Chapter 34: Rest and Sleep
A newly admitted client states to the nurse, "I average about 5.5 hours of sleep per night," What determination of this client's sleep patterns does the nurse discuss with the client?
they are sleep deprived to some degree.
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.
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 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.
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 is educating a client about restless leg syndrome. What statement made by the client indicates that further education regarding restless leg syndrome is required?
"I will try to lose weight so I can sleep better at night."
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.
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 expectation that the onset of sleep will be difficult increases the person's anxiety. The anxiety floods the brain with stimulating chemicals that interfere with relaxation, which is a prerequisite for natural sleep. Given the client's anxiety about the surgery, as well as the expectation that they will not sleep, it is likely that the client will not be able to sleep. Worry may cause exhaustion, but it will not cause the client to fall asleep quickly. Since the client will likely not sleep, the nurse does not anticipate patterns of wakening for the client.
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. 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 guideline does the nurse apply to discussion of sleep patterns with older adult clients?
Total sleep time decreases as the clients age. As people age, the amount of stage 4 sleep decreases significantly. Sleeping patterns may become polyphasic, with a shorter nocturnal period plus daytime naps.
The nurse has entered the room of a newly admitted client and observed a continuous positive airway pressure (CPAP) on the client's bedside table. The nurse would recognize that this client likely has a history of what condition?
Obstructive sleep apnea
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.
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 A small snack containing protein and carbohydrates may be effective in promoting calmness and relaxation prior to bedtime.
While instructing young adults about the need for adequate sleep, the nurse instructs the group that to improve sleep quality, individuals should:
have a consistent time for arising. A regular time of rising is one of the most effective means of improving sleep quality and synchronizing circadian rhythms with clock time.
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.
In Stage 4 sleep, the:
pulse rate is slow
Which factor necessitates the need for more sleep in the adolescent population?
rapid growth
The nurse is promoting bedtime rituals with a family. Which statement indicates the nurse may need to provide further instructions to the mother?
"My boys love to rough-house in their room right before bedtime." Bedtime rituals such as reading stories, having a healthy carbohydrate snack, holding a favorite stuffed toy, and use of a nightlight promote a healthy sleep routine for children. Most studies show that exercise right before going to bed impedes the person's ability to fall asleep quickly.
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." 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.
REM sleep in a toddler is about:
30% REM sleep in the toddler and preschooler drops to about 30%, which is still higher than adults.
A client with a diagnosis of insomnia is returning to share the success of the sleep plan. Which is the best indication that the client met the goal of restful sleep? A.) Client describes the dreams experienced. B.) Client identifies how many NREM cycles progressed through nightly. C.) Client verbalizes feeling rested. D.) Client can explain the direct actions of the hypnotic prescribed.
Answer: C.) Client verbalizes feeling rested.
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.
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. 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.
A nurse on the night shift notices that a client is grinding his teeth while sleeping. How should the nurse document the diagnosis for the client?
Bruxism
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.
An older adult client with mild hypothermia has been admitted to the health care facility. What should the nurse do to provide an appropriate environment to an older adult client?
Ensure that the environment is warmer.
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.
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.
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.
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
The nurse is caring for a client on the acute care unit who experiences automatic behaviors associated with narcolepsy. What is the priority nursing intervention?
Keep the client safe by monitoring ambulation on the unit
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.
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. 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. 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.
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 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.
When the nurse attempts to wake a client who has just closed his eyes and appears asleep, the client states he is not asleep. What stage of sleep is this client in?
Stage 1
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
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)
A nursing student is changing the client's bed. Which action requires intervention from the nursing instructor?
tossing soiled linen on the floor
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."
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
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.
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. 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 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
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 On average, infants require 14 to 20 hours of sleep each day.
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 The pediatric nurse informs the new parent that on average, infants require 14 to 20 hours of sleep each day.
The parents of a newborn ask when they can expect the baby to sleep through the night. The nurse responds that the baby will most likely sleep through the night by:
3 months of age
The nurse is administering medications for a group of clients. Which client will the nurse administer a benzodiazipne-like medication to?
A client who is being treated for short-term insomnia
A nurse is reviewing the medication administration record. Which order does the nurse question?
A diuretic administered twice daily at 9am and 9pm.
A nurse is reviewing the medication administration record. Which order does the nurse question?
A diuretic administered twice daily at 9am and 9pm. 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 nurse caring for a client with hypersomnia assesses the possible cause of the sleep disorder. What possible causes should the nurse consider? Select all that apply. - Another sleep disorder, such as sleep apnea - Depression - Malnourishment - Alcohol use - Some medications - Eating disorders
Answer: - Another sleep disorder, such as sleep apnea - Depression - Alcohol use - Some medications
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? Select all that apply. - Establish a set time to go to sleep each night. - Drink one or two ounces of alcohol before bedtime. - Eat a snack that contains a small amount of fat. - Perform moderate exercise three or four times each week. - Participate in an enjoyable activity each day.
