ATI: RN Comfort, Rest, and Sleep Assessment 2.0
A nurse is reviewing the concepts of central sleep apnea with a colleague. Which of the following statements by the colleague indicates an understanding of central sleep apnea? a. "Common causes of CSA are opioid overdose and congestive heart failure." b. "CSA is caused by obesity and an inactive tongue." c. "CSA is easily diagnosed using polysomnography." d. "CSA is related to the recurrent episodes of upper airway collapse and obstruction."
a. "Common causes of CSA are opioid overdose and congestive heart failure." -Central sleep apnea (CSA) is the result of reduction of the brain's transmission of signals to the respiratory muscles. This results in the cessation of breathing and is commonly caused by opioid overdose and heart failure.
A nurse is caring for a client who was admitted following a report of lumbar pain. In addition to administering pain meds, which of the following interventions should the nurse implement to promote comfort? a. Present information honestly. b. Have another nurse present difficult information. c. Do not include the client's concerns in the POC if they interfere with treatment. d. Perform cognitive behavioral therapy with the client.
a. Perform information honestly. -Presenting information and answering questions honestly can help the client to feel safe. The nurse should also be present to respond to client needs and should remain supportive of the client's choices.
A nurse is caring for a client who reports that they use their smartphone at night while they are in bed. The nurse should identify that excessive smartphone use can increase the client's risk for which of the following? a. Depression b. Binge eating disorder c. Restless leg syndrome d. Diminished circadian rhythm
a. Depression -Excessive smartphone use is a risk factor for both depression and poor sleep.
A nurse is caring for a client who works overnight shifts. The nurse should identify that individuals who perform shift work are at an increased risk for developing which of the following conditions? a. Diabetes mellitus b. Central sleep apnea c. Hypersomnia d. Restless leg syndrome
a. Diabetes mellitus -Individuals who perform shift work are at an increased risk for developing health conditions, including diabetes mellitus, obesity, and cardiovascular disease.
A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse plan to include to promote emotional comfort for the client? a. Encourage the client to verbalize their needs and concerns. b. Limit time spent with client. c. Ask the client to splint the incision when coughing. d. Administer pain meds as prescribed.
a. Encourage the client to verbalize their needs and concerns. -The nurse should encourage the client to verbalize their needs and concerns. Listening to the client's concerns and incorporating those concerns into the plan of care promotes client comfort by allowing the client to feel valued and that they are a vital part of the process.
A nurse is contributing to a presentation about hypersomnia. Which of the following information should the nurse recommend including in the presentation? a. Hypersomnia does not improve with increased sleep. b. Hypersomnia is associated with a disturbed circadian rhythm. c. Clients who experience hypersomnia have a longer attention span. d. Clients who experience hypersomnia lack the hormone hypocretin.
a. Hypersomnia does not improve with increased sleep. -The nurse should recommend including that hypersomnia is characterized by excessive daytime fatigue that does not improve if the client receives additional sleep.
A nurse is caring for a client who has narcolepsy (NT1) with cataplexy. The nurse should identify that this condition is caused by a lack of which of the following hormones? a. Hypocretin b. Melatonin c. Estrogen d. Insulin
a. Hypocretin -Hypocretin is a hormone produced in the hypothalamus and is responsible for maintaining alertness. Narcolepsy (NT1) with cataplexy is caused by a lack of hypocretin.
An employee health nurse is providing teaching about sleep promotion to a group of newly licensed nurses. Which of the following statements should the nurse include? a. "Taking a cool shower before bedtime can help with sleep." b. "If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music." c. "To promote nighttime sleep, limit daytime naps to 1 hr." d. "Exercising 1 hr before bedtime can help promote relaxation and sleep."
b. "If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music." -The nurse should instruct the newly licensed nurses to go to bed when tired, and to get out of bed if sleep does not occur within 20 min. Getting out of the bed and reading a book or listening to soft music can help promote relaxation and sleep.
