33)

A comprehensive nursing assessment and individualized interventions may be effective in long-term care Emphasize for safe environment because not uncommon for adults to be temporarily confused and disoriented when they first wake Use sedatives with extreme caution, concern for polypharmacy Discuss sleep concerns with their physicians

What's the difference between acute and chronic pain? (T.37)

Acute - rapid onset, up to 6 months Chronic - long term, recurring (remission or exacerbation)

What are nursing teaching for adolescents regarding sleep pattern? (T.33)

Adolescents complaint of fatigue or inability to do well in school may be related to not enough sleep Excessive daytime sleepiness (EDS) may also make teenager more vulnerable to accidents and behavioral poblems

Why is it difficult for people to describe chronic pain? (T.37)

Because it is poorly localized, people individualized response is unique, hard to assess, healthcare personnel may view people with chronic pain in general as hysterical personalities

Why is eating peanut butter on toast or cheese and crackers may be more effective for sleep? (T.33)

Carbohydrates make tryptophan more available to the brain, and tryptophan promote sleep

How do we treat intractable pain? (T.37)

Combining it with alternative treatment

Explain the classification of pain by source. (T.37)

Cutaneous - superficial pain (skin, paper cut) Somatic - Diffuse and scattered, tendons, ligaments (sprain) Visceral - poorly localized, internal organs (abdominal pain)

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. (T.33) a. A patient who is taking iron supplements for anemia b. A patient with Parkinson disease who is taking dopamine c. An elderly patient taking diuretics for congestive heart failure d. A patient who is taking antibiotics for ear infection e. A patient who is prescribed antidepressants f. A patient who is taking low-dose aspirin prophylactically

Drugs that decrease REM sleep: Barbituates - used to depress CNS, anxiety, insomnia Amphetamine - is a potent central nervous system stimulant that is used in the treatment of attention deficit hyperactivity disorder, narcolepsy, and obesity Antidepressants Additional Common cause of sleep problems: Diuretics Antiparkinsonian drugs some antidepressants Antihyptertensive steroids decongestants caffeine asthma medications

How is pain classified? (T.37)

Duration (acute, chronic) Source (Visceral, somatic, cutaneous) Mode of transmission (referred pain) Etiology (neuropathic, intractable, phantom, pyschogenic pain)

What are nursing teaching for toddlers regarding sleep pattern? (T.33)

Establish regular bedtime routine Encourage attention to child once move from crib to bed and moving across the room, folding gate may be necessary

What is psychogenic pain? (T.37)

Physical cause for the pain cannot be identified

What influences the circadian rhythm? (T.33)

Internal and external factors such as light and dark acting as regulators of the sleep-wake circadian rhythm A person's individual biologic clock also responds to numerous influences such as occupational demands and social pressure

What are nursing teaching for middle-aged adults regarding sleep pattern? (T.33)

Investigate consistent sleep difficulties to exclude pathology or anxiety and depression as causes encourage adult to avoid use of sleep-inducing medication on a regular basis

What is presbycusis? (T. 43)

Loss of hearing due to age

List effective interventions for sensory deprivations. (T.43)

Maintain sufficient level of arousal by increasing sensory stimuli by: 1. self-simulation - singing 2. external environment - having a pet 3. Visual stimulation - colorful sheets 4. Auditory stimulation - reading to a patient 5. Gustatory and olfactory stimulation - food of different textures, smelling food before eating

Why is it hard to determine pain for children? (T.37)

Misconception that they cannot feel pain but are very sensitive to pain stimuli Parent reluctant to give because of fear of dependent Children may see pain as a punishment

What is neuropathic pain? (T.37)

Mostly described as burning, electric, tingling or stabbing abnormal function of the PNS and CNS

Describe stage 1 of the NREM stage? (T.33)

Person is somewhat aware of surroundings, in relaxed state In transitional stage between wakefulness and sleep Involuntary muscle jerkin may occur and waken the patient Can be aroused easily 5% of total sleep, lasts only minutes

What are nursing teaching for newborns and infants regarding sleep pattern? (T.33)

Position infant on back (less than 1 year old) to prevent SIDs Advise parents to look for: eye movements, groaning, grimacing, and moving are NORMAL activities for this age Caution parents about placing pillows, crib bumpers, quilts, stuffed animals, and so on to prevent suffocation risk

What stage describes a patient that has: (T.33) Eyes dart back and forth quickly Small muscle twitching such as on face Large muscle immobility, resembling paralysis Respirations irregular, sometimes interspersed with apnea Rapid or irregular pulse Blood pressure increases or fluctuates Increase in gastric secretions Metabolism increases; body temperature increases Encephalogram tracings active Enters stage II of NREM sleep and reenters NREM sleep at stage II; arousal from sleep is difficult 20-25% of sleep