Answer: - 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.
A client reports periodic difficulty falling asleep. Which teaching will the nurse provide? Select all that apply. - Take intermittent daytime naps to feel refreshed. - Go on a daily walk. - Adhere to a regular schedule for waking and going to sleep. - Decrease caffeine intake. - Sleep in on weekends to catch up from weekday lack of sleep.
Answer: - Go on a daily walk. - Adhere to a regular schedule for waking and going to sleep. - Decrease caffeine intake.
The nurse is teaching a first-time parent about the newborn's sleep needs. The nurse would inform the parent that newborns sleep approximately how many hours per day? A.) 8 to 10 hours B.) 10 to 12 hours C.) 14 to 18 hours D.) 18 to 20 hours
Answer: C.) 14 to 18 hours
The student nurse is providing an education program for preschool parents. The nursing student should include which intervention to improve the child's sleep? A.) The child should drink milk at bedtime. B.) The parents should keep the child up until 10 PM. C.) The child should sleep with the parents. D.) The child should limit fluids after supper.
Answer: D.) The child should limit fluids after supper. Rationale: Parents and other caregivers can assist children in establishing the habit of voiding as part of preparing for bedtime. Drinking milk at bedtime, keeping the child up until 10 PM and sleeping with the parents will not improve the child's 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: A.) they nap in the afternoon, which lessens their hours of sleep at night. B.) they are typically prone to sleep walking. C.) they are the age group least likely to use prescribed sleep medications. D.) they may be disoriented on awakening.
Answer: D.) they may be disoriented on awakening.
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. 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.
What factor has been hypothesized by researchers regarding current thoughts on sleep?
Chronic sleep deprivation is present. 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?
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? 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. 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.
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. Clients tend to adapt to the unique sounds where they live, such as traffic, trains, and the hum of appliance motors or furnaces. Unfamiliar sounds tend to interfere with the ability to fall or stay asleep. The nurse will recommend that the client find an app that plays sounds of the city, which mimics the sounds with which the client is most familiar. Ignoring the problem by telling the client to adapt to the new environment does not address the problem. Avoiding eating before bedtime could cause the client to wake up hungry in the middle of the night. The nurse does not recommend alcohol, a depressive drug, to clients.
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
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 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.
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. 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.
A nurse is explaining to an insomniac client the effect of a prescribed medication and the different phases of sleep. Which statement is true for non-rapid eye movement (NREM) sleep?
It is called slow wave sleep.
When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which intervention?
Low-flow oxygen The pattern of frequent arousals seen in people with chronic obstructive pulmonary disease may result from the body's adaptation to maintain adequate oxygenation. Usually, these clients require low doses of oxygen at night.
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns?
Newborns sleep 16 to 17 hours per day.
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patters?
Newborns sleep 16 to 17 hours per day. Newborns sleep an average of 16 to 17 hours per 24 hours a day, divided into about seven sleep periods distributed fairly evenly throughout the day and night.
The nurse is teaching a client with seasonal affective disorder about proper use of a full-spectrum light. Which teaching will the nurse include?
Sit within 3 ft (1 m) of the light for approximately 2 hours soon after awakening.
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. 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 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.
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.
The student nurse is providing an education program for preschool parents. The nursing student should include which intervention to improve the child's sleep?
The child should limit fluids after supper. Parents and other caregivers can assist children in establishing the habit of voiding as part of preparing for bedtime. Drinking milk at bedtime, keeping the child up until 10 PM and sleeping with the parents will not improve the child's sleep.
An elderly client is complaining of disturbed sleep during the night because of excessive urination. What information should the nurse address with the client as a possible cause related to the complaint?
Timing of diuretic medication
A newly admitted client states to the nurse, "I average about 5.5 hours of sleep per night." What determination of this client's sleep patterns does the nurse discuss with the client? They are in need of medication to aid sleep. They are sleep deprived to some degree. They are an efficient sleeper. They are in need of a sleep clinic visit.
They are sleep deprived to some degree. Optimum daytime performance with minimal sleepiness and no accumulation of sleep debt in adults is related to obtaining 8 hours of sleep each night. Sleeping less than 6 hours has been linked to an increase in morbidity and early mortality.
The nurse is educating a client about nonpharmacologic measures to alleviate restless leg syndrome (RLS). Which education points would the nurse include in the plan? Select all that apply.
• applying heat or cold to the extremity can help relieve the symptoms • Biofeedback and TENS can help relax the client and relieve symptoms • massaging the legs may relieve symptoms
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.
