Sleep Alterations
Treatment of CSA
1st = treat underlying cause meds CPAP, biPAP, noninvasive positive pressure ventilation
Treatment for Narcolepsy
2-4 planned naps/day lasting 15-30 minutes each Medications
A 22 year old man is being seen in the clinic because he has been falling asleep two or three times a day for the past few years. Yesterday, he also experienced profound muscle weakness. You expect that - A. A spinal tap will be performed to check his hypocretin levels B. There is no family history of similar symptoms C. His sudden sleep attacks are due to boredom with his life activities D. No other diagnostic tests are needed to confirm his diagnosis
A. A spinal tap will be performed to check his hypocretin levels
Which treatment should the nurse consider appropriate for the client with restless leg syndrome (RLS)? A. Correcting ferritin levels B. Increasing caffeine intake C. Staying still without moving the legs or walking D. Administering calcium channel blockers
A. Correcting ferritin levels Rationale: Correcting iron and ferritin levels, a cause of anemia, decreases the occurrence of restless leg syndrome (RLS) symptoms. Caffeine should be decreased and calcium channel blockers should be discontinued. Walking and activity often relieve the symptoms of RLS.
Patients with COPD, HF, OSA/CSA may awaken with hypoxemia & hypercapnia due to ...
Mild hypoventilation caused by sleep (during sleep, the brain compensates less for decreased respirations -> decreased O2 & CO2 levels)
Clinical manifestations of OSA
Poor memory, Decreased ability to maintain attention, Problems processing information, Increased reaction time
T/F - Chronic short sleep increases risk for weight gain & obesity
True Rationale: Chronic short sleep -> decreased leptin & increased ghrelin. Leptin decreases appetite & increases energy use. Ghrelin increases appetite & saves energy
Clinical manifestations of RLS
URGE = Urge to move legs (sensations described as pain, itching, tingling, pins/needles) Rest provokes Sx's Getting active (moving) relieves Sx's Evening/night worsen's Sx's
A 40 year old man is brought to the health center by his wife. The man suffered a traumatic brain injury 6 months ago, and since then he has multiple episodes of violent movements during sleep, which worry his wife, who is his bed partner. Which of the following is correct? A. His wife should be encouraged to continue sleeping as his bed partner so that she can restrain him when he has these episodes. B. You feel confident that these episodes are occuring during NREM sleep stage. C. You suspect REM sleep behavior disorder D. His symptoms are unrelated to his history of TBI
c
A middle-aged client complains of sleepiness during the day and difficulty concentrating. Which follow-up question should the nurse ask this client to investigate sleep apnea? A. "Have you noticed changes in your short-term memory?" B. "Do you experience any strange sensations with your legs?" C. "Have you recently had a major loss or stressful life event?" D. "Have you recently traveled?"
A. "Have you noticed changes in your short-term memory?" Rationale: The nurse asks the client about changes in short-term memory, because this is a manifestation of sleep apnea along with sleepiness during the day and difficulty concentrating. Recent travel may lead to jet lag. Changes in the legs may indicate restless leg syndrome (RLS). A major loss or stressful event can lead to insomnia.
Treatment of RLS
- Correct low iron & serum ferritin levels, Dopamine supplementation - Meds
Clinical manifestations of Insomnia
- Decreased cognitive ability, Impaired performance on monotonous tasks - Decreased immune function
Clinical manifestations of Narcolespy
- Excessive daytime sleepiness & fatigue, Bouts of sleep, Sleep paralysis - Hallucinations - Cataplexy
Risk factors for OSA (obstructive sleep apnea)
- Male, middle aged, postmenopausal - Anatomic abnormality of the upper airway - Edentulous, Alzeheimer's - Overweight
Risk factors of CSA (central sleep apnea)
- Male, older age - Hypocapnia - Atrial fibrillation, Systolic HF
Clinical manifestations of sleep deprivation
- Memory loss, Delusions, Decreased coordination, Slow reaction time, Slurred speech - Irritable, Inattentive, Labile emotions - Blurry vision - Impaired immune system function - Weight gain
Risk factors for RLS (restless leg syndrome)
- Pregnancy, Overweight, Sedentary lifestyle - Anemia - DM - Caffeine use, Smoking
Treatment for OSA
- Weight loss, Smoking cessation - CPAP, oral appliances - Surgery to correct anatomical abnormality
Which clinical manifestation should the nurse expect for a client with insomnia following significant life events of job loss and the death of a close family member. (Select all that apply.) A. Decreased cognitive function B. Hypotension C. Irritability D. Immunocompromised E. Fatigue
A. Decreased cognitive function C. Irritability D. Immunocompromised E. Fatigue Rationale: Insomnia, the inability to fall asleep or maintain sleep, leads to fatigue, irritability, a compromised immune system, and decreased cognitive function. Insomnia may lead to hypertension, not hypotension, and cardiovascular disease.