REM sleep

What is the Healthy People 2020 Goal regarding sensory functions? (T. 43)

Reduce the prevalence and severity of disorders of hearing and balance; smell and taste; and voice, speech and language At least 1 out of 6 people have sensory or communication impairment or disorder

When a patient has a heart attack, what is the mode of transmission for their pain? (T.37)

Referred pain (pain can originate in one place but be perceived in area distant for its origin)

What are nursing teaching for Young adults regarding sleep pattern? (T.33)

Reinforce good sleeping habits If loss of sleep, then explore lifestyle demands and stress as possible causes Suggests use of relaxation techniques and stress-reduction exercises rather than resorting to medication to induce sleep

What is Intractable pain? (T.37)

Resistant to therapy

What is circadian rhythm? (T.33)

Rhythmic biologic clock known to exist in plants, animals, and humbs

What are nursing teaching for Preschoolers regarding sleep pattern? (T.33)

Routine bedtime Advise that waking up from nightmares or night terrors (awakening about 20 minutes after falling asleep) are more common during this stage Daytime napping decreases and by age of 5 years, no longer nap Continue to resist going to bed at night

Term for patient sleepwalking, not remembering the next day? (T.33)

Somnambulism

List some examples of parasomnias (T.33) - pattern of waking behavior taht appear during REM or NREM stages of sleep

Somnambuslism - sleep walking REM behavior disorder (RBD) - "acting out" dreams Sleep terrors - during deepest part of sleep, seem awake but not Nightmares Bruxism Enuresis Sleep-related eating disorder - eat while sleeping but doesn't remember in morning

Nurse observes muscle jerkins in a sleeping patient, he/she most likely in what stage of sleep? (T.33) a. Stage I NREM sleep b. Stage II NREM sleep c. Stage IV NREM sleep d. REM sleep

Stage I NREM sleep. In other stages, muscle relaxed to large muscle immobility

The depth increases, and arousal becomes increasingly difficult, composing of 10% of sleep, what stage is this? (T.33)

Stage II NREM sleep

What stage constitutes of 50-55% of sleep, and the person can be aroused with relative ease? (T.33)

Stage II NREM sleep

What are nursing teaching for school-aged children regarding sleep pattern? (T.33)

Stress of beginning school may interrupt normal sleep patterns Relaxed bedtime is most helpful Inform parents about child's awareness of the concept of death possibly occurring at this stage, so parents should try to alleviate child's concern

What are some scales to assess child's pain? (T.37)

Wong-Baker FACES pain rating scale (3 years or older) - 0 to 10 with facial expression CRIES (0 to 6 months)

A new mother calls the pediatric nurse to talk about her baby, who sleeps "all day long." The nurse informs the new mother that an infant requires how many hours of sleep? (T.33) a) 14 to 20 hours each day b) 12 to 14 hours each day c) 8 to 9 hours each day d) 9 to 12 hours each day

a

A nursing caring for patients in a long-term care facility is implementing interventions to help promote sleep in elderly patients. Which action is recommended for these patients? (T.33) a. Increase physical activities during the day b. Encourage short periods of napping during the day c. Increase fluids during the evening d. Dispense diuretics during the afternoon hours

a

The parents of a newborn ask when they can expect the baby to sleep through the night. The nurse responds that the baby will most likely sleep through the night by: (T.33) a) 3 months of age b) 6 weeks of age c) 1 year of age d) 6 months of age

a

The client being seen in the employee wellness clinic reports difficulty sleeping for the past several months. The most important assessment the nurse could make is: (T.33) a) reviewing the client's sleep diary for the past 2 weeks. b) asking the client's bed partner to describe the sleep problem. c) identifying specific foods that negatively impact sleep. d) having client recall the number of sleep hours each night for the past week.

a A sleep diary kept for 2 weeks will provide a more detailed history of the client's sleep-wakefulness pattern than having the client identify foods that impact sleep, or having the client recall the number of hours of sleep each day for the past week. Client recall may be inaccurate. The client should describe the sleep problem, not the client's bed partner.

Which of these is a physiological change during NREM sleep? (T.33) a) decreased brain activity from wakefulness b) body temperature is not regulated c) muscle tone absent d) sympathetic nerve activity increases from wakefulness

a Brain activity decreases from wakefulness. During slow-wave sleep (SWS), muscles are relaxed, but muscle tone is maintained during NREM. Sympathetic nerve activity decreases from wakefulness Body temperature is regulated at a lower level from wakefulness.