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
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.
The nurse recognizes that sleep deprivation related to environmental concerns will apply to which clients? Select all that apply.
• a 67-year-old male who has two beers during the late night newscast • a 32-year-old male machinist, two pack a day smoker • an 84-year-old male hospitalized for prostate surgery
In Stage 4 sleep, the:
pulse rate is slow 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.
When a nurse notes that a sleeping client is demonstrating irregular respirations and is showing eye movement, the nurse identifies the stage of sleep the client is experiencing as:
rapid eye movement (REM)
Which factor necessitates the need for more sleep in the adolescent population?
rapid growth 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.
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
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
A 62-year-old woman informs the nurse that her mother has been anxious and disoriented in the morning, and that she sleeps 4 hours per night, while getting up from sleep to use the bathroom. What factor in the client's health regimen could interfere with healthy sleep?
taking diuretic medicine at 10 a.m. and 10 p.m.
A student nurse is preparing a presentation regarding hypnotic medications. What information should the student nurse include? Select all that apply.
• Hypnotics may impair waking in a client. • Hypnotics may be addictive. • Tapering of doses may be required after long-term use.
The nurse is admitting a client that has obesity and is diagnosed with obstructive sleep apnea (OSA). The client states, "I just wake up a lot and don't feel rested but it's not a big deal." What education should the nurse provide about the complications related to OSA? -OSA contributes to hypertension and heart disease. -OSA is the cause of depression. -OSA can cause a condition called respiratory alkalosis -OSA can cause you to have seizures.
-OSA contributes to hypertension and heart disease. In healthy people, OSA may impair cardiac function over time and lead to the development of heart failure. If heart failure has already been diagnosed, OSA may result in progression of this condition. OSA is not directly associated with depression, respiratory acidosis, or seizure activity.
A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply. - smokes 1 pack of cigarettes daily - drinks coffee with all meals - history of hyperthyroidism - exercises 30 to 60 minutes daily - works 30 hours per week
Answer: - smokes 1 pack of cigarettes daily - drinks coffee with all meals - history of hyperthyroidism
The nurse is assessing a client with a history of sleep apnea who is noncompliant regarding wearing the continuous positive airway pressure (CPAP) apparatus. Which statement made by the client indicates understanding of risks related to noncompliance? A.) "I know if I do not wear the CPAP the oxygen in my blood may drop and damage my heart." B.) "Not wearing CPAP at night may cause my blood pressure to become low and I may fall." C.) "There is no reason why I should wear the mask other than because the doctor says I should." D.) "Wearing the mask when I sleep may cause me to gain weight as I will sleep more."
Answer: A.) "I know if I do not wear the CPAP the oxygen in my blood may drop and damage my heart."
A client with difficulty sleeping is prescribed ramelteon. The client asks the nurse, "How does this medicine work?" Which information would the nurse include in the response? A.) Activates the receptors for the hormone melatonin B.) Causes a change in the circadian rhythms C.) Decreases impulses to the cerebral cortex D.) Stimulates the reticular activating system
Answer: A.) Activates the receptors for the hormone melatonin
The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take? A.) Assess the client's vital signs and pulse oximetry. B.) Call a code blue, as the client is not breathing. C.) Ask a peer to come and observe the sleep pattern. D.) Review the client's medical record for sleep disturbances.
Answer: A.) Assess the client's vital signs and pulse oximetry.
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? A.) Assess the factors that the client believes contribute to the problem. B.) Obtain a PRN order for a sedative hypnotic from the client's physician. C.) Educate the client on relaxation techniques and reduce noise levels on the unit. D.) Facilitate a change in the client's diet to ensure more carbohydrates at dinner.
Answer: A.) Assess the factors that the client believes contribute to the problem.
A nurse is caring for a client with insomnia. Which teaching will the nurse provide to help the client improve sleep? A.) Create a bedtime routine." B.) "Limit fluids in the evening." C.) "Eat a heavy meal for dinner." D.) "Watch television in bed before sleep."
Answer: A.) Create a bedtime routine."
A client calls a sleep clinic helpline and describes the spouse's sleep patterns of snoring loudly then becoming startled and waking up five or six times a night. The client is asking how to improve the spouse's sleep patterns. Which Information will the nurse include in teaching about healthy sleep patterns? A.) Discuss the sleep pattern with the health care provider. B.) Sleep in another room to limit your disruption of the spouse's sleep. C.) Limit food intake before bed. D.) The spouse's sleeping pattern seems normal.
Answer: A.) Discuss the sleep pattern with the health care provider.
