HESI Case Study: Sleep Patterns

The nurse provides client teaching on the effects of diet, exercise, stress reduction medications, and the environment on sleep patterns. 7. Which statement by Mr. Olham reflects correct client teaching?

"Changes in my environment can make it difficult to sleep." Any changes in the environment can inhibit sleep, including a quiet, peaceful environment when the client is accustomed to noise.

Mr. Olham reports that his son sleeps sometimes until noon in the summer, but he often stays up very late at night. 23. Which response by the nurse is accurate?

"Many adolescents start developing this type of pattern as they develop independence." This is particularly common during the summer months, if there are no school obligations to make them rise earlier.

During the follow-up visit, Mr. Olham states, "I'm a little worried about my son. He is 16 and seems to be sleeping too much. If this keeps up, I'm afraid that I may have trouble sleeping due to the stress again!" 22. Which initial response by the nurse is best?

"Please tell me about your son's sleep habits." This information is needed to determine what is "too much." This response also invites the client to continue expressing his concerns.

While reviewing discharge paperwork with Mr. Olham, he states, "I really need to get back to work. All of this has caused a great strain on my job." 20. How should the nurse respond to Mr. Olham's statement?

"You seem concerned about missing work and the pressures of your job." The nurse is therapeutically the client's feelings, which is likely to encourage the client to continue the conversation.

Mr. Olham reports that a few years ago he took temazepam for sleep and it worked for a while. He asks if he can have a new prescription. 3. Which response by the nurse is most appropriate?

"You should be re-evaluated by a healthcare provider before resuming this medication." The client should always be re-evaluated before resuming any medication. A new prescription needs to be filled if indicated. Continued evaluation is also needed if temazepam is used for more than 2 weeks or in high doses, both of which put the client at risk for tolerance and/or physical dependence.

The nurse obtains a health history that reveals that Mr. Olham is worried about the pressures of his growing family and new job. He was unable to maintain his normal exercise routine and has gained 15 lbs. in the last 6 months. Mr. Olham admits he frequently smokes when he cannot sleep. His wife, who has accompanied him on the visit to the clinic, states that his snoring has worsened in both frequency and noise level over the last 3 months. Mr. Olham has even resorted to taking one of his wife's diazepam tablets before bedtime. 2. How does the nurse respond to Mr. Olham's disclosure that he used his wife's diazepam tablets to help him sleep?

"You should not take someone else's prescription." It is never appropriate for a nurse to suggest that a client take someone else's prescription, due to the risk of contraindications or drug interactions.

Based on the results from the assessment, the nurse formulates a plan of care for Mr. Olham. 5. Which statements reflect potential expected outcomes for the nursing diagnosis "disturbed sleeping pattern related to stress from new job?" (Select all that apply) -Client can identify way to relieve stress during the day and before bedtime. -Client will report a 50% decrease in night awakenings within 1 week. -Client establishes bedtime rituals, such as having a glass of wine before bed. -Client maintains a sleep/wake log for 1 month. -Client reports less incidences of dozing off during the day.

-Client can identify way to relieve stress during the day and before bedtime. -Client will report a 50% decrease in night awakenings within 1 week. -Client reports less incidences of dozing off during the day. It is important for the client to be able to ways to relieve stress before going to bed at night. This outcome is directly related to the nursing diagnosis, is specific and measurable, and is realistically timed. It is important for the client to report less daytime sleepiness. This outcome is directly related to the nursing diagnosis.

After providing teaching about the use of the CPAP machine, the nurse schedules Mr. Olham for a follow-up visit, and he is instructed to call if questions arise. Mr. Olham returns to the clinic after using the CPAP machine at home for 3 months. He reports no improvement in his symptoms and appears disheveled and irritable. He describes only sleeping 3 or 4 hours each night and blames it on discomfort caused by the CPAP machine. The nurse records Mr. Olham's appearance and his complaints in the charts. 10. The nurse considers which information to be subjective data? (Select all that apply) -Client states he only sleeps 3 or 4 hours per night. -The client is irritable and yells at his wife when she points out his irritability. -The client has gained an additional five pounds. -The client reports that the CPAP apparatus is uncomfortable. -The client's wife states he has been yawning a lot at home.