The nurse is caring for an adolescent with a family history of narcolepsy. Which clinical manifestation should the nurse explore with the client for an early sign of narcolepsy? (Select all that apply.) A. Fatigue B. Hallucinations C. Cataplexy D. Excessive daytime sleepiness E. Sleep paralysis
A. Fatigue D. Excessive daytime sleepiness Rationale: Fatigue and excessive daytime sleepiness are early signs of narcolepsy that usually appear in adolescence. Later in narcolepsy, the client may experience cataplexy, hallucinations, and sleep paralysis.
An EEG may be used to determine the stage of sleep. Which of the following is correct? A. Healthy young adults spend most of their sleep time in NREM sleep. B. Restorative sleep is REM sleep. C. Infants spend most of their sleep time in NREM sleep. D. A persona with obstructive sleep apnea typically has snoring episodes during NREM sleep
A. Healthy young adults spend most of their sleep time in NREM sleep.
Which cause of hypoxia and hypercapnia in the client with chronic obstructive pulmonary disease (COPD) related to sleep should the nurse expect to treat? A. Hypoventilation B. Hyperventilation C. Hypotension D. Hypertension
A. Hypoventilation Rationale: Hypoventilation during sleep exacerbates hypoxia and hypercapnia in the COPD client
The nurse is preparing a teaching pamphlet on obstructive sleep apnea for clients. Which risk factor should the nurse include? (Select all that apply.) A. Overweight B. Lacking teeth C. Female gender D. Thin neck E. Upper airway abnormality
A. Overweight B. Lacking teeth E. Upper airway abnormality Rationale: Excess weight, lack of teeth, and upper airway abnormalities all contribute to airway obstruction and the risk of developing obstructive sleep apnea. Men are more likely than women to have obstructive sleep apnea. A thick, not thin, neck contributes to the risk of airway obstruction and obstructive sleep apnea.
The nurse in a pediatric clinic is gathering health information from the mother of a 10-year-old child. The mother states that the child moves a great deal during sleep as if acting out dreams. Which sleep disorder does the nurse suspect? A. REM behavior disorder B. Sleep inertia C. Enuresis D. Night terrors
A. REM behavior disorder Rationale: During REM behavior disorder, the muscles do not relax, and dreams are acted out. Enuresis is bedwetting at night. Sleep inertia is difficulty waking up after sleep. Night terrors are abrupt wakefulness with a feeling of inescapable fear.
A nurse is beginning full-time work from 11:00 p.m. to 7:00 a.m. five days a week. Which sleep disorder is this nurse prone to developing? A. Shift work disorder B. Sleep phase delay C. Jet lag D. Insomnia
A. Shift work disorder Rationale: Shift work disorder is a circadian rhythm disorder stemming from working night hours and exposure to light in the daytime when trying to sleep. Sleep phase delay occurs with adolescents as they stay up later and then consequently sleep later the next day. Jet lag occurs after traveling across time zones and with the internal circadian rhythm not matching the new location's time. Insomnia is a sleep disorder precipitated by factors of stress and worry.
An older adult man with hypertension and urinary frequency continues to complain of insomnia. Which treatment would work best for this client? A. Cognitive-behavioral therapy B. Medication C. Mindfulness meditation D. Tai chi
A. Cognitive-behavioral therapy Rationale: Nonpharmacologic management of insomnia is the desired course of therapy in the older adult client with cognitive-behavioral therapy proving to be most effective over tai chi and mindfulness. Medication is not the best course of action for the older adult client because their insomnia is frequently related to chronic disease and medication use.
The nurse monitoring a client during a sleep study who has entered slow wave sleep understands which neurotransmitter is working properly? A. Gamma-aminobutyric acid B. Glutamine C. Dopamine D. Norepinephrine
A. Gamma-aminobutyric acid Rationale: Gamma-aminobutyric acid (GABA) enhances slow wave sleep. Dopamine and glutamine play roles in increasing wakefulness. Norepinephrine regulates REM sleep.
A client with chronic heart failure has been diagnosed with central sleep apnea. Which treatment should the nurse consider a priority in the care of this client? A. Exposure to daylight to resynch the circadian rhythm B. Administration of medication to treat the heart failure C. Mindful meditation to reduce stress D. Administration of hypnotic drugs to attain prolonged sleep
B. Administration of medication to treat the heart failure Rationale: The priority treatment for this client is management of the heart failure that is causing central sleep apnea. Exposure to daylight can assist with sleeping disorders like jet lag. Meditation and hypnotic medication are strategies to promote sleep in the client with insomnia.
A client complains of poor sleep patterns and weight gain. Which hormone does the nurse suspect is causing the weight gain? (Select all that apply.) A. Prolactin B. Leptin C. Ghrelin D. Growth hormone E. Cortisol
B. Leptin C. Ghrelin Rationale: Leptin and ghrelin are hormones that can cause weight gain when people experience short periods of sleep. Cortisol increases just before waking, and prolactin and growth hormone increase during sleep but are not related to weight gain with poor sleep patterns.