A group of student nurses is observing an older adult client sitting by the nurses' station folding towels and washing clothes. One student verbalized that it was not appropriate to have the client do this. Which response will show good understanding of this activity? (T. 43) a) Folding towels is a self-stimulating activity. b) This activity is better than being restrained in the bed. c) This activity will keep the client from being noncompliant with instructions. d) Keeping the client at the nurses' station allows the nurses to guard him. Submit your answer

a Encourage clients to provide self-stimulation, such as singing, reading, and talking into a tape recorder and playing it back. Self-care activities also are forms of self-stimulation. Provide various different types of stimulation to encourage maximum use of the client's available senses. Doing so also helps the person adapt to any changes.

at factor has been hypothesized by researchers regarding current thoughts on sleep? (T.33) a) Chronic sleep deprivation is present. b) More sleep is obtained through napping. c) The current population requires less sleep. d) Population is healthier due to sleep.

a Most recently, researchers have hypothesized that much of the population in industrialized nations may be chronically sleep deprived

To promote sleep in a patient, a nurse suggests what intervention? (T. 33) a. Follow usual bedtime routine if possible b. Drink two or three glasses of water at bedtime c. Have a large snack at bedtime d. Take a sedative-hypnotic every night at bedtime

a c. small protein and carbohydrate snack is recommended d. taking a sedative-hypnotic disrupts REM and NREM sleep and they loose effectively quickly

A nurse who provides care in a long-term setting is aware of the need to promote and protect sensory stimulation for residents. What interventions should the nurse choose in order to achieve this goal? Select all that apply. (T.43) a) Assess residents for the CNS effects of drugs and the potential for polypharmacy. b) Regularly reorient residents who are disoriented to person, place, or time. c) Ensure that residents who require assistive devices are regularly using them. d) Regularly assess residents for age-related sensory losses. e) Maintain a low-light environment to preclude sensory overload.

a, b, c, d Adequate lighting is an important environmental modification that helps to accommodate age-related vision losses. Assessing residents' sensory function, reorienting residents, ensuring the use of appropriate assistive devices, and assessing for the effects of drugs are all nursing actions that can positively impact sensory stimulation for older adults

Choice Multiple question - Select all answer choices that apply. The nurse is managing the environment for clients on a busy hospital ward. Which interventions would the nurse perform to facilitate a more restful environment? Select all that apply. (T.33) a) Maintain a brighter room during daylight hours and dim lights in the evening. b) Decrease the volume on alarms, pages, telephones, and staff conversations. c) Keep the doors to the clients' rooms open. d) Medicate for pain if needed. e) Keep the room warm and provide earplugs and eye masks if requested. f) Schedule procedures separately to avoid tiring out the clients.

a, b, d The nurse could perform several of the interventions listed to facilitate a more restful environment. First, the nurse could maintain a brighter room during daylight hours and dim lights in the evening. Opening the curtains in the room during the day is an excellent way to carry out this intervention. The nurse would decrease the volume on alarms, pages, telephones, and staff conversations. The nurse would medicate the client for pain if needed. The nurse would not keep the room warm, but cool to aid in sleep. Procedures should be scheduled together if at all possible to decrease the amount of time the client is involved in procedures and promote rest. The nurse should keep the door to the client's room closed if possible to facilitate a more restful environment.

Choice Multiple question - Select all answer choices that apply. A nurse is working with a 60-year-old man who has been diagnosed with onset insomnia. He tells the nurse that he wakes up at least once during the night. Which are good examples of health promotion for this client? Select all that apply. (T.33) a) The nurse encourages the client to remove the television from his bedroom. b) The nurse encourages the client to minimize caffeine intake several hours prior to bedtime. c) The nurse teaches the client that shorter, unbroken sleep periods are not normal. d) The nurse advises the client to exercise at least 6 hours before bedtime. e) The nurse helps the client come up with a bedtime routine that he can implement each night.

a, b, d, e Avoiding strenuous activities and caffeine for several hours before bedtime can help an individual who is having difficulty falling asleep. This client could also benefit from removing any distractions in his bedroom, by improving his sense of security, by decreasing any feelings of social isolation, and by creating a routine around bedtime. Teaching the client that shorter unbroken sleep periods are not normal not only provides him with false information but may also cause him to feel abnormal.

Choice Multiple question - Select all answer choices that apply. A nurse caring for a client with hypersomnia investigates the cause of the sleep disorder. What are possible causes to consider? Select all that apply. (T.33) a) Another sleep disorder, such as sleep apnea b) Depression c) Malnourishment d) Some medications e) Eating disorders f) Alcohol abuse

a, b, d, f The possible causes to hypersomnia could include another sleep disorder (such as sleep apnea), depression, alcohol abuse, or the effect of some medications. Malnourishment and eating disorders would not be a cause of hypersomnia.