Which statement about the sleep patterns of toddlers should the nurse incorporate into an education plan for parents? A.) Getting the child to sleep can be difficult. B.) Most toddlers fall asleep easily. C.) Nightmares are rare in toddlers. D.) Slow-wave sleep occurs less in toddlers than in adults.
Answer: A.) Getting the child to sleep can be difficult.
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: A.) Sleep Pattern Disturbance related to acute pain. B.) Anxiety related to hospitalization. C.) Mobility, Impaired Physical related to Restless Leg Syndrome (RLS). D.) Role Performance, Ineffective related to inability to work at occupation.
Answer: A.) Sleep Pattern Disturbance related to acute pain.
A maternity nurse is instructing new parents on the proper sleeping position for their newborn child. In what position does the nurse instruct the parents to place the infant? A.) Supine position B.) Prone position C.) High-Fowler's position D.) Side-lying position
Answer: A.) Supine position
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? A.) The client's eyes dart back and forth quickly B.) The client has a slow, regular pulse. C.) The client's metabolism and body temperature have decreased. D.) The client's blood pressure decreases.
Answer: A.) 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.
Which factor necessitates the need for more sleep in the adolescent population? A.) rapid growth B.) increased nutritional needs C.) increased life stresses D.) part-time employment
Answer: A.) 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 awakens a client while the client is experiencing rapid eye movement sleep. What statement made by the client indicates they were awakened during REM sleep? A.) "It feels like I just went to sleep." B.) "I was having a great dream and I remember all of it." C.) "I heard you immediately when you came in my room." D.) "I feel really cold."
Answer: B.) "I was having a great dream and I remember all of it."
The nurse is promoting bedtime rituals with a family. Which statement indicates the nurse may need to provide further instructions to the mother? A.) "Our rituals include a short bedtime story each night." B.) "My boys love to roughhouse in their room right before bedtime." C.) "I let the kids have a snack of peanut butter crackers or fruit shortly before bed." D.) "My daughter sleeps soundly when she has her bear in bed with her and the night light is on."
Answer: B.) "My boys love to roughhouse in their room right before bedtime."
The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep? A.) Enjoy the peace and quiet of the country. B.) Find a phone app that plays sounds of the city. C.) Avoid eating right before bedtime. D.) Ingest 1 ounce of liquor before going to sleep.
Answer: B.) Find a phone app that plays sounds of the city.
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? A.) Help the client maintain normal bedtime routine and time for sleep. B.) Provide an opportunity for the client to talk about concerns. C.) Use tactile relaxation techniques, such as a back massage. D.) Bring the client a warm glass of milk at bedtime.
Answer: B.) Provide an opportunity for the client to talk about concerns.
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? A.) The client will likely sleep all night. B.) The client will likely not be able to sleep. C.) The worry will make the client fall asleep quickly. D.) The client will probably not be able to stay asleep.
Answer: B.) The client will likely not be able to sleep.
The nurse is assessing a client for sleep disorders. The initial step in sleep assessment is: A.) measure neck circumference and auscultate the abdomen. B.) observe the client's hours of sleep and review the client's sleep diary. C.) auscultate the lung fields and perform neuro checks. D.) measure the client's weight and assess visual acuity.
Answer: B.) observe the client's hours of sleep and review the client's sleep diary.
In Stage 4 sleep, the: A.) blood pressure is elevated B.) pulse rate is slow C.) respirations are irregular D.) temperature increases
Answer: B.) 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 client comes to the clinic and states to the nurse, "I am traveling overseas for a project frequently and am having a difficult time adjusting because of jet lag. What is the best response by the nurse? A.) "If you have jet lag once, you shouldn't have any further problems on your next trip overseas." B.) "You should take sleeping pills when you board so that you will sleep until you arrive at your destination. C.) "Light therapy can be beneficial and help ease the transition to a new time schedule or zone." D.) "Try to stay awake for the duration of the flight and sleep when you arrive."
Answer: C.) "Light therapy can be beneficial and help ease the transition to a new time schedule or zone."
A client asks the nurse if hot chocolate at bedtime will improve the client's sleep. Which is the best response by the nurse? A.) "Hot chocolate relaxes you and can help you sleep." B.) "Tea is the best option for promoting sleep." C.) "Milk is a better option to help you sleep." D.) "You should try cola to promote sleep."
Answer: C.) "Milk is a better option to help you sleep."
