Ch. 43 Sleep (Rationales on bank)
The nurse is beginning a sleep assessment on a patient. Which question will be most appropriate for the nurse to ask initially? a. "What is going on?" b. "How are you sleeping?" c. "Are you taking any medications?" d. "What did you have for dinner last night?"
"How are you sleeping?"
A patient has sleep deprivation. Which statement by the patient will indicate to the nurse that outcomes are being met? a. "I wake up only once a night to go to the bathroom." b. "I feel rested when I wake up in the morning." c. "I go to sleep within 30 minutes of lying down." d. "I only take a 20-minute nap during the day."
"I feel rested when I wake up in the morning."
The nurse is discussing with a new mother the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching? a. "I can't wait to get the baby home to play with the brothers and sisters." b. "I will ask my mom to come after the first week, when the baby is more alert." c. "I can get the baby on a sleeping schedule the first week while my mom is here." d. "I won't be able to nap during the day because the baby will be awake."
"I will ask my mom to come after the first week, when the baby is more alert."
The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which of these statements by the nurses would best indicate that learning has occurred? a. "If the patient has a disease process in the central nervous system, it can influence the functions of sleep." b. "If the patient has a disease process in the cranial nerves, it can influence the functions of sleep." c. "If the patient has an interruption in the urinary pathways, it can influence the functions of sleep." d. "If the patient has an interruption in the spinal reflexes, it can influence the functions of sleep."
"If the patient has a disease process in the central nervous system, it can influence the functions of sleep."
A single parent is discussing with the nurse the sleep needs of a preschooler with the nurse. Which information will the nurse share with the parent? a. "Most preschoolers sleep soundly all night long." b. "It is important that the 5-year-old get a nap every day." c. "On average, the preschooler needs to sleep 10 hours a night." d. "Preschoolers may have trouble settling down after a busy day."
"Preschoolers may have trouble settling down after a busy day."
The patient and the nurse discuss the need for sleep. After the discussion, the patient is able to state factors that hinder sleep. Which statements indicate that the patient has a good understanding of sleep? (Select all that apply.) a. "Drinking coffee at 7 PM could interrupt my sleep." b. "Staying up late for a party can interrupt sleep patterns." c. "Exercising 2 hours before bedtime can decrease relaxation." d. "Changing the time of day that I eat dinner can disrupt sleep." e. "Worrying about work can disrupt my sleep." f. "Taking an antacid can decrease sleep."
-"Drinking coffee at 7 PM could interrupt my sleep." -"Staying up late for a party can interrupt sleep patterns." -"Changing the time of day that I eat dinner can disrupt sleep." "Worrying about work can disrupt my sleep."
The nurse is caring for a patient who has not been able to sleep well while in the hospital, leading to a disrupted sleep-wake cycle. Which assessment findings will the nurse monitor for in this patient? (Select all that apply.) a. Changes in physiological function such as temperature b. Decreased appetite and weight loss c. Anxiety, irritability, and restlessness d. Shortness of breath and chest pain e. Nausea, vomiting, and diarrhea f. Impaired judgment
-Changes in physiological function such as temperature -Decreased appetite and weight loss -Anxiety, irritability, and restlessness -Impaired judgment
The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. Which information will the nurse include in the teaching session? (Select all that apply.) a. NREM sleep contributes to body tissue restoration. b. During NREM sleep, biological functions increase. c. Restful sleep preserves cardiac function. d. Sleep contributes to cognitive restoration. e. REM sleep decreases cortical activity.
-NREM sleep contributes to body tissue restoration. -Restful sleep preserves cardiac function -Sleep contributes to cognitive restoration.
A community health nurse is providing an educational session at the senior center on how to promote sleep. Which practices should the nurse recommend? (Select all that apply.) a. Take a nap in the afternoon. b. Sleep where you sleep best. c. Use sedatives as a last resort. d. Watch television right before sleep. e. Decrease fluids 2 to 4 hours before sleep. f. Get up if unable to fall asleep in 15 to 30 minutes.
-Sleep where you sleep best. -Use sedatives as a last resort. -Decrease fluids 2 to 4 hours before sleep. -Get up if unable to fall asleep in 15 to 30 minutes.
The nurse is caring for a group of patients who have sleeping disruptions. Match the condition to the intervention the nurse will use. a. Use continuous positive airway pressure. b. Offer a small meal several hours before bedtime. c. Administer antidepressants. d. Administer modafinil (Provigel). e. Do not startle. f. Administer benzodiazepine-like drugs. 1. Cataplexy 2. Narcolepsy 3. Insomnia 4. Hiatal hernia 5. Sleepwalking 6. Obstructive sleep apnea
1. Cataplexy= C. Administer antidepressants 2. Narcolepsy= D. Administer modafinil (Provigel) 3. Insomnia= F. Administer benzodiazepine-like drugs 4. Hiatal hernia= B. Offer a small meal several hours before bedtime 5. Sleepwalking= E. Do not startle 6. Obstructive sleep apnea= A. Use continuous positive airway pressure
The nurse is discussing lack of sleep with a middle-aged adult. Which area should the nurse most likely assess to determine a possible cause of the lack of sleep? a. Anxiety b. Loud teenagers c. Caring for pets d. Late night television
Anxiety
The nurse is caring for a patient on the medical-surgical unit who is experiencing an exacerbation of asthma. Which of the following interventions would be most appropriate to help the patient sleep? a. Place bed in semi-Fowler's position. b. Offer iron-rich foods for meals. c. Provide a snack before bedtime. d. Encourage the patient to read.
