Chapter 33 rest and sleep / Chapter 34: Comfort

The nurse is preparing the client for the administation of an enema. The nurse will place the client into which position?

Sims'

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

Chronic sleep deprivation is present.

A client begins snoring and is sleeping lightly. The stage of sleep is:

Stage 2

A client is worried and states, "I just know I won't be able to sleep before my surgery." What sleeping pattern would the nurse anticipate?

The client will likely not be able to sleep.

The nurse makes the following assessment: A middle-age 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. The nurse further assesses by asking:

"Have you had any recent head injury?"

The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary?

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

A parent reports their 4-year-old child wakes up frequently at night screaming and roccurs shortly after the child has fallen asleep. The nurse determines that the child takes a tub bath and the parent reads a story prior to bedtime at 8 p.m. What is the best response to the parent? Select all that apply.

"It is common for this to occur in this age group." "Comforting your child when this occurs may help." "You may find a nightlight in his room is helpful."

The nurse is educating a client and spouse about sudden jerking that occurs during sleep. What is the most appropriate nursing response?

"Sudden twitches that occur during the early phases of sleep are common."

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

The nurse is instructing a parent on how to promote restful sleep for a child. What food would be the best bedtime snack for the child?

Apple slices

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.

The nurse is preparing to apply compression stockings for a client that is at risk for the development of deep vein thrombosis. What actions by the nurse demonstrate to the client the appropriate way to apply the stockings?

Assess the skin and neurovascular status of the legs and feet before applying Have the client lie down with legs and feet elevated for at least 15 minutes before applying Launder the stockings at least every 3 days

A middle-age client reports to the nurse that he has difficulty falling asleep at night. The nurse assessed the client as having poor sleep hygiene habits. Which instruction does the nurse provide to the client?

Avoid activities after 5 p.m that are stimulating. Participate in a quiet activity, such as reading, prior to attempting to fall asleep.

The nurse is attempting to wake a client from sleep and is having a difficult time arousing them. What stage of sleep does the nurse identify the client is experiencing?

REM sleep

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?

A nurse is logrolling a client who has a spinal injury. Which nursing action follows the recommended guidelines for this procedure?

Enlist the assistance of two or three other nurses to perform the procedure.

A middle-aged client reports to the nurse that the client has difficulty falling asleep at night. The nurse assessed the client as having poor sleep hygiene habits. What should the nurse instruct the client to try?

Establish a set time to go to sleep each night. Perform moderate exercise three or four times each week. Participate in an enjoyable activity each day.

The nurse is caring for a client who reports insomnia. The client has recently moved from an area nearby a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep?

Find a phone app that plays sounds of the city.

A client reports periodic difficulty falling asleep. Which teaching will the nurse provide?

Go on a daily walk. Adhere to a regular schedule for waking and going to sleep. Decrease caffeine intake.

The client is sleeping, and arousal is easy. Occasionally, the client exhibits involuntary muscle jerking, which appears to startle the client. Vital signs are unchanged from 1 hour ago. The nurse assesses the stage of non-rapid eye movement (NREM) sleep, which the client exhibits as Stage:

I

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer?

If the client is in pain, administer analgesics in advance of the transfer.

A nurse is providing community education about the importance of getting enough sleep. Which information about REM sleep is most accurate?

It plays a role in memory.

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 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.

A client reports to the nurse, "Sleep really isn't necessary." Which teaching by the nurse is appropriate?

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."

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

A client tells the nurse that the client often has a difficult time falling asleep at night. What suggestion offered by the nurse may assist the client in achieving sleep?

a snack containing carbohydrates and protein

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

all clients admitted to a health care agency

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

The nurse directs the nurse aide to assist a client with eating. Into which position will the nurse delegate the UAP to place the client?

high Fowler's

A nurse is assessing a client's mobility status. What data would the nurse document as normal findings?

independent maintenance of correct alignment head, shoulders, and hips aligned in bed full range of motion

The nurse is preparing to transfer a client from the bed to a stretcher. What action should the nurse take to prevent injury to the client and nurse?

leave the friction-reducing sheet in place once the client is transferred.

The nurse is discussing sleep interventions with a client. What statement made by the client indicates an understanding of sleep restruction?

limiting time in bed to actual sleep time.

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.

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

placing the client in good alignment with joints slightly flexed

The nurse is caring for a client who has a lower body injury and who is able to partially assist with transfers. The nurse should:

provide the client with an overhead trapeze.

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

The nurse is completing a sleep history on a client who reports sleeping problems. Which of the client's regular behaviors will cause the client to have difficulty with sleep?

taking a diuretic at 9 a.m. and 5 p.m. daily

The nurse is caring for a client who is having difficulty sleeping. Which medication does the nurse anticipate will be prescribed by the healthcare provider?

temazepam (Restoril)

The nurse is assessing an older adult client and observe the client attempting To compensate for the shift in the center of gravity, What assessment does the nurse document?

the client flexes the knees for support.

Which factor has the most influence on an individual's sleep-wake patterns?

the inner biologic clock

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.

The nurse makes the following assessment. A middle-age 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), 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.