Which client could be diagnosed with insomnia? A.) A 45-year-old woman who has been reporting fatigue for the last year. When asked about her sleep schedule, she states that she usually goes to bed around 1 a.m. and gets up at 7 a.m. when her 5-year-old daughter gets up. She describes herself as a night owl. B.) A 40-year-old obese man who is reporting fatigue. He states that he goes to bed around 9 p.m. every night and wakes up between 5 and 6 in the morning. He feels like he gets a good night's sleep, but his wife says that she constantly has to poke him throughout the night because he "stops breathing." C.) A 50-year-old woman who is reporting increased irritability for the past 2 months. She states that she goes to bed at 10 p.m. every night and tries to sleep in but, no matter what she does, she always wakes up around 4 a.m. D.) A 20-year-old man who is reporting excessive drowsiness at work to the point that he falls asleep while at his computer. He goes to bed at 11 p.m. and wakes up at 7 a.m. without difficulty. Twice in the last year he passed out after getting extremely angry.
Answer: C.) A 50-year-old woman who is reporting increased irritability for the past 2 months. She states that she goes to bed at 10 p.m. every night and tries to sleep in but, no matter what she does, she always wakes up around 4 a.m.
When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which intervention? A.) A hypnotic medication B.) A narcotic medication C.) Low-flow oxygen D.) Warm milk
Answer: C.) Low-flow oxygen
The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to: A.) take a prescribed sedative before trying to sleep. B.) insert an oral appliance prior to attempting sleep. C.) anticipate sleeping overnight at a health care center. D.) apply a facial mask that will deliver positive air pressure.
Answer: C.) anticipate sleeping overnight at a health care center.
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? A.) In what way does the sleep you get each day affect your everyday living? B.) How much sleep do you think you need to feel rested? C.) What do you usually do to help yourself fall asleep? D.) Do you usually go to bed and wake up about the same time each day?
Answer: D.) Do you usually go to bed and wake up about the same time each day?
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns? A.) Newborns have shorter periods of REM sleep. B.) Newborns are inactive when awake. C.) Newborns will nap two times per day. D.) Newborns sleep 16 to 17 hours per day.
Answer: D.) Newborns sleep 16 to 17 hours per day.
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. Getting the child to fall asleep is the most commonly reported problem, but frequent awakenings and occasional night terrors may also occur.
The nurse is managing the environment for clients on a busy hospital ward. Which interventions would the nurse perform to facilitate a more restful environment? Select all that apply.
Maintain a brighter room during daylight hours and dim lights in the evening. Decrease the volume on alarms, pages, telephones, and staff conversations. Medicate for pain if needed. The nurse could perform several of the interventions listed to facilitate a more restful environment. First, the nurse could maintain a brighter room during daylight hours and dim lights in the evening. Opening the curtains in the room during the day is an excellent way to carry out this intervention. The nurse would decrease the volume on alarms, pages, telephones, and staff conversations. The nurse would medicate the client for pain if needed. The nurse would not keep the room warm, but cool to aid in sleep. Procedures should be scheduled together if at all possible to decrease the amount of time the client is involved in procedures and promote rest. The nurse should keep the door to the client's room closed if possible to facilitate a more restful environment.
When a client tells the clinic nurse that he has irresistible sleep attacks throughout the day lasting from 10 to 15 minutes, the nurse suspects that the client may be experiencing what?
Narcolepsy
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.
A client begins snoring and is sleeping lightly. The stage of sleep is:
Stage 2 Stage 2 is relatively light sleep from which the client is easily awakened. Rolling eye movements continue, and snoring may occur.
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.
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. 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.
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 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 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 shorter sleep cycles increased amount of total sleep increased stage IV NREM sleep (delta sleep)
decreased REM sleep Alcohol is known to decrease the amount of REM sleep. Alcohol does not typically shorten sleep cycles or increase the total amount of sleep. Delta sleep is decreased by alcohol consumption, not increased.
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
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 taking a short 15- to 30-minute nap stretching exercises focusing thoughts on a pleasant scene away from work going for a short walk
drinking an 8 oz cup of a caffeinated beverage
When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which intervention?
low flow oxygen
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 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 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.
The nurse is caring for a client who is having difficulty sleeping. Which medication does the nurse anticipate will be prescribed by the health care provider? temazepam furosemide amlodipine simvastatin
temazepam Benzodiazepines such as temazepam are often used to treat difficulty sleeping. Furosemide is a diuretic; amlodipine is a calcium channel blocker; and simvastatin is a HMG CoA reductase inhibitor (statin) used to treat high cholesterol.
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) Benzodiazepines such as temazepam (Restoril) are often used to treat difficulty sleeping. Furosemid (Lasix) is a diuretic; amlodipine (Norvasc) is a calcium-channel blocker; and simvastatin (Zocor) is a HMG CoA reductase inhibitor ("statin") used to treat high cholesterol.
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. The client is describing hypersomnia and is at increased risk for a motor vehicle accident when drowsy while driving an automobile. The client is to avoid alcohol, caffeine, and late night activities.
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.
use of a mandibular advancement device (MAD) use of a continuous passive airway pressure (CPAP) machine a weight loss plan 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.
