Chapter 33: Rest and Sleep

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. Rationale: 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.

The nurse knows that a client understands the purpose of a sleep diary when the client states:

"I will record the time I go to bed and how long it takes me to fall asleep." Rationale: 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.

Which statement about the sleep patterns of toddlers should the nurse incorporate into an education plan for parents?

Getting the child to sleep can be difficult. Rationale: Getting the child to fall asleep is the most commonly reported problem, but frequent awakenings and occasional night terrors may also occur.

A client reports periodic difficulty falling asleep. Which teaching will the nurse provide? (Select all that apply.)

Go on a daily walk. Adhere to a regular schedule for waking and going to sleep. Decrease caffeine intake. Rationale: The nurse will educate the client about sleep-promoting nursing measures, such as maintaining sleep rituals, reducing the intake of stimulating chemicals, promoting daytime exercise, and adhering to a regular schedule for retiring and awakening. Catching up on sleep and taking intermittent nap do not help in maintaining consistent sleep rituals.

Which activity for rest break should not be incorporated into care planning for clients to aid in healing and recovery?

drinking an 8 oz cup of a caffeinated beverage Rationale: Drinking a caffeinated beverage is not as energizing as a short 15- to 30-minute nap, stretching exercises, or taking a short walk.

Which beverage does the nurse recommend to a client with insomnia that may promote the ability to sleep?

milk Rationale: Milk contains L-tryptophan, a chemical that is known to facilitate sleep. Hot chocolate and cola contain caffeine. The nurse should never recommend alcohol, which is a depressive drug.

A factory worker has a work schedule involving rotating work hours between days, evenings, and nights. The client tells the nurse he is a "morning" person, and is not sleeping well when he has to work nights. The nurse recommends:

modifying the sleep environment to simulate quiet and darkness. Rationale: The factory worker needs interventions that will promote natural, restful sleep. Caffeine and stimulant medications will exacerbate the problem. Applying for a different job may be possible, but is more of a long-term solution.

The nurse is assessing a client for sleep disorders. The initial step in sleep assessment is:

observe client's hours of sleep and review client's sleep diary. Rationale: Observing the sleeping patterns and checking the client's sleep diary can lead the nurse to clues about the quality of the client's sleep. Neck circumference can be a factor in obstructive sleep apnea, but it is not routinely measured during assessment. Being overweight is a common finding in sleep disorder clients, but visual acuity issues are not. Auscultation of the lungs and abdomen are not pertinent to the potential disorder.

In Stage 4 sleep, the:

pulse rate is slow Rationale: 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 reviewing the medication administration record. Which order does the nurse question?

A diuretic administered twice daily at 9am and 9pm. Rationale: A diuretic should not be administered after 6pm. This will promote sleep if a full bladder does not awaken the client. Once daily dosing and every other day dosing is not cause for question.

A client reports to the nurse, "Sleep really isn't necessary." Which teaching by the nurse is appropriate? (Select all that apply.)

"Sleep helps your blood flow to the brain." "Sleep helps you to learn easier and remember more." "Sleep helps your immune system to fight off infections." Rationale: In addition to promoting emotional well-being, sleep enhances various physiologic processes. Sleep is believed to play a role in the following: reducing fatigue, stabilizing mood, improving blood flow to the brain, increasing protein synthesis, maintaining the disease-fighting mechanisms of the immune system, promoting cellular growth and repair, and improving the capacity for learning and memory storage. It is not appropriate, nor accurate, to teach the client that sleep can be stressful or that sleep can cause mood fluctuations.

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?

14 to 20 hours each day Rationale: The pediatric nurse informs the new parent that on average, infants require 14 to 20 hours of sleep each day.

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." Rationale: 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 client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:

0100 Rationale: During REM sleep, the client's temperature, pulse, blood pressure, and respirations increase. The client may experience small muscle twitching, such as facial muscles twitching, and irregular pulse rate and respirations. During non-eye movement sleep, the client will exhibit a decrease in body temperature, pulse, blood pressure, and respirations.

A nurse is visiting the home of a first-time mother and her newborn. The nurse is teaching the mother about the newborn's sleep needs. The nurse would inform the mother that newborns sleep approximately how many hours per day?

14 to 20 hours Rationale: On average, infants require 14 to 20 hours of sleep each day.

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?

Assess the factors that the client believes contribute to the problem. Rationale: Assessment is the first step in the nursing process. Consequently, the nurse should determine the factors contributing to the client's problem before performing interventions.

What factor has been hypothesized by researchers regarding current thoughts on sleep?

Chronic sleep deprivation is present. Rationale: Most recently, researchers have hypothesized that much of the population in industrialized nations may be chronically sleep deprived.

Which interview question would be the best choice for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern?

Do you usually go to bed and wake up about the same time each day? Rationale: 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 questions are possible to ask the client, but are 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. Rationale: 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 the morning assessment, the client reports to the nurse that the client is experiencing a hangover from a sleeping pill. The nurse reviews the Medication Administration Record. Which medication is most likely to cause the client's complaint?

Flurazepam (Dalmane) Rationale: 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.

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?

Hypothalamus Rationale: The hypothalamus has control centers for several involuntary activities of the body, one of which concerns sleeping and waking. Injury to the hypothalamus may cause a person to sleep for abnormally long periods. The medulla and midbrain are part of the reticular activating system (RAS), which plays a part in the cyclic nature of sleep. The cerebral cortex does not have any role in the sleep process.