Bed placed in semi-Fowler's position
An older-adult patient is visiting the clinic after a fall during the night. The nurse obtains information on what medications the patient takes. Which medication most likely contributed to the patient's fall? a. Melatonin b. L-tryptophan c. Benzodiazepine d. Iron supplement
Benzodiazepine
The nurse is completing an assessment on an older patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient? a. Depression b. Mild fatigue c. Hypertension d. Hypothyroidism
Depression
The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which nursing action should the nurse take? a. Talk with the adolescent's parent about staying up with friends and the need for sleep. b. Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness. c. Refer the adolescent for counseling about alcohol abuse problems. d. Take no action for this normal occurrence.
Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness.
The nurse is caring for a patient who is having trouble sleeping. Which action would the nurse take? a. Suggest snug-fitting nightwear. b. Provide a favorite beverage. c. Encourage deep breathing. d. Walk with the patient.
Encourage deep breathing
The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate? a. Close the door to decrease noise from unit activities. b. Adjust temperature in the patient's room to 21° C (70° F). c. Ensure that the night-light in the patient's room is working. d. Encourage the discontinuation of a soda and chocolate nightly snack.
Encourage the discontinuation of soda and chocolate nightly snack.
The nurse is caring for a patient who has been in holding in the emergency department for 24 hours. The nurse is concerned about the patient experiencing sleep deprivation. What would be the best action for the nurse to take? a. Expedite the process of obtaining a medical-surgical room for the patient. b. Pull the curtains shut, dim the lights, and decrease the number of visitors. c. Obtain an order for a hypnotic medication to help the patient sleep. d. Ask everyone in the unit to try to be quiet so the patient can sleep.
Expedite the process of obtaining a medical-surgical room for the patient.
Which nursing observation of the patient in intensive care indicates that the patient is sleeping comfortably during NREM sleep? a. Eyes closed, lying quietly, respirations 12, heart rate 60 b. Eyes closed, tossing in bed, respirations 18, heart rate 80 c. Eyes closed, mumbling to self, respirations 16, heart rate 68 d. Eyes closed, lying supine in bed, respirations 22, heart rate 66
Eyes closed, lying quietly, respirations 12, heart rate 60
The patient presents to the clinic with reports of irritability, being sleepy during the day, not being able to fall asleep, and being tired. Select the most appropriate nursing diagnosis. a. Anxiety b. Fatigue c. Insomnia d. Sleep deprivation
Insomnia
The nurse adds a nursing diagnosis of ineffective breathing pattern to a patient's care plan. Which sleep condition caused the nurse to assign this nursing diagnosis? a. Insomnia b. Narcolepsy c. Sleep deprivation d. Obstructive sleep apnea
Obstructive sleep apnea
******The patient shares with the nurse the vivid, full color dreams experienced by the patient last night. These data would indicate that the patient has reached what stage of sleep?
REM
The nurse is preparing an older patient's evening medications. Which treatment will the nurse recognize as relatively safe for difficulty sleeping in older adults? a. Ramelteon (Rozerem) b. Benzodiazepine c. Antihistamine d. Kava
Ramelteon (Rozerem)
A patient has obstructive sleep apnea. Which assessment is the priority? a. Gastrointestinal function b. Neurological function c. Respiratory status d. Circulatory status
Respiratory status
The patient has just been diagnosed with narcolepsy. The nurse teaches the patient about management of the condition. Which information from the patient will cause the nurse to intervene? a. Takes antidepressant medications b. Naps shorter than 20 minutes c. Sits in hot, stuffy rooms d. Chews gum
Sitting in hot, stuffy rooms.
The nurse is caring for a postpartum patient. The patient's labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. Which nursing diagnosis will the nurse document in the patient's care plan? a. Insomnia b. Impaired parenting c. Ineffective coping d. Sleep deprivation
Sleep deprivation
A young mother has been hospitalized for an irregular heartbeat (dysrhythmia). The night nurse makes rounds and finds the patient awake. Which action by the nurse is most appropriate? a. Inform the patient that it is late and time to go to sleep. b. Ask the patient if she would like medication for sleep. c. Recommend a good movie that is on television tonight. d. Take time to sit and talk with the patient about her inability to sleep.
Take time to sit and talk with the patient about her inability to sleep.
The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM? a. The patient awakens easily. b. The patient's eyes rapidly move. c. The patient is difficult to awaken. d. The patient's vital signs are elevated.
The patient is difficult to awaken.
The nurse is evaluating outcomes for the patient with Insomnia. Which key principle will the nurse consider during this process? a. The patient is the best evaluator of sleep. b. The nurse is the best evaluator of sleep. c. Effective interventions are the best evaluators of sleep. d. Observations of the patient are the best evaluators of sleep.
The patient is the best evaluator of sleep.
The nurse is caring for a young adult patient on the medical-surgical unit. When doing midnight checks, she sees that the patient is awake and is doing a puzzle. What is the best explanation for the patient being awake? a. The patient misses family and is lonely. b. The patient was waiting to talk with the nurse. c. The patient has been kept up with the noise on the unit. d. The patient's sleep-wake cycle preference is late evening.
The patient's sleep-wake cycle preference is late evening.
The nurse is completing a sleep assessment on a patient. Which tool will the nurse use to complete the assessment? a. Visual analog scale b. Cataplexy scale c. Polysomnogram d. RAS scale
Visual Analog Scale
A nurse is teaching the staff about the sleep cycle. Which sequence will the nurse include in the teaching session? a. NREM Stage 1, 2, 3, 4, REM b. NREM Stage 1, 2, 3, 4, 3, 2, 1, REM c. NREM Stage 1, 2, 3, 4, REM, 4, 3, 2 REM d. NREM Stage 1, 2, 3, 4, 3, 2, REM
d. NREM Stage 1, 2, 3, 4, 3, 2, REM