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 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.
When evaluating a client's sleep plan success, the nurse would expect the client to:
verbalize feeling rested
A parent reports their 4-year-old child wakes up frequently at night screaming and occurs 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."
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."
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? Select all that apply.
• Avoid activities after 5 p.m that are stimulating. • Participate in a quiet activity, such as reading, prior to attempting to fall asleep.
A student nurse is preparing a presentation on sleep hygiene practices. What information should the nurse include? Select all that apply.
• Eliminate caffeine intake 6 hours prior to bedtime. • Do not watch television in bed. • Use blackout or other types of curtains/blinds to keep the room as dark as possible.
The nurse is managing the environment for clients on a busy hospital unit. Which interventions would the nurse perform to facilitate a more restful environment? Select all that apply.
• Maintain a brighter room during daylight hours and dim lights in the evening. • Decrease the volume on alarms, pages, telephones, and staff conversations. • Medicate for pain if needed.
The nurse is teaching the practice of stimulus control to a patient who has insomnia. The nurse would include which teaching points in the teaching plan? (Select all that apply.)
• Recommend that the patient use the bedroom for sex and sleep only. • Instruct the patient to leave the bedroom if he or she cannot get to sleep within 15 to 20 minutes; he or she should return to the bedroom when sleepy. • Instruct the patient to get up the same time every day, no matter what time he or she fell asleep.
A client informs the nurse about difficulty getting a restful sleep. What education can the nurse provide to encourage adequate sleep and rest? Select all that apply.
• eat a small protein- and carbohydrate-containing snack about an hour before bedtime • discontinue the use of tobacco or tobacco products • Perform moderate exercise
A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply.
• smokes 1 pack of cigarettes daily • drinks coffee with all meals • history of hyperthroidism
Which guideline does the nurse apply to discussion of sleep patterns with older adult clients?
Total sleep time decreases as the clients age.
The client reports unpleasant sensation in the legs with an urge to move them. Which questions will be important for the nurse to ask to determine what the client is experiencing? Select all that apply. "Do you use tobacco products?" "Have you been using any type of antihistamines for allergies?" "Do you have the same sensation in your arms?" "Does massaging the legs provide any relief?" "Are symptoms worse during the day?"
"Do you use tobacco products?" "Have you been using any type of antihistamines for allergies?" "Does massaging the legs provide any relief?" Unpleasant sensations in the legs with an urge to move the legs are symptoms of restless leg syndrome. Ingestion of antihistamines may exacerbate the symptoms. Avoiding use of tobacco and massaging of legs may bring relief. The sensation is present in the legs, not the arms. Symptoms are worse during the evening and night.
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.
A client comes to the clinic and states to the nurse, "I am traveling overseas for a project frequently and am having a difficult time adjusting because of jet lag. What is the best response by the nurse?
"Light therapy can be beneficial and help ease the transition to a new time schedule or zone."
The nurse is promoting bedtime rituals with a family. Which statement 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 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.
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.
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." "It might be a problem. You should discuss this with your pediatrician." "Five-year-olds sleep only 10 to 12 hours at night, but napping is very important at this stage." "Don't let your child eat any candy or chocolate after dinner."
"This is normal development for children in this age group." 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.
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 nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take? Assess the client's vital signs and pulse oximetry. Call a code blue, as the client is not breathing. Ask a peer to come and observe the sleep pattern. Review the client's medical record for sleep disturbances.
Assess the client's vital signs and pulse oximetry. Considering the client's sleep pattern, including periods of apnea; obesity; and cardiovascular disease, the client is likely experiencing sleep apnea. Sleep apnea may result in periods of life-threatening apnea, hypoxia, and bradycardia. As such, the nurse should awaken the client, obtain and record vital signs, and notify the health care provider of the sleep pattern and vital sign results. Calling a code blue is inappropriate, as the client is experiencing periods of apnea that are consistent with a sleep disorder and there is no indication that the client does not have a pulse. Asking a peer to observe the sleep pattern is inappropriate, as the nurse should assess the client's well-being. Reviewing the medical record is inappropriate, as attention should be on the client's well-being.
A client calls a sleep clinic helpline and describes the spouse's sleep patterns of snoring loudly then becoming startled and waking up five or six times a night. The client is asking how to improve the spouse's sleep patterns. Which Information will the nurse include in teaching about healthy sleep patterns? Discuss the sleep pattern with the health care provider. Sleep in another room to limit your disruption of the spouse's sleep. Limit food intake before bed. The spouse's sleeping pattern seems normal.