Nurse formulates diagnosis of elderly patient who is having trouble sleeping at night: Disturbed sleep pattern: initiation of sleep. Which of following nursing interventions would nurse perform related to this diagnosis? Select all that apply (T.33) a. Arrangement for assessment for depression and treatment b. Discourage napping during the day c. Decrease fluids during the evening d. Administer diuretics in morning e. Encourage patient to engage in some type of physical activity f. Assess medication for side effects of sleep pattern distrubances

a, b, e, f - age related changes and nursing strategies for rest and sleep Limiting fluids and administering diuretics in the morning are appropriate interventions for disturbed sleep pattern: maintaining sleep - to avoid RLSyndrome, nocturia

Choice Multiple question - Select all answer choices that apply. A nurse explains cognitive behavioral therapy (CBT) to a client who is experiencing chronic insomnia. Which statements by the nurse best describe this therapy? Select all that apply. (T.33) a) "Used with other complementary therapies, CBT is very successful." b) "Sedatives and hypnotics are used in conjunction with CBT." c) "You will meet with a therapist to work through any maladaptive sleep beliefs." d) "CBT may include progressive muscle relaxation measures, stimulus control, and sleep restriction therapy." e) "Clients undergoing CBT are asked to stay in bed during normal sleep hours even if they are unable to sleep." f) "Pharmacologic approaches should be attempted prior to CBT to resolve the insomnia."

a, c, d Cognitive behavior therapy (CBT) requires a therapist to work through any maladaptive sleep beliefs. CBT can be very successful is used with other complementary therapies. CBT can include progressive muscle relaxation measures, stimulus control, and sleep restriction therapy. Sedatives and hypnotics would not be used in conjunction with CBT. Pharmacologic approaches do not have to be attempted prior to CBT initiation. A client undergoing CBT is not asked to stay in bed during normal sleep hours if the client is not able to sleep.

Choice Multiple question - Select all answer choices that apply. A nurse explains cognitive behavioral therapy (CBT) to a client who is experiencing chronic insomnia. Which statements by the nurse best describe this therapy? Select all that apply. (T.33) a) "Used with other complementary therapies, CBT is very successful." b) "Pharmacologic approaches should be attempted prior to CBT to resolve the insomnia." c) "Sedatives and hypnotics are used in conjunction with CBT." d) "CBT may include progressive muscle relaxation measures, stimulus control, and sleep restriction therapy." e) "Clients undergoing CBT are asked to stay in bed during normal sleep hours even if they are unable to sleep." f) "You will meet with a therapist to work through any maladaptive sleep beliefs."

a, d, f Cognitive behavior therapy (CBT) requires a therapist to work through any maladaptive sleep beliefs. CBT can be very successful is used with other complementary therapies. CBT can include progressive muscle relaxation measures, stimulus control, and sleep restriction therapy. Sedatives and hypnotics would not be used in conjunction with CBT. Pharmacologic approaches do not have to be attempted prior to CBT initiation. A client undergoing CBT is not asked to stay in bed during normal sleep hours if the client is not able to sleep

Which conditions occur in clients who are experiencing the effects of sensory deprivation? Select all that apply. (T.43) a) inability to control direction of thought content b) increased coordination and equilibrium c) emotionally caring attitude and stable moods d) difficulty with memory, problem solving, and task performance e) increased attention span and ability to concentrate f) inaccurate perception of sights, sounds, tastes, and smells

a, d, f Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. Common conditions that result from sensory deprivation include inaccurate perception of sights, sounds, tastes, and smells; inability to control the direction of thought; and difficulty with memory, problem solving, and performing tasks. Decreased coordination and equilibrium, lack of a caring attitude, and unstable moods are also common conditions associated with sensory deprivation

Choice Multiple question - Select all answer choices that apply. During an orientation class for new RN graduates, the nurse educator identifies which conditions as potential risks for clients to experience sleep pattern disturbance? Select all that apply. (T.33) a) Constipation b) Substance abuse c) Depression d) Type 1 diabetes mellitus (DM) e) Glaucoma f) Stroke

a,b,c,f People engaged in changing shift work, particularly overnights, can be prone to higher risk of depression, loneliness, substance abuse, type 2 DM, and gastrointestinal and cardiovascular symptoms. Type 1 DM and glaucoma are not related to sleep-cycle disruption

A nurse is teaching a patient to keep a sleep diary, which data should nurse have patient document? Select all that apply. (T.33) a. Daily mental activities b. Daily physical activities c. Morning and evening body temperature d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings

a,b,e A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary

The nurse is instructing a parent on how to promote restful sleep for a child. The food that would serve as the best bedtime snack for the child is? (T.33) a) Chocolate bar b) Apple slices c) Tuna salad d) Almonds

b

For which of the following clients would the nurse most likely administer a benzodiazepine-like drug? (T.33) a) A client who needs long-term therapy for chronic insomnia b) A client who is being treated for short-term insomnia c) A client who has insomnia and awakens in the middle of the night d) A client who has insomnia combined with restless leg syndrome

