Sleep Prep U
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?
Continuous positive airway pressure (CPAP)
A nurse understands the client's stage of sleep that requires the greatest stimulus to awaken a client is:
REM sleep
A new mother calls the pediatric nurse to talk to the nurse about her baby who sleeps "all day long." The nurse informs the new mother that an infant requires how many hours of sleep?
14 to 20 hours of sleep each day Explanation: The pediatric nurse informs the new parent that on the average, infants require 14 to 20 hours of sleep each day.
A nurse instructor is instructing her students on the role of hormones in sleep patterns. Which statement would indicate to the nursing instructor that the student needs additional teaching?
A hyperactive thyroid can make the client sleepy all the time."
To obtain subjective data about a newly admitted client's sleep pattern, the nurse
Asks the client what promotes sleep Explanation: The assessment of sleep and rest focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.
The nurse learns during the assessment of a client that the client has difficulty falling asleep, wakes up early, and does not feel refreshed in the morning. Which of the following is this client most likely experiencing?
Disturbed sleep pattern
An older adult informs the nurse that she is having a difficult time sleeping at night. What action may assist the patient in getting a better night of sleep?
Encourage a routine for sleeping and waking. Explanation: If sleep and rest is an area of concern for an older adult, the nurse should discourage excessive napping and encourage a routine for sleeping and waking. The nurse should assess normal bedtime patterns, time for rising, bedtime rituals, effects of pain, medications, anxiety, and depression. The routine use of sleeping pills and varied bedtime rituals should not be encouraged
The nurse is promoting bedtime rituals with a family. Which of the following statements indicates the nurse may need to provide further instructions to the mother?
My boys love to rough-house in their room right before bedtime
A new patient in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is: Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis?
Provide an opportunity for the patient to talk about concerns.
An intoxicated client is admitted to the hospital for alcohol withdrawal. What should the nurse do to help the client become sober?
Provide the client with a quiet room to sleep in
The client with rheumatoid arthritis is seen in the clinic. Which assessment finding indicates the client is having difficulty implementing self-care?
Reports increased fatigue Explanation: Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen.
The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and complaints of severe lumbar and right leg pain. The nurse suspects a nursing diagnosis of:
Sleep Pattern Disturbance related to acute pain. Explanation: The client is demonstrating classic signs of sleep disturbance from the acute back and leg pain he is experiencing. Anxiety may be present but that is a symptom of his problem rather than the nursing diagnosis. He may have impaired mobility, but it is not due to RLS. Also, his role of construction worker may be disrupted by the injury/treatment, but it is not the cause of this assessment data.
The nurse is completing a sleep history on a client who reports sleeping problems. The client does the following behaviors. Which will cause the client to have difficulty with sleep?
Taking a diuretic at 9 AM and 5 PM daily Explanation: Various factors may affect sleep. Taking a diuretic, particularly late in the day, is a common cause for sleep problems. The diuretic may still affect the client at hours of sleep. The other behaviors are acceptable in promoting sleep: exercising more than 2 hours before sleep, ingesting caffeine early in the day, and using a white noise machine to keep the environment quiet.
At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing?
a state of deep sleep Explanation: At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate's respiratory rate of 35 breaths/min is normal
Which factor has the most influence on an individual's sleepwake patterns?
inner biological clock
A nurse working in a health clinic assesses sleep patterns during each health assessment. Based upon the nurse's knowledge regarding sleep needs, the nurse recognizes which age group as generally needing the least amount of sleep?
older adults
The nurse makes the following assessment. A middle-aged client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night even though the number of hours of sleep are unchanged, and continues to feel tired and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to
use caution when driving an automobile. Explanation: The client is describing hypersomnia and is at increased risk for a motor vehicle accident when drowsy or falling asleep while driving an automobile. The client is to avoid alcohol, caffeine, and late night activities.
Most older adults gradually modify activities or lifestyle to accommodate for declines in strength and health. The nurse recognizes the need for older adults to maintain activity and exercise in order to preserve all physiologic functions. When encouraging activity, it is important to consider which of the following:
• Chronic illness often accompanies aging. • There is an increased risk of sleep disorders. • Assistive devices help to maintain mobility and safety. Explanation: The physical strength and health of the older adult declines and requires lifestyle modifications. Older adults have more chronic illness and have the potential for sleep disruptions and the increased risk of falls, thus the need for a cane/walker for assistance. Pain should not be assumed to be a normal consequence of aging.
A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. What measures should the nurse implement to promote sleep? Select all that apply.