-Client states he only sleeps 3 or 4 hours per night. -The client reports that the CPAP apparatus is uncomfortable. -The client's wife states he has been yawning a lot at home. These statements are made by the client and/or his wife, so they are subjective data.

6. Which interventions should the nurse add to Mr. Olham's plan of care? (Select all that apply) -Encourage an increase in carbohydrates and move the evening meal to 1 hour before bedtime to promote sleep. -Monitor food and beverage intake, which might interfere with sleep. -Instruct the client to keep reading material from work at the bedside to review when he awakens. -Instruct the client to get out of bed if unable to fall back asleep within 30 minutes and to do a quiet activity until becoming sleepy. -Suggest the use of a soft, conforming mattress and pillow set for better body alignment.

-Monitor food and beverage intake, which might interfere with sleep. -Instruct the client to get out of bed if unable to fall back asleep within 30 minutes and to do a quiet activity until becoming sleepy. Food and drinks containing caffeine, stimulants, or alcohol can interfere with sleep patterns. Lying in bed for more than 30 minutes may increase anxiety and inhibit the onset of sleep. A quiet activity such as reading or muscle relaxation can be helpful.

4. The nurse performs a focused assessment on Mr. Olham, before he sees the health care provider (HCP). As part of the assessment, the nurse evaluates Mr. Olham for which additional symptoms that are commonly associated with sleep deprivation? (Select all that apply) -Nocturia -Tachycardia -Euphoria -Paresthesia -Sleep apnea

-Nocturia -Sleep apnea Urination during the night disrupts the sleep cycle and contributes to sleep deprivation. Sleep apnea occurs when there is a lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep, resulting in sleep deprivation.

The nurse monitors Mr. Olham's postoperative lab values. The nurse notes that his white blood cell count (WBC) is 15,000 mm. 17. Which observation should be documented in the nurse's assessment? (Select all that apply) -Observe for excessive drainage. -Measure oxygen saturation. -Determine skin turgor. -Measure the tympanic temperature. -Blood glucose level.

-Observe for excessive drainage. -Measure the tympanic temperature. Abnormal drainage could indicate the presence of infection. The nurse should evaluate the surgical wound as well. The client's WBC is elevated, indicating a possible infection. The client should be assessed for fever.

16. In managing Mr. Olham's postoperative care, which task should the RN delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) -Complete a focused respiratory assessment every 4 hours. -Obtain pulse oximetry and respiratory rate every 2 hours. -Take vital signs and complete body systems assessment every 8 hours. -Administer prescribed throat lozenges every 2 hours as needed. -Serve the prescribed breakfast tray to the client.

-Obtain pulse oximetry and respiratory rate every 2 hours. -Serve the prescribed breakfast tray to the client. Both of these task may be delegated. However, the nurse must evaluate the data after it is obtained by the UAP.

19. Mr. Olham is prescribed levofloxacin (Levaquin) 750 mg PO daily. The nurse has received 250 mg tablets from the pharmacy. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the whole number.)

3 750mg divided by 250mg= 3 3 tablets of 250 mg= 750mg

After further examination and testing by the HCP, Mr. Olham is referred to a surgeon and is scheduled for a uvulopalapharyngoplasty, the removal of tissue in the throat, to treat the obstructive sleep apnea. Mr. Olham is admitted to the hospital, and an apnea monitor is prescribed. 11. The charge nurse should assign Mr. Olham to which room?

A private room near the nursing station and report room. Due to the increased monitoring necessitated by the client's sleep apnea, the client's room should be near the nursing station.

Joshua Olham is a 40-year-old male seen in the medical clinic, who is complaining of severe fatigue during the day. Joshua also reports waking up frequently throughout the night. He states that he has a new baby at home and a new job, which requires a daily commute of 1 hour each way to and from work. He almost fell asleep while driving home last week, and this is making him afraid to drive. 1. Which statement is the best description of a sleep pattern for a normal adult?

An adult has four to six sleep cycles, each with non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep, during a normal night's sleep. Every 90 minutes REM sleep recurs. When a sleeper awakens at any stage of the sleep cycle, it must start again at Stage I.