b Although most benzodiazepine-like drugs provide several nights of excellent sleep, the medication often loses its effect after 1 or 2 weeks. These drugs should be used for the client who is being treated for short-term insomnia. Zolpidem tartrate sublingual tablets have recently been approved by the FDA for insomnia associated with middle-of-the-night awakening. It is intended for use when at least 4 hours of sleep time remain. Eszopiclone is prescribed for longer-term treatment of chronic insomnia. Ropinirole and pramipexole dihydrochloride are drugs that have been approved by the U.S. Food and Drug Administration (FDA) to treat restless leg syndrome (RLS). Two additional medications have been approved for treatment of moderate to severe RLS: gabapentin enacarbil (extended-release tablets) and rotigotine transdermal system. Both are sustained-release medications that have proved effective for relief of the symptoms of RLS.

A client will require further education about Restless Leg Syndrome when he tells the nurse: (T.33) a) "I understand this has something to do with my diabetes." b) "I will try to lose weight so I can sleep better at night." c) "My heating pad will decrease the tingling in my legs." d) "I won't drink any wine with dinner or in the evening."

b Abstaining from alcohol consumption and using a heating pad to the affected area at night can help decrease the symptoms of Restless Leg Syndrome (RLS). RLS may be related to diabetic neuropathy. Being overweight is not a risk factor for RLS

During the morning assessment the client reports to the nurse he is experiencing a hangover from his sleeping pill. The nurse reviews the Medication Administration Record. Which of the following medications is more likely to cause the client's complaint? (T.33) a) Ramelteon (Rozerem) b) Flurazepam (Dalmane) c) Eszopiclone (Lunesta) d) Zolpidem (Ambien)

b All of the listed medications are ones that promote sleep. Flurazepam is the drug most likely to cause the client's complaint of a morning hangover.

he nurse is instructing a parent on how to promote restful sleep for a child. The food that would serve as the best bedtime snack for the child is? (T.33) a) Chocolate bar b) Apple slices c) Tuna salad d) Almonds

b Carbohydrates promote sleep by making tryptophan available to the brain. Simple carbohydrates such as fruit slices or juice are effective. Chocolate provides high sugar content and possibly caffeine exposure which will promote wakefulness. Tuna salad and almonds are protein, not carbohydrates

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem? (T.43) a) Acute confusion b) Impaired memory c) Disturbed sensory perception d) Chronic confusion

b Impaired memory is a state in which an individual experiences the inability to remember or recall bits of information or behavioral skills. Disturbed sensory perception is a state in which the individual experiences a change in the amount, pattern, or interpretation of incoming stimuli. Acute confusion is the abrupt onset of a cluster of global, transient changes, and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycle. Chronic confusion is an irreversible, long-standing, or progressive deterioration of intellect and personality, characterized by decreased ability to interpret environmental stimuli or decreased capacity for intellectual thought.

The nurse assesses that the client has sensory impairment from longterm furosemide (Lasix) use. Which of the following actions will the nurse implement? (T.43) a) Encourage the client to participate in exercise classes. b) When communicating with the client, use a lower tone of voice. c) Provide enlarged print for reading. d) Protect the client's skin from temperature extremes.

b Longterm use of furosemide (Lasix) is ototoxic and can impair auditory function. For clients with hearing deficits, the nurse would communicate with the client using a lower tone of voice. Furosemide use does not decrease a client's sense of touch (protecting the client's skin from temperature extremes) or vision (providing enlarged print for reading). Encouraging the client to participate in exercise classes would be used for sensory deprivation, which is not caused by furosemide use.

The nurse is implementing nursing interventions to promote sleep on a busy hospital ward. Which intervention is the best choice for these clients? (T.33) a) Have the clients set an alarm clock so they are not worried about getting up. b) Offer clients a small carbohydrate and protein snack before bedtime. c) Encourage the clients to take a shower prior to bedtime. d) Create a warm, dark environment in the clients' rooms.

b Offering a client a small carbohydrate and protein snack before bedtime would be the best choice. Peanut butter on toast or cheese and crackers would be an example of an appropriate snack. The temperature of the room should be cool, not warm. An alarm clock would not be necessary for a client who is an inpatient in the hospital. A shower could possibly be helpful, but it is not the best answer.

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to: (T.33) a) take prescribed sedative before trying to sleep. b) anticipate sleeping overnight at a health care center. c) apply facial mask that will deliver positive air pressure. d) insert an oral appliance prior to attempting sleep.

b Polysomnography is a sleep study. The client will be scheduled for the study at a health care center and sleep overnight as part of the study. The client should avoid sedatives as this will aggravate OSA. Interventions for OSA include inserting an oral appliance or applying a facial mask for continuous positive airway pressure.

A client begins snoring and is sleeping lightly. The stage of sleep is: (T.33) a) Stage 4 b) Stage 2 c) Stage 1 d) Stage 3

b Stage 2 is relatively light sleep from which the client is easily awakened. Rolling eye movements continue, and snoring may occur.