• Providing a back massage • Assisting with progressive relaxation • Promoting daytime exercises Explanation: In order to promote sleep in a client, the nurse could use the following measures: promoting daytime exercise, providing a back massage, and assisting the client with progressive relaxation. However, the nurse should reduce the intake of stimulating chemicals to promote sleep in a client. Diuretics may awaken those who take them with a need to empty the bladder. For this reason, diuretics generally are administered early in the morning so that the peak effect has diminished by bedtime.
A nurse is assessing patients in a burn unit for sensory alterations. Which factors contribute to severe sensory alterations?
• Sensory overload • Sensory deprivation • Sleep deprivation Severe sensory alterations can occur, especially in certain areas, such as the critical care or intensive care units (termed intensive care unit [ICU] psychosis). Factors contributing to severe sensory alteration include sensory overload, sensory deprivation, sleep deprivation, and cultural care deprivation. Sensory saturation and sensory discrepancies are not terms typically used.
A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in her teaching?
"If you have excessive vaginal bleeding, massage your fundus and call the physician." Explanation: Advising the client to massage the fundus and call the physician if excessive bleeding occurs is the priority because such bleeding can lead to hemorrhage, causing loss of fluid balance and fainting. Although recommending that a new mother sleep when her neonate sleeps can help the mother avoid exhaustion, this teaching point isn't the top priority. Sleeping with the neonate is a potential hazard; rolling over can suffocate the infant. Telling the client not to worry doesn't provide proper instruction and doesn't address concerns the client may have.
Which statement made by an adolescent who has just begun taking an antidepressant would indicate the need for further teaching?
"Now that I have been taking my antidepressant for 1 week, I am going to feel better about myself." In the first week or so of taking an antidepressant, the vegetative symptoms of depression (poor sleep, appetite, and energy level) improve. However, it takes 3 to 4 weeks for improvement in self-concept/self-esteem to take place.
Parents tell the nurse that their 5 year old is only sleeping 10 hours now and is refusing to take an afternoon nap.The nurse should teach the parents:
"This is normal development for children in this age group." Explanation: Preschoolers typically sleep 10-16 hours, but become less dependent on napping as they approach school age. By 5 years, they usually do not need routine naps. Telling them to call their pediatrician is passing off responsibility. Sweets are not recommended before bedtime, and this child has normal sleep habits.
The nurse is providing discharge instructions for a new mother about sleep practices for her newborn child. The mother will be breastfeeding her infant. The nurse includes the following information:
"Your newborn will probably sleep an average of 16 hours each day"
A new mother asks the maternity nurse about sudden infant death syndrome (SIDS). The nurse tells the mother that SIDS most likely to occur at what age?
1 week to 1 year, peaking at 2 to 4 months Explanation: SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2 to 4 months.
The nurse is evaluating a client with hyperthyroidism who is taking propylthiouracil (PTU) 100 mg/day in three divided doses for maintenance therapy. Which statement from the client indicates the drug is effective?
I am able to sleep and rest at night."
A physician diagnoses leukemia in a child, aged 4, who complains of being tired and sleeps most of the day. Which nursing diagnosis reflects the nurse's understanding of the physiologic effects of leukemia?
Activity intolerance related to hypoxia and weakness Explanation: A nursing diagnosis of Activity intolerance related to hypoxia and weakness reflects the nurse's understanding of leukemia's physiologic effects because a child with leukemia may experience weakness and lack of oxygen. The nurse's findings don't support the other diagnoses of Ineffective airway clearance related to fatigue, Imbalanced nutrition: More than body requirements related to lack of activity, or Ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells.
The nurse is caring for a primipara who gave birth to a viable neonate 12 hours ago. The client says, "Look at all of the beautiful things my family brought for the new baby." The nurse should become concerned if the client has:
a soft pillow for the neonate's crib.
Ms. Dowe was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. Which of the following would not be a part of teaching plan for her condition?
Applications of ice Explanation: Application of ice is not part of the treatment regimen. Encouraging the client to eat a healthy diet, avoiding caffeine and alcohol, regular exercise, and stress reduction are part of the teaching plan.
Which item in the care plan for a toddler with a seizure disorder should a nurse revise?
Arm restraints while asleep Explanation: The nurse should revise a care plan that includes restraints. Restraints should never be used on a child with a seizure disorder because they could harm him if a seizure occurs. Padded side rails will prevent the child from injuring himself during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure
When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should record the breathing pattern as:
Cheyne-Stokes respiration. Explanation: Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is associated with an increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Biot's respiration, also known as "cluster breathing," is periods of normal respirations followed by varying periods of apnea.