A nurse is caring for a client diagnosed with sleep apnea. Which nursing diagnosis should the nurse include in her nursing care plan?

Impaired Gas Exchange Rationale: 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 For Injury are not appropriate diagnoses because the client's loss of sleep is not due to a new place; there is also no immobility or injury risk involved with sleep apnea.

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include?

Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. Rationale: 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.

For the last 3 weeks, a nurse in a long-term care facility has administered a sedative-hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation?

Most sedative-hypnotics lose their effect after 1 or 2 two weeks of administration. Rationale: Although most sedative-hypnotic drugs provide several nights of excellent sleep, the medication often loses its effects after 1 or 2 weeks. Alcohol and diphenhydramine should not be administered with a sedative-hypnotic drug. Increased activity assists the client in sleeping. Foods such as protein and carbohydrates have been shown to help a client sleep.

A new client 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 client to talk about concerns. Rationale: 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 factor necessitates the need for more sleep in the adolescent population?

Rapid growth Rationale: The growth spurt that occurs during adolescence may necessitate the need for more sleep. However, the stresses of school, activities, and part-time employment may cause adolescents to have restless sleep, and many adolescents do not get enough sleep.

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 that he reports severe lumbar and right leg pain. The nurse suspects a nursing diagnosis of:

Sleep Pattern Disturbance related to acute pain. Rationale: 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.

A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which nursing diagnosis is most appropriate for this client?

Sleep deprivation Rationale: 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 for Injury would be incorrect.

A client taking a diuretic twice daily for treatment of hypertension reports being awakened often by a full bladder. What teaching regarding the diuretic will the nurse provide?

Take before 6:00 PM at night. Rationale: The client taking a diuretic may awaken at night with a full bladder. The nurse will teach the client to take the second dose of the medication before 6:00 PM at night so that urination is accomplished before going to sleep. The other options are not appropriate for the nurse to teach the client.

A nurse on the night shift checks on a client and suspects that the client is in REM sleep. Which client cue is indicative of this stage of sleep?

The client's eyes dart back and forth quickly Rationale: The nurse would find the client's eyes dart back and forth quickly during REM sleep. The client would have a rapid or irregular pulse. The client's metabolism and body temperature would increase. The client's blood pressure would increase.

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.

a weight loss plan use of a continuous passive airway pressure (CPAP) machine use of a mandibular advancement device (MAD) Rationale: 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.

The nurse should obtain a sleep history on which clients as a protocol?

all clients admitted to a health care agency Rationale: Interview questions help identify the client's sleep-wakefulness patterns, the effect of these patterns on everyday functioning, the client's use of sleep aids, and the presence of sleep disturbances and contributing factors. If the client's sleep is adequate and poses no problems, the sleep history may be brief but should still be conducted. As issues or concerns are identified in the general assessment, more detailed questions can be asked to gather more information.

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:

anticipate sleeping overnight at a health care center. Rationale: 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 nursing instructor is describing the difference between sleep and rest. Which characteristic would the instructor identify as distinguishing sleep from rest?

decrease in awareness of environment Rationale: There is a decrease in the awareness of the environment in sleep; this does not happen during rest. Motor and cognitive response to stimuli may be decreased in both sleep and rest. Sleep is a whole body phenomenon; whereas, rest may involve the whole body system or only a part.

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?

decreased REM sleep Rationale: 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 nurse is caring for a client with insomnia. The nurse is explaining the importance of sleep to the client. Which role is sleep supposed to play?

reduce fatigue Rationale: Sleep is believed to play an important role in reducing fatigue, stabilizing mood, and improving blood flow to the brain, among other things. Sleep increases, not reduces, protein synthesis. Sleep does not eliminate accumulation of fat in a person's body. Regular exercise or physical activity reduces fat accumulation. Sleep increases pain tolerance in a person, whereas sleep deprivation decreases pain tolerance.

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:

reviewing the client's sleep diary for the past 2 weeks. 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.

The nurse is caring for a client with narcolepsy. The client reports experiencing being unable to move upon awakening from sleep. The client's spouse states that the client makes sandwiches in the middle of the night, yet the client does not recall this behavior. How does the nurse document these concerns?

sleep paralysis and automatic behavior Rationale: Sleep paralysis occurs when the person cannot move for a few minutes just before falling asleep or awakening. Cataplexy occurs with a sudden loss of muscle tone triggered by an emotional change such as laughing or anger. Hypnogogic hallucinations are dream-like auditory or visual experiences while dozing or falling asleep. Automatic behavior is the performance of routine tasks without full awareness, or later memory, of having done them. This client experiences sleep paralysis and automatic behavior.

A nursing student is changing the client's bed. Which action requires intervention from the nursing instructor?

tossing soiled linen on the floor Rationale: Soiled linen should be placed directly into a pillow case or laundry hamper to prevent transferring microorganisms. Placing soiled linen on the floor requires intervention by the instructor, to prevent the unnecessary spread of microorganisms. Placing the bed in high position is appropriate as it reduces back strain. Anything attached to the linens should be removed prior to changing the bed and clean linen should be placed on a clean, dry surface, such as the bedside table or chair.

An 82-year-old client is newly admitted to an assistive living facility. Which intervention promotes safety at night for the client?

using a night light in the bathroom Rationale: Using night lights rather than bright room lights is preferred if an older adult arises during the night. Bright lights stimulate the brain and interfere with efforts to resume sleep. Administering a diuretic at night will cause nocturnal diuresis causing the client to be up more at night. Leaving the door open to the nursing hallway does not promote safety.