A nurse attempts to wake a client who is scheduled for tests and is able to arouse him relatively easily. Which stage of sleep is this client most likely experiencing? (T.33) a) Stage I b) Stage III c) Stage IV d) Stage II

b The client is most likely experiencing Stage II sleep. Stage II sleep is when the client is aroused with relative ease. This stage constitutes 50% to 55% of sleep. Stage I is a transitional stage between wakefulness and sleep. The client is still somewhat aware of the surroundings. Involuntary muscle jerking may occur and waken the person. This stage normally lasts only minutes. Stage III composes about 10% of sleep. This stage is when the depth of sleep increases, and arousal becomes increasingly difficult. Stage IV is when arousal from sleep is difficult. This stage is called delta sleep. This stage constitutes about 10% of sleep. The pulse, blood pressure, and respiratory rate decrease in Stage IV.

A nurse in a family clinic asks a client, "How do you spend a typical day?" The nurse is collecting information about: (T.43) a) risk identification. b) normal pattern identification. c) outcome identification. d) dysfunction identification.

b The nurse asking the client a general question to determine his normal pattern of sensory perception is using normal pattern identification. Dysfunction identification involves the collection of data about actual sensory perception problems. Risk identification involves eliciting information about factors that may place the client at increased risk of sensory perception dysfunction. Goals for achieving optimal sensory function are determined during outcome identification

In Stage 4 sleep, the: (T.33) a) temperature increases b) pulse rate is slow c) blood pressure is elevated d) respirations are irregular

b During slow-wave sleep, the muscles are relaxed, but muscle tone is maintained; respirations are even; and blood pressure, pulse, temperature, urine formation, and oxygen consumption by muscle all decrease.

A nurse is providing community education about the importance of getting enough sleep. Which information about REM sleep is most accurate? (T.33) a) The blood pressure decreases. b) It plays a role in memory. c) Muscle tone is enhanced. d) The person is easily arousable.

b REM sleep is believed to play a role in learning, memory, and adaptation. It is more difficult to arouse a person during REM sleep than during NREM sleep. During REM sleep, the pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase, whereas general skeletal muscle tone and deep tendon reflexes are depressed

During an assessment to determine sleep disorder for a patient, the patient fell asleep in middle of conversations. The nurse would suspect with disorder? (T.33) a. REM behavior disorder b. Narcolepsy c. Enuresis d. Sleep apnea

b - narcolepsy - incontrollable desire to sleep; the person may fall asleep in middle of conversation REM behavior disorder (RBD) - characterized by "acting out" dreams while asleep Enuresis is urinating during sleep or bedwetting Sleep apnea - condition in which breathing ceases for a period of time between snoring

A nurse caring for patients in busy hospital environment should implement which recommendation to promote sleep? (T.33) a. Keep the room light dimmed during the day b. Keep the room cool c. Keep the doctor room open d. Offer a sleep aid medication to patient on a regular basis

b - should keep the room cool and provide earplugs and eye mask dim light in evening and bright light in day keep door closed sleep aid medications should only be offered as prescribed

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include? (T.33) a) Inform parents about the preschool child's awareness of the concept of death possibly occurring and encourage parents to help alleviate the child's fears. b) Teach parents of infants to report any eye movements, groaning, or grimacing by their infant during sleep periods. c) Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. d) Advise parents that waking from nightmares or night terrors is common during the adolescent stage.

c The nurse would include the education point that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. It is normal for infants to have eye movements, groaning, or grimacing during sleep periods. School-age children become aware of the concept of death, not preschool children. Waking from nightmares or night terrors is common during the preschooler stage.

A client in the intensive care unit becomes very cognizant of the nurse's touch. This is a function of which system? (T.43) a) Peripheral nervous system b) Local adaptation syndrome c) Reticular activating system d) General adaptation syndrome

c The reticular activating system (RAS) is responsible for bringing together information from the cerebellum and other parts of the brain with information obtained from the sense organs. Awareness of the world depends on the RAS, which is located between the nerve centers of the medulla oblongata in the brain stem. Sensory, visceral, kinesthetic, and cognitive input stimulate the RAS

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at factory changed from the day shift to the night shift. Which diagnosis would be most appropriate for this patient? (T.33) a. Ineffective coping: multiple stressors of new job b. Sleep deprivation: difficulty falling asleep c. Disturbed sleep pattern: altered sleep-wake pattern d. Risk for injury: activity intolerance/sleep deprivation

c b. sleep deprivation if problem is prolonged

Choice Multiple question - Select all answer choices that apply. What are characteristics of rapid eye movement sleep? Select all that apply. (T.33) a) A person is unable to move during this stage. b) Sleepwalking and bed-wetting are most likely to occur during this stage. c) Blood pressure and pulse rate show wide variations and may fluctuate rapidly. d) Muscles are relaxed but muscle tone is maintained. e) Theta waves often have a sawtooth or notched appearance.