What factor has been hypothesized by researchers regarding current thoughts on sleep?
Chronic sleep deprivation is present Explanation: Most recently, researchers have hypothesized that much of the population in industrialized nations may be chronically sleep deprived.
A nurse is obtaining the health history of a 72-year-old woman who has come to the ambulatory care center for an evaluation. When obtaining information about the woman's sleep patterns, which of the following would the nurse expect to assess?
Complaints about frequently waking up during the night Explanation: Older adults tend to take longer to fall asleep, awaken more frequently and easily, and spend less time in deep sleep. They may experience variations in their normal sleep-wake cycles. Coupled with the lack fo quality of sleep at night, napping during the day is a common complaint.
The nurse is performing an intake assessment of a 60-year-old patient 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 patient's sleep?
Decreased REM sleep 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.
The nurse is performing an intake assessment of a 60-year-old patient 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 patient's sleep?
Decreased REM sleep Correct Explanation: 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.
A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. He has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client?
Decreasing environmental stimulation Explanation: This client is at increased risk for injuring himself or others. Decreasing environmental stimulation, a measure the nurse may take independently, may reduce the client's hyperactivity. If this nursing intervention is ineffective, the nurse may administer a sedative, as ordered. Providing adequate hygiene is an appropriate nursing intervention but isn't the highest priority. Because the overall goal is to reduce the client's hyperactivity, involving him in unit activities is contraindicated.
A client who had a colectomy 8½ hours ago and has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
Dim the lights in the room. Explanation: The nurse is helping the client manage pain and comfort level. The nurse has completed the assessment of the client and should now dim the lights and create a quiet environment. Such nonpharmacologic measures as adjusting the light level in the room facilitate pain management. Decreasing stimulation from the environment, such as brightness to the optic nerve, promotes the client's ability to relax skeletal muscles and fall asleep. It is too soon to reassess vital signs. Checking that the family is comfortable is important but is not the next thing to do for this client. Increasing the oxygen flow rate is not indicated, and, if needed, should have been done before repositioning the client.
What interview question would be the best choice for the nurse to use to assess for recent changes in a patient's sleep-wakefulness pattern?
Do you usually go to bed and wake up about the same time each day? Explanation: The best interview question for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern would be to ask if the client usually goes to bed and wakes up about the same time each day. The other question options are possible questions to ask the client, but not related to recent changes in the client's sleep-wakefulness pattern.
Which activity would be appropriate to suggest to the client who reports having difficulty falling asleep every evening?
Eat some crackers with peanut butter at bedtime. Explanation: Carbohydrates make tryptophan more available to the brain, thereby promoting sleep. Therefore, a small protein- and carbohydrate-containing snack such as peanut butter on toast or cheese and crackers are effective. Nicotine contained in cigarettes has a stimulating effect, and smokers usually have a more difficult time falling asleep. The client must be encouraged to quit smoking or to eliminate cigarette smoking after the evening meal. Exercise that occurs within a 3-hour interval before normal bedtime can hinder sleep. Caffeinated products, such as chocolate, coffee, and tea are considered stimulants and can interfere with sleep
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the client tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. What would be the nurse's best response?
Formula is the food best digested by the baby until about 4 to 6 months of age." Explanation: The American Academy of Pediatrics recommends that all neonates should receive only formula or breast milk for the first 4 to 6 months of life. Cereal will not help the neonate sleep through the night and may result in allergies and other digestive disorders.
When caring for a patient with insomnia, the nurse would appropriately institute which intervention?
Have the patient eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle.
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
I should become involved in a weight loss program." Explanation: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea. (less)
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?
I sleep on three pillows each night." Correct Explanation: Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.
A nurse is caring for a client diagnosed with sleep apnea. Which of the following nursing diagnoses should the nurse include in her nursing care plan?
Impaired gas exchange Explanation: The nurse should include the nursing diagnosis of impaired gas exchange in her nursing care plan. During the apneic or hypopneic periods, ventilation decreases, and blood oxygenation drops. The accumulation of carbon dioxide and the fall in oxygen cause brief periods of awakening throughout the night. Relocation stress syndrome, impaired bed mobility, and risk of injury are not appropriate diagnoses because the client's loss of sleep is not due to a new place and there is no immobility or injury risk involved with sleep apnea.
For the last 3 weeks, a nurse in a long-term care facility has administered a sedative-hypnotic to a patient who complains of insomnia. The patient does not seem to be responding to the drug and is now laying awake at night. Which of the following is the most likely explanation?