Discuss the sleep pattern with the health care provider. The description of the client's snoring is suggestive of sleep apnea. The treatment plan should be to attempt detection of this disorder rather than disguising it by lowering the spouse's sensitivity to it. The client's spouse should discuss the symptoms with the health care provider. Advising the spouse that partners often sleep in separate rooms is not therapeutic and is masking potential sleep apnea. Snacks do not affect sleep apnea.
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? In what way does the sleep you get each day affect your everyday living? How much sleep do you think you need to feel rested? What do you usually do to help yourself fall asleep? Do you usually go to bed and wake up about the same time each day?
Do you usually go to bed and wake up about the same time each day? 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.
The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep? Enjoy the peace and quiet of the country. Find a phone app that plays sounds of the city. Avoid eating right before bedtime. Ingest 1 ounce of liquor before going to sleep.
Find a phone app that plays sounds of the city. Clients tend to adapt to the unique sounds where they live, such as traffic, trains, and the hum of appliance motors or furnaces. Unfamiliar sounds tend to interfere with the ability to fall or stay asleep. The nurse will recommend that the client find an app that plays sounds of the city, which mimics the sounds with which the client is most familiar. Ignoring the problem by telling the client to adapt to the new environment does not address the problem. Avoiding eating before bedtime could cause the client to wake up hungry in the middle of the night. The nurse does not recommend alcohol, a depressive drug, to clients.
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.
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.
A 62-year-old client informs the nurse that the parent has been anxious and disoriented in the morning. The client also informs the nurse that the parent gets up frequently to use the bathroom. Which nursing intervention can decrease the disruption of sleep? Have your parent take diuretic medicine in the morning. Offer your parent iced tea before bed. Suggest your parent sleep without socks. Encourage your parent to take frequent naps during the day.
Have your parent take diuretic medicine in the morning. Taking a diuretic will promote the need for voiding within a few hours, interrupting the sleep cycle if taken at night. Taking the diuretic during the morning can lessen voiding effects later in the day. Tea is a weak stimulant but should be avoided close to bedtime. Older adults can have difficulty sleeping if they feel cold, so wearing socks to bed can promote restful sleep. Taking naps during the day can interfere with sufficient sleep at night.
A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client?
Insomnia
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. The nurse needs to administer another drug such as diphenhydramine for effectiveness. The client's daily activity is interfering with the drug. The client is eating protein prior to bedtime.
Most sedative hypnotics lose their effect after 1 or 2 two weeks of administration. 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, as this can intensify the medication. Increased activity assists the client in sleeping. Carbohydrates have been shown to help a client sleep.
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.
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns? Newborns have shorter periods of REM sleep. Newborns are inactive when awake. Newborns will nap two times per day. Newborns sleep 16 to 17 hours per day.
Newborns sleep 16 to 17 hours per day. Newborns sleep an average of 16 to 17 hours per 24 hours a day, divided into about seven sleep periods distributed fairly evenly throughout the day and night.
A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. Which measures should the nurse implement to promote sleep? Select all that apply. Administration of diuretics Promoting daytime exercises Providing a back massage Increasing the intake of stimulating chemicals Assisting with progressive relaxation
Promoting daytime exercises Providing a back massage Assisting with progressive relaxation 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 client begins snoring and is sleeping lightly. The stage of sleep is:
Stage 2
The student nurse is providing an education program for preschool parents. The nursing student should include which intervention to improve the child's sleep?
The child should limit fluids after supper.
The student nurse is providing an education program for preschool parents. The nursing student should include which intervention to improve the child's sleep? The child should limit fluids after supper. The child should drink milk at bedtime. The parents should keep the child up until 10 PM. The child should sleep with the parents.
The child should limit fluids after supper. Parents and other caregivers can assist children in establishing the habit of voiding as part of preparing for bedtime. Drinking milk at bedtime, keeping the child up until 10 PM and sleeping with the parents will not improve the child's sleep.
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.
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 The client has a slow, regular pulse. The client's metabolism and body temperature have decreased. The client's blood pressure decreases.
The client's eyes dart back and forth quickly 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.
A nurse is working with an older adult client who has been diagnosed with onset insomnia and informs the nurse about waking at least once during the night. What actions by the nurse can help promote adequate sleep? Select all that apply. The nurse advises the client to exercise no closer than 6 hours to bedtime. The nurse encourages the client to remove the television from the bedroom. The nurse encourages the client to minimize caffeine intake several hours prior to bedtime. The nurse helps the client come up with a bedtime routine that can be implemented each night. The nurse teaches the client that shorter, unbroken sleep periods are not normal.