Mr. Olham is seen in the surgeon's office for his follow-up evaluation 2 weeks after his surgery. 21. Which is the most effective method to evaluate improvement of the client's OSA?

Ask Mrs. Olham about her husband's snoring and respiratory pattern at night. Speaking with Mrs. Olham about her observations regarding snoring, respiration rate and sleeping pattern corroborates the nursing diagnosis of ineffective respiratory patterns.

12. To promote sleep for a hospitalized client, which intervention should the nurse implement?

Close the door to the client's room whenever possible to decrease the noise level and light coming into the room. Reducing the amount of light and the noise of call lights, hallway traffic, and overhead paging are important nursing interventions to facilitate sleep in a hospitalized client.

Mr. Olham's surgery is completed without complications. After a 2-hour stay in the postanesthesia unit, he returns to his room. The next day, the nurse observes the following vital signs. Mr. Olham's heart rate drops from 80 BPM to 65 BPM while he is sleeping. His oxygen saturation remains greater than 95% with regular respirations of 16 to 20 per minute. 15. What action should the nurse implement?

Document this expected finding. A decrease of up to 20 bpm during NREM sleep is a normal finding and a part of the body's circadian rhythm.

The nurse is teaching the client and his wife about ways to promote rest and sleep. The nurse demonstrates techniques for administering a back massage on Mr. Olham. 8. Which statement by the nurse is accurate?

Effleurage the entire back using slow movement and light pressure. Effleurage is a French term meaning "to touch lightly." This type of massage typically uses a gentle, sweeping, relaxing stroke that glides over the skin.

At 3:00 am Mr. Olham awakes and requests a sleeping pill, stating that he needs to make sure he gets some sleep the night before his surgery. His prescriptions include zolpidem tartrate (Ambien) 5 mg PO at bedtime PRN for sleep. His last respiratory rate while sleeping was 12 with an oxygen saturation level of 89%. His current vital signs are P 80 beats/min, BP 120/70 mmHg, R 22 breaths/min, T 98.9 F, and oxygen saturation 95%. 14. How should the nurse proceed?

Explain that his oxygen saturation level is too low and that it wouldn't be safe. Mr. Olham's saturation level is too low in order to tolerate the hypnotic drug, which will likely drop his oxygen saturation level even further.

Mr. Olham refuses to wear the CPAP mask while hospitalized. The night before his surgical procedure, the pulse oximeter alarms. The nurse enters Mr. Olham's room, and observes that Mr. Olham is sleeping and that his oxygen saturation has decreased to 84%. 13. Which priority action should the nurse implement?

Gently shake the client to awaken him. Although the nurse wants to promote sleep, the client must be awakened to relieve the obstruction and increase oxygen saturation.

The HCP conducts a physical exam. While the HCP agrees that job stress is likely exacerbating the disturbed sleep pattern, the wife's report of repeat snoring episodes is concerning. Diagnostic test is prescribed. A polysomnogram (sleep study) reveals more than 200 episodes of sleep apnea during the night. A pulse oximeter is used during the testing, and Mr. Olham's oxygen saturation level drops to 82% periodically. Mr. Olham is diagnosed with obstructive sleep apnea (OSA), and is prescribed a nasal continuous positive airway pressure (CPAP) device to be used at night. 9. Which is the best explanation by the nurse for instructing Mr. Olham about the use of OSA?

There is a lack of airflow through through the nose and/or mouth for periods of 10 seconds or longer during sleep. This describes destructive sleep apnea. Efforts by the brain and respiratory muscles continue, but the airflow is obstructed.

The nurse notifies the healthcare provider of the elevation of WBC and receives a prescription for an oral antibiotic. Mr. Olham is to receive the first dose prior to discharge. When entering his room with the medication, the nurse observes that Mr. Olham is asleep. His wife asks the nurse to leave the medication at the bedside for self-administration when he awakens. 18. Which is the most important action for the nurse to implement?

Wake the client and administer the first dose of antibiotic. Although the client may need sleep, his need for the antibiotic is greater.