c, d, e During REM sleep, blood pressure and pulse rate show wide variations and may fluctuate rapidly, a person is unable to move Theta waves often have a sawtooth or notched appearance. Muscles are relaxed but muscle tone is maintained. Sleepwalking and bed-wetting are most likely to occur during NREM

For which conditions would the nurse assess a client to determine if he is able to adequately receive the data necessary to experience the world? Select all that apply. (T.43) a) a receptor or sense organ b) a response c) a stimulus d) an arousal mechanism e) a functioning brain f) an intact nerve pathway

c, d, e, f For a person to receive the necessary data to experience the world, four conditions must be met: · A stimulus—an agent, act, or other influence capable of initiating a response by the nervous system—must be present. · A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. · The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. · A particular area in the brain must receive and translate the impulse into a sensation. A response and an arousal mechanism are not included in these conditions.

Choice Multiple question - Select all answer choices that apply. The nurse is providing client education for the parents of an obese child diagnosed with obstructive sleep apnea. What treatment measures would the nurse explain during the education session? Select all that apply. (T.33) a) treatment with intranasal antibiotics b) counseling for depression c) use of a mandibular advancement device (MAD) d) a weight loss plan e) treatment with sleeping pills f) use of a continuous passive airway pressure (CPAP) machine

c, d, f A weight loss plan, use of a continuous passive airway pressure (CPAP) machine, and the use of a mandibular advancement device (MAD) are treatment measures that the nurse would explain during the education session on obstructive sleep apnea. The use of antibiotics and sleeping pills would not be included. Counseling for depression is not necessary as the question is written

Slight increase in vital signs, according to stage of sleep, what can the nurse say is true? Select all that apply (T.33) a. He is aware of his surroundings at this point b. He is in delta sleep at this time c. It would be most difficult awaken him at this time d. This is most likely an NREM stage e. The stage constitutes around 20% to 25% of total sleep f. The muscles are relaxed in this stage

c, e REM sleep: hard to arouse, vital signs increase, 20-25% Delta sleep is stage III, and IV Stage IV of NREM sleep, muscles are relaxed Small muscle twitching may occur in REM sleep

A nurse is discussing with an older female patients the factors that affect sleep. What does the nurse teach her? (T.33) a. Drinking a cup of regular tea at night induces sleep b. Using alcohol moderately promotes a deep sleep c. Aging decreases the amount of REM sleep a person experiences d. Exercising decreases REM and NREM sleep

c. Tea contains caffeine so increase alertness Large quantities of alcohol limit REM and delta sleep (should not be used within 6 hours of sleep, women and older adults are more vulnerable to effect of alcohol) Physical activity increase both REM and NREM sleep but within 3 hours of sleep can hinder sleep (excessive or exhaustion can decrease the quality of sleep) Smoking has nicotine, stimulating effects

Which situation demonstrates sensory adaptation? (T.43) a) A client with vision loss has begun buying large-print books. b) A client believes his hearing has become more acute since he lost his vision. c) A client with hearing loss has learned to communicate using sign language. d) A client has learned to sleep through the frequent beeping of her intravenous pump.

d Adaptation occurs when the body adapts to constant stimuli, such as the continuous beeping of a hospital device. Adaptation is not the same as the compensation in routines or other senses that occurs when clients experience sensory losses.

Which client condition indicates the presence of a parasomnia? (T.33) a) a woman whose restless leg syndrome often awakens her b) a man who takes several hours to fall asleep each night c) a child who awakens with nightmares three to four times a week d) a child who wets his bed each night

d Enuresis is considered a parasomnia. Insomnia and RLS are classified as dyssomnias.

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and she believes she is in a hotel. How should the nurse best respond to this client's disorientation? (T.43) a) Thank the client for her responses and document her cognitive status. b) Ask the client what she was doing in 1949 and what hotel she believes she is in. c) Provide hints during conversation as to the correct year and place. d) Reorient the client to place and time.

d It is appropriate to reorient clients who are confused. Doing so in an effective and empathic manner requires the astute implementation of nursing skills. Engaging more deeply with the client's incorrect responses does not reorient her. Attempting to reorient the client in a subtle and indirect manner is not likely to be effective. Documenting the client's response is necessary, but this should be followed up by reorientation

The nurse, who frequently cares for spinal cord injury clients, is studying the effects of sensory deprivation. Which of her following statements is most accurate? (T.43) a) "Perceptual disturbances can include daydreams." b) "With decreased sensory input, the reticular activiating system (RAS) still projects a normal level of activation to the brain." c) "Cognitive disturbances result from inaccurate perception of sights, sounds, tastes, smells, and body position." d) "Emotional disturbances involve the client's inability to control direction of thought content."

d Sensory deprivation can lead to perceptual, cognitive, and emotional disturbances. Perceptual responses can range from mild distortions such as daydreams, to gross distortions such as hallucinations. Perceptual responses result from inaccurate perception of sights, sounds, tastes, smells, and body position. Cognitive responses involve the client's inability to control the direction of thought content. Emotional responses typically are manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. With decreased sensory input, the RAS is no longer able to project a normal level of activation to the brain.