Most sedative-hypnotics lose their effect after 1 or 2 weeks of administration.
A new patient in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is: Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis?
Provide an opportunity for the patient to talk about concerns. Explanation: Stress and anxiety interfere with a person's ability to relax, rest, and sleep. The client is scheduled for a surgical procedure in the morning. The nursing diagnosis addresses this particular concern. Providing an opportunity for the client to talk about concerns and issues would be beneficial. The other options are incorrect because the options do not address the situation at hand, or the nursing diagnosis that is noted.
Which of the following symptoms characterizes Korsakoff syndrome?
Psychosis, disorientation, delirium, insomnia, and hallucinations Explanation: Korsakoff syndrome is a personality disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations. Creutzfeldt-Jacob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson's disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.
The nurse is assessing sleep habits of an elderly client who reports difficulty falling asleep and staying asleep. The nurse intervenes when the client reports he
Reads in bed before going to sleep Explanation: Sleep hygiene behaviors include avoiding the use of bed for activities other than sleeping or sex, maintaining a consistent time for bedtime, limiting alcohol to one or two drinks a day, and avoiding caffeine after noon.
A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which of the following nursing diagnoses is most appropriate for this client?
Sleep deprivation Explanation: Sleep deprivation is the most appropriate nursing diagnosis for this client because the symptoms of restless legs syndrome keep the person awake and prevent continuous sleep. Eventually, sleep deprivation affects the person's life, damaging work productivity and personal relationships. Relocation stress syndrome would not be an appropriate diagnosis because the symptoms are not due to relocation to a new place. Impaired bed mobility is an inappropriate diagnosis because the client is not confined to a bed. The client does not have a risk for injury; therefore, the diagnosis of risk of injury would be incorrect.
An elementary school nurse is conducting a program for parents on attention deficit hyperactivity disorder (ADHD). Which of the following is the most important information for the nurse to include in the program?
Sleep disturbances are common for children with ADHD. Explanation: Sleep disturbances are common for children with ADHD. The diagnosis is commonly made after the child starts attending school and is unable to display attentive behavior in class.
A client begins snoring and is sleeping lightly. The stage of sleep is
Stage 2 Explanation: Stage 2 is relatively light sleep from which the client is easily awakened. Rolling eye movements continue, and snoring may occur.
A client who has been experiencing depression for 3 months was recently placed on sertraline. The client calls a nurse and reports that her mood has improved significantly and that she is very optimistic about the future. Which piece of additional information would require a rapid nursing intervention?
The client is sleeping only 3 hours per night and does not feel fatigued in the morning. Some individuals who start on antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs), may develop hypomania or mania. The client's limited sleep and lack of fatigue despite limited sleep are indications that she may be having a hypomanic or a manic episode, which requires rapid nursing intervention and contacting the physician. Appetite may increase or decrease in depression. Craving sweets is not an immediate problem. Sexual difficulties are common for people taking SSRIs and for people who are depressed. Although these adverse effects should be addressed — especially because many individuals stop taking SSRIs because of them — they are not an immediate concern. Changes in adult relationships do not require rapid nursing intervention
A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first?
The client with unilateral leg swelling who's complaining of anxiety and shortness of breath Explanation: The client who is complaining of anxiety and shortness of breath and has unilateral leg swelling should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Crackles, fever, and pleuritic pain are signs and symptoms of pneumonia. Anorexia, weight loss, and night sweats are signs and symptoms of tuberculosis. Difficulty sleeping, daytime fatigue, and morning headache are symptoms of sleep apnea. Pneumonia, sleep apnea, and tuberculosis aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolism
The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they state:
The inner biologic clock Explanation: The inner biologic clock is the regulating mechanism for the body's sleepwake patterns. No formula exists for the duration of sleep. Although light and dark appear to be powerful regulators of the sleepwake pattern, they do no exert primary control.
A hospitalized patient informs the evening shift nurse that he has a routine that he follows prior to going to sleep. The patient inquires about his ability to perform his bedtime routine before sleep. How does the nurse respond?
We will include this routine into your evening plan of care."
At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing?
a state of deep sleep Explanation: At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate's respiratory rate of 35 breaths/min is normal.
During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client's mother tearfully states, "I can hardly sleep because I am so worried about my daughter. I am afraid to leave her alone in the house. What if something should happen while I am gone?" Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client's plan of care?
caregiver role strain Explanation: The nurse recognizes the mother's feelings of being overwhelmed with the issues concerning the management of her daughter at home as caregiver role strain. Anxiety, fear, and sleep disturbances all contribute to caregiver role strain. The nurse should help the mother elicit the support of other family members or friends, continue with psychoeducation, and help the family connect with a support group.