A nurse is reviewing the concept of comfort with an AP. Which of the following statements by the AP indicates an understanding of comfort? a. "Providing comfort for a client is achieved by the relief of physical pain through the administration of medication." b. "Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy." c. "Providing comfort for a client is achieved by taking control of the client's care and creating routines for the client to become familiar with." d. "Providing comfort to a client requires staff members to smile and remain cheerful no matter the outcome the client is facing."
b. "Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy." -Providing comfort to a client involves easement of mental distress, as well as physical distress.
A nurse manager is conducting an in-service about the physiological functions of sleep for a group of staff nurses. Which of the following statements by one of the nurses indicates an understanding of the teaching? a. "Sleep is a process that decreases the development of new neural pathways that assist with retention of knowledge and memorization." b. "The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake." c. "The circadian rhythm is an external process that controls the sleep-wake cycle." d. "Clients experience the highest quality sleep when they complete 3/4 stages of sleep."
b. "The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake."
A nurse is reviewing the plan of care for a client who was admitted with insomnia and recent weight gain. Which of the following is a benefit of increased sleep that could help prevent further weight gain for the client? a. Increased ghrelin production b. Increased leptin production c. Decreased hypocretin levels d. Decreased melatonin levels
b. Increased leptin production -Sleep helps to prevent weight gain by increasing the production of leptin, the hunger-reducing hormone.
A nurse is caring for a client who is being evaluated for obstructive sleep apnea. Which of the following findings should the nurse identify as a risk factor for OSA? a. Hypersomnia b. Obesity c. Active glossal muscle d. History of tonsillectomy
b. Obesity
A nurse is caring for a client who has a history of migraines. The client tells the nurse, "I have not been sleeping well. My migraine headaches have returned after not having one for over a year." The nurse should identify that which of the following are potential contributing factors to the client's migraines? Select all that apply. a. Sleep-wake homeostasis b. Sensory overload c. Sleep deprivation d. Increased melatonin e. Decreased hypocretin levels
b. Sensory overload c. Sleep deprivation
A nurse is teaching a newly licensed nurse about the development of dreams. The nurse should include that which of the following areas of the brain transmits the sensory data that is used to develop dreams? a. Hypothalamus b. Thalamus c. Cerebral cortex d. Pineal gland
b. Thalamus -The nurse should include that the thalamus transmits images, sounds, and sensations to the cerebral cortex, which are used to develop dreams during rapid eye movement (REM) sleep.
A nurse is caring for an older adult client who is having difficulty sleeping and has a new prescription for a medication to help them sleep. Which of the following medications should the nurse identify as a first line sleep aid for older adults? a. Alprazolam b. Eszopiclone c. Controlled-release melatonin d. Diphenhydramine
c. Controlled-release melatonin -The nurse should identify that controlled-release melatonin is a first-line sleep aid that is recommended for older adult clients. It is cost-effective, non-habit forming, and has few adverse effects.
A nurse is contributing to a presentation about nonpharmacological interventions used to promote sleep. Which of the following information should the nurse recommend including in the presentation? a. Nonpharmacological interventions should only be practiced in the client's home setting. b. Massage is a NI that should be used to promote sleeping for clients who are taking anticoagulants. c. NI used to help promote sleep include acupuncture and thermotherapy. d. Before implementing NI, clients should be evaluated by a sleep specialist for sleep apnea and chronic lung disease.
c. NI used to help promote sleep include acupuncture and thermotherapy.
A nurse is assessing a client who reports difficulty staying awake during the day and experiencing involuntary episodes of lost muscle tone. The nurse should identify that these are manifestations of which of the following conditions? a. Hypersomnia b. Narcolepsy (NT2) c. Narcolepsy (NT1) d. Insomnia
c. Narcolepsy (NT1) -The nurse should identify that the client is exhibiting manifestations of narcolepsy (NT1). Narcolepsy (NT1) is a chronic sleep condition that is characterized by sudden sleepiness and sudden periods of sleep accompanied by cataplexy, or episodes of involuntary loss of muscle tone brought on by strong emotions, such as laughter. Clients who have narcolepsy (NT1) with cataplexy lack hypocretin in their central nervous system. Clients who have both NT1 and NT2 narcolepsy might experience nocturnal hallucinations, paralysis while asleep, and vivid dreams.