The nurse is performing an intake assessment of a 60-year-old client who admits to having a "nightcap" of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep? (T.22) a) increased stage IV NREM sleep (delta sleep) b) increased amount of total sleep c) shorter sleep cycles d) decreased REM sleep

d Alcohol is known to decrease the amount of REM and delta sleep an individual experiences. Alcohol does not typically shorten sleep cycles or increase the total amount of sleep.

Which client is most likely susceptible to the effects of disturbed sensory perception? (T.43) a) A client who is having cataract surgery in an outpatient eye clinic b) A client who has just been admitted to the emergency department with reports of chest pain c) An older adult client whose lung disease is being treated in the acute care for elders (ACE) unit of the hospital d) A client who is receiving care in the intensive care unit (ICU) for the treatment of septic shock Submit your answer

d Clients in critical care settings are particularly susceptible to severe sensory alterations. A client who has been in a setting for a short time, such as an emergency or day surgery setting, is less likely to experience disturbed sensory perception. Older adults are often vulnerable to sensory disturbances, but the risks posed by an ICU setting likely supersede a geriatric medical unit

A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client? (T.33) a) Nightmares b) Somnambulism c) Nocturnal enuresis d) Insomnia

d Insomnia and hypersomnia are often manifestations of depression in older clients. Nightmares, somnambulism (sleepwalking), and nocturnal enuresis are examples of parasomnias. These are conditions associated with activities that cause arousal, or partial arousal, usually during transitions in NREM periods of sleep. However, these are not manifestations of depression in an older adult client. (less)

Which factor has the most influence on an individual's sleep-wake patterns? (T.33) a) the body's need for 8 hours of sleep b) bedtime rituals c) daylight and darkness d) the inner biologic clock

d The inner biologic clock is the regulating mechanism for the body's sleep-wake patterns. No formula exists for the duration of sleep. Although light and dark appear to be powerful regulators of the sleep-wake pattern, they do not exert primary control

A nurse working the night shift at a hospital observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply (T.33) a. REM Sleep constitutes most of sleep cycle of a preschool child b. By age of 8 years old, most children no longer take naps c. Sleep needs usually decrease when physical growth peaks d. Many adolescents do not get enough sleep e. Total sleep decreases in adults with a decrease in stage IV sleep f. Sleep is less sound in older adults and stage IV sleep may be absent

d,e,f a- REM constitutes most sleep for infant/newborns b. By 5 years old c. increase when physical growth peaks d. yes, because time of school is early, having restless sleep due to stress of school, activities, and part-time employment resulting in 7 - 7.5 hours e. yes, the percentage of time awake in bed increases f. yes, average of 7 - 9 hours, periods of REM sleep shorten, have difficulty falling asleep, also with decline of physical health, psychosocial factors, effects of drug therapy (nocturia), or environmental factors may be implicated as causes of inability to sleep

The nurse knows that a client understands the purpose of a sleep diary when the client states: (T.33) a) "I will keep track of my sleep information for 2 months." b) "I will only keep track of my sleep habits at home, not when I am traveling out of town." c) "I will write down all my morning activities." d) "I will record the time I go to bed and how long it takes me to fall asleep."

d. Keeping notes of times of sleep and waking are important details to record in a sleep diary. The notes are usually maintained for 14 days and include specifics such as all wakeful activities and sleep patterns in strange environments.

What is the effect of alcohol on sleep? (T.33)

decrease REM sleep

What is cataplexy? (T.33)

is a sudden loss of motor tone that may cause the person to fall asleep, but is usually experience during a period of strong emotion

What would be considered at a higher risk for having sleep disturbances? Select all that apply. (T.33) a. A patient who has uncontrolled hypothyroidism b. A patient with coronary artery disease c. A patient who has gastroesophageal reflux (GERD) d. A patient who is HIV positive e. A patient who is taking corticosteroids for arthritis f. A patient with a urinary tract infection

sleep disturbances mean sleep pattern a, b, c Hypothyroidism decreased amount of NREM especially stage II and III sleep Pain associated with CAD and myocardial infarction is more likely with REM sleep GERD awaken at night with heartburn The rest does not change sleep patterns

What is Bruxism? (T.33)

the involuntary or habitual grinding of the teeth, typically during sleep.