The nurse advises the client to exercise no closer than 6 hours to bedtime. The nurse encourages the client to remove the television from the bedroom. The nurse encourages the client to minimize caffeine intake several hours prior to bedtime. The nurse helps the client come up with a bedtime routine that can be implemented each
A nurse is reviewing the medication administration record. Which order does the nurse question? a diuretic administered twice daily at 9 a.m. and 9 p.m. a diuretic administered once daily at 9 a.m. a diuretic administered twice daily at 9 a.m. and 5 p.m. a diuretic administered every other day at noon
a diuretic administered twice daily at 9 a.m. and 9 p.m. A diuretic should not be administered after 6 p.m. 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.
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 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.
The nurse is educating a client about nonpharmacologic measures to alleviate restless leg syndrome (RLS). Which education points would the nurse include in the plan? Select all that apply. drinking a cup of coffee before bed can help relieve the tingling sensations applying heat or cold to the extremity can help relieve the symptoms an alcoholic drink is recommended before bed to relax the client Biofeedback and TENS can help relax the client and relieve symptoms massaging the legs may relieve symptoms A mild analgesic before bed can help relieve symptoms
applying heat or cold to the extremity can help relieve the symptoms Biofeedback and TENS can help relax the client and relieve symptoms massaging the legs may relieve symptoms The nurse would instruct the client that applying heat or cold to the extremity can help relieve the symptoms of restless leg syndrome (RLS). The nurse would instruct the client that biofeedback and TENS can help relax the client and relieve symptoms. The nurse would instruct the client that massaging the legs may relieve RLS symptoms. Caffeine and alcohol should be avoided by the client before bed. A mild analgesic before bed will not help relieve RLS symptoms.
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.
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.
The nurse identifies that a client is in stage 3 sleep. What assessment finding by the nurse is indicative of this stage?
enuresis
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
While instructing young adults about the need for adequate sleep, the nurse instructs the group that to improve sleep quality, individuals should:
have a consistent time for arising.
A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client? insomnia nightmares somnambulism nocturnal enuresis
insomnia Insomnia and hypersomnia are often manifestations of depression in older clients. Nightmares, somnambulism (sleepwalking), and nocturnal enuresis are examples of parasomnias. These are conditions associated with activities that cause arousal, or partial arousal, usually during transitions in NREM periods of sleep. However, these are not manifestations of depression in an older adult client.
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: blood pressure is elevated pulse rate is slow respirations are irregular temperature increases
pulse rate is slow 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.
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 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.
A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep? "By maintaining the oxygen in your body during sleep other health problems can be avoided." "Using the CPAP will increase your energy during the day by allowing you to sleep at night." "The CPAP assures you get enough oxygen throughout the night." "The CPAP prevents you from snoring so your spouse can sleep."
"The CPAP assures you get enough oxygen throughout the night." The nurse can explain that 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. Sleep apnea occurs in conjunction with snoring which can be difficult for a spouse but less urgent than a lack of oxygen in the body. By getting more oxygen during sleep the client may have more daytime energy, and associated health problems can be avoided when the body has proper oxygen balance. These outcomes, however, are not guaranteed and should be considered less urgent than the lack of oxygen.
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
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.
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.
What factor has been hypothesized by researchers regarding current thoughts on sleep? The current population requires less sleep. More sleep is obtained through napping. The population is healthier due to sleep. Chronic sleep deprivation is present.
Chronic sleep deprivation is present. Most recently, researchers have hypothesized that much of the population in industrialized nations may be chronically sleep deprived.
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.
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.
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.
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.
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? Help the client maintain normal bedtime routine and time for sleep. Provide an opportunity for the client to talk about concerns. Use tactile relaxation techniques, such as a back massage. Bring the client a warm glass of milk at bedtime.
Provide an opportunity for the client to talk about concerns. 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.
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
A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which nursing diagnosis is most appropriate for this client? Relocation Stress Syndrome Sleep Deprivation Impaired Bed Mobility Risk for Injury
Sleep Deprivation 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.
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
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.
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. take a prescribed sedative before trying to sleep. insert an oral appliance prior to attempting sleep. apply a facial mask that will deliver positive air pressure.
anticipate sleeping overnight at a health care center. 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.
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.
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 hypnogogic hallucinations cataplexy and hypnogogic hallucinations hypnogogic hallucinations and sleep paralysis sleep paralysis and automatic behavior
sleep paralysis and automatic behavior 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 client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply. smokes 1 pack of cigarettes daily drinks coffee with all meals history of hyperthyroidism exercises 30 to 60 minutes daily works 30 hours per week
smokes 1 pack of cigarettes daily drinks coffee with all meals history of hyperthyroidism Insomnia is associated with the consumption of stimulants (e.g., caffeine, nicotine, methamphetamine, and other drugs of abuse). Insomnia is also a side effect of hyperthyroidism. Exercising 30 to 60 minutes daily can help a client fall asleep faster.
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.
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.
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
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.