A nurse is discussing the stages of the sleep cycle with a client. The nurse should include that the immune system is strengthened, and tissues and bones are repaired during which of the following stages of the sleep cycle? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
c. Stage 3 -The nurse should include that the immune system is strengthened and tissues and bones are repaired during stage 3 of the sleep cycle.
A nurse is caring for a client who needs to be awakened for the administration of an oral medication. Which of the following findings should indicate to the nurse that the client was in stage 3 of the sleep cycle when awakened? a. The client was easily awakened. b. The client states that they were having a pleasant dream. c. The client experiences mental cloudiness for 30-60 min. d. Prior to being awakened, the client's breathing was irregular, and their heartrate was elevated.
c. The client experiences mental cloudiness for 30-60 min. -Stage 3 of the sleep cycle is the deepest stage of sleep in which muscle, tissue, and bones regenerate and the immune system strengthens. If a client is awakened during stage 3 of the sleep cycle, the nurse should expect the client to experience mental cloudiness for 30 to 60 min.
A nurse is evaluating a client after measures to promote comfort have been implemented. Which of the following statements by the client indicates that the client has been comforted? a. "I wish the staff would listen closer to my needs." b. "I am concerned about what is going to happen during my tests tomorrow." c. "It seems to take the staff a while to answer my call light." d. "My health care team has helped me feel safe during my stay."
d. "My health care team has helped me feel safe during my stay." -This statement indicates that the client feels comforted. A client who is comforted will verbalize feelings of safety, acceptance, and value.
A nurse is caring for a client who is having difficulty falling asleep. Which of the following interventions should the nurse implement to promote sleep for the client? a. Offer the client a caffeinated beverage 3 hr before their bedtime. b. Turn on client's tv before they go to bed. c. Warm the temperature of the client's room before they go to bed. d. Dim the lights in the client's room at bedtime.
d. Dim the lights in the client's room at bedtime. -The nurse should dim the lights in the client's room at bedtime to promote sleep for the client. Dimming the lights in the client's room improves relaxation and makes it easier for the client to fall asleep.
A nurse is caring for a client who has a new prescription for a nonbenzodiazepine hypnotic to promote sleep. For which of the following adverse effects should the nurse monitor the client? a. Retrograde amnesia b. Urinary discomfort c. Dry mouth d. Hallucinations
d. Hallucinations -The nurse should monitor the client for hallucinations, which can be an adverse effect of nonbenzodiazepine hypnotics.
A nurse is caring for an older adult client who reports that they wake up frequently during the night. The nurse should identify that which of the following is a characteristic of older adult sleep patterns that might explain the client's frequent awakenings? a. Older adults tend to spend more time in stage 4 sleep. b. Older adults tend to spend more time in stage 3 sleep. c. Older adults tend to spend less time in stage 1 sleep. d. Older adults tend to spend more time in stage 2 sleep.
d. Older adults tend to spend more time in stage 2 sleep. -Older adults tend to spend more time in stage 2 sleep compared to adults. Stage 2 is a lighter stage of sleep than stages 3 and 4. This can contribute to the client's frequent awakenings because environmental factors, such as noise, are more likely to rouse someone who is in stage 2 sleep.
A client is caring for a client who takes OTC sleep aid medication every evening. Which of the following findings should the nurse identify as a potential adverse effect of OTC sleep aid medications? a. Hyperactivity b. Diarrhea c. Excessive salivation d. Urinary retention
d. Urinary retention -The nurse should identify that OTC sleep aid medications can cause urinary retention, as well as daytime drowsiness, dry mouth, visual disturbances, and constipation.