A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which change in her husband's behavior may confirm her fears?
disturbance in his sleep patterns Explanation: Depression can be a mixture of affective responses (feelings of worthlessness, hopelessness, sadness), behavioral responses (appetite changes, withdrawal, sleep disturbances, lethargy), and cognitive responses (decreased ability to concentrate, indecisiveness, suicidal ideation). Increased decisiveness, problem-solving ability, and increased social interactions are reflective of adaptive coping.
A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client's daily assessment, the nurse should be especially alert for which finding?
exhaustion Explanation: The client in the manic phase experiences insomnia, as evidenced by his sleeping only for about 4 hours a night for the past 5 days. The client experiencing an acute manic episode is not capable of judging the need for sleep. Therefore, the nurse should assess the amount of rest the client is receiving daily to prevent exhaustion. The development of vertigo, gastritis, or bradycardia typically does not result from acute mania.
A nurse is caring for a veteran, who exhibits signs and symptoms of posttraumatic stress disorder (PTSD). Signs and symptoms of posttraumatic stress disorder include:
hyperalertness and sleep disturbances.
Modafinil has been ordered for a client diagnosed with narcolepsy. The nurse understands that this medication:
promotes wakefulness. Explanation: Although modafinil's mechanism of action isn't fully known, this drug promotes wakefulness. It's indicated for treatment of individuals with narcolepsy, obstructive sleep apnea, or shift work type sleep-wake disorder. It would increase anxiety and elevate mood. CNS depressants and antianxiety agents would worsen the symptoms of narcolepsy. Mood stabilizers aren't indicated for narcolepsy.
An 81-year-old patient is in a long-term-care facility. His family could no longer cope with his progressing senile dementia, including wandering away and unpredictable behavior. Late one night the nurse finds the patient wandering in the hall. He says he is looking for his wife. The nursing approach should be to:
remind him of where he is and assess why he is having difficulty sleeping. Explanation: Reminding the patient where he is is a form of orienting him to his surroundings. Assessment is needed to determine any need that may be disturbing the patient, such as need to use the bathroom, feeling cold/warm, etc. The other responses do not include orienting the disoriented/confused patie
A client is admitted to the psychiatric unit accompanied by her husband. She brings six suitcases and three shopping bags. She orders the nurse to carry her bags. Her husband states she has been purchasing items that they cannot afford and has not slept for 4 nights. Which additional information would be a priority for the nurse to seek from the client's husband?
the client's fluid and food intake Explanation: Assessing nutritional status is a priority in this situation. Clients with bipolar disorder, manic phase, commonly do not have time to eat or drink because of their state of constant activity and easy distractibility. Altered nutritional status and constant physical activity can lead to malnutrition, weight loss, and physical exhaustion. These states can lead to death if appropriate intervention is not instituted. Financial status is neither important nor something that the nurse can modify. Clients with bipolar disorder, manic phase, have disturbed sleep patterns; however, their hydration and nutritional status are the first priority.
A 77-year-old client is brought to the emergency department by her son. The client has a severe headache and lack of sleep because "I am so worried about everything." Her son says that she has heart failure and chronic schizophrenia. "In addition to all of her heart medicines, she is on aripiprazole, which was increased to 30 mg by her health care provider (HCP) 3 days ago." In addition to documenting all of the client's medications and exact dosages, the nurse should particularly investigate which factors? Select all that apply.
the dose of aripiprazole • the client's symptoms of heart failure • the client's symptoms of schizophrenia
A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because:
they may be disoriented on awakening. Explanation: The elderly sleep less soundly for less time, and have little or no Stage IV deep sleep. It is common for them to be confused upon awakening, which could lead to injury. Napping does not alter their safety. Somnabulism is commonly seen in children. Older adults commonly take prescribed or over-the-counter sleep aids.
Which intervention should the nurse implement to manage pain for the client with rheumatoid arthritis? Select all that apply.
• Support joints with splints and pillows. • Assist the client to develop a sleep routine. Explanation: To manage pain, the nurse maintains normal alignment of extremities as much as possible by supporting the joints with splints and pillows. Diversional activities distract the client's focus from the pain. Providing opportunities for the client to express concerns facilitates coping and helps the client deal with disturbed body image. Assistive devices for self-feeding help the client meet nutritional needs independently. Assisting the client to develop a sleep routine promotes rest and minimizes fatigue.