Which type of narcolepsy manifests a hypocretin level less than 110 pg/mL and a polysomnogram (PSG) demonstrating fragmented sleep? A. Short-term narcolepsy B. Narcolepsy with cataplexy C. Narcolepsy without cataplexy D. Secondary narcolepsy
B. Narcolepsy with cataplexy Rationale: The polysomnogram (PSG) of a client with narcolepsy with cataplexy will demonstrate fragmented sleep. Because this type of narcolepsy is usually caused by the loss of neurons that produce hypocretin (orexin) in the hypothalamus, a spinal tap will show an abnormally low level of hypocretin-1 (less than 110 pg/mL). A daytime PSG, the Multiple Sleep Latency Test (MSLT), will show episodes of sleep beginning soon after the individual lies down in a dark room. Secondary narcolepsy contains the clinical manifestation of hypocretin levels less than 110 pg/mL, but excessive daytime sleepiness is attributable to another sleep disorder. Narcolepsy without cataplexy contains the clinical manifestation of hypocretin levels greater than 110 pg/mL. There is no such diagnosis as short-term narcolepsy.
While observing a client during a sleep study, the nurse recognizes that the sleep cycle begins with which phase? A. REM sleep B. Sleep latency C. N1 D. Delta sleep
B. Sleep latency Rationale: The sleep cycle begins with sleep latency, which is the body attempting to enter sleep.
Which condition should the nurse recognize as a risk factor for central sleep apnea? (Select all that apply.) A. Hypercapnia B. Sleeping at a high altitude C. Renal failure D. Heart failure E. Atrial fibrillation
B. Sleeping at a high attitude C. Renal failure D. Heart failure E. Atrial fibrillation Rationale: Risk factors for central sleep apnea, the cessation of breathing during sleep because of lack of output from the brain to stimulate breathing, include chronic conditions such as heart failure, renal failure, and atrial fibrillation as well as sleeping in high altitudes. Hypercapnia, the presence of CO2 in the blood, would drive respiratory effort, but hypocapnia would place one at risk for central sleep apnea.
Which diagnostic testing should a nurse expect to be ordered for a client suspected of having narcolepsy? A. Just a daytime Multiple Sleep Latency Test (MSLT) B. Just an all-night polysomnogram (PSG) C. An all-night polysomnogram (PSG) and a daytime Multiple Sleep Latency Test (MSLT) D. No diagnostic testing at this time
C. An all-night polysomnogram (PSG) and a daytime Multiple Sleep Latency Test (MSLT) Rationale: The most comprehensive testing for narcolepsy would be to perform both the all-night polysomnogram (PSG) and a daytime Multiple Sleep Latency Test (MSLT) to monitor night and daytime manifestations of the disorder.
The nurse is reviewing a client's polysomnogram (PSG) results. The report indicates that muscle tension was normal, but chest and abdominal movement were absent during events. Which sleep disorder should the nurse suspect? A. REM behavior disorder B. Obstructive sleep apnea C. Central sleep apnea D. Narcolepsy
C. Central sleep apnea Rationale: With central sleep apnea, the respiratory center in the brain does not signal for breathing, so no chest or abdominal wall movement is observed. In REM behavior disorder, the muscles do not relax as they normally would during REM sleep. Narcoleptics continue to breathe normally during sleep. Paradoxical chest and abdominal movement may be noted in the person with obstructive sleep apnea.
Diagnostic testing fro RLS includes laboratory tests for anemia and iron levels. The reason for this diagnostic test in RLS evaluation is that low iron levels - A. Cause muscle cramping B. Cause muscle weakness C. Reduce dopamine activity in the brain D. Indicate a poor diet
C. Reduce dopamine activity in the brain
The nurse is caring for a client with a recently diagnosed tumor of the pineal gland. Which concern should the nurse have that may potentially impact sleep for the client? A. A tumor of the pineal gland will cause obstructive sleep apnea. B. A tumor of the pineal gland will induce narcolepsy. C. The pineal gland secretes melatonin, a hormone that promotes sleep. D. The pineal gland secretes hypocretin, a hormone that stimulates wakefulness.
C. The pineal gland secretes melatonin, a hormone that promotes sleep. Rationale: The pineal gland secretes melatonin, a hormone that promotes sleep, which could potentially alter the sleep patterns of the client.
A client newly diagnosed with mild obstructive sleep apnea asks the nurse what changes can be made in lifestyle to treat the sleep apnea. How should the nurse respond? A. "Consuming an alcoholic drink before bed will decrease apnea." B. "You will need CPAP to treat your sleep apnea." C. "Losing weight can alleviate the problem of obstructive sleep apnea." D. "Sleep on your back to improve your breathing."
C. "Losing weight can alleviate the problem of obstructive sleep apnea." Rationale: Weight loss can alleviate mild obstructive sleep apnea. Clients with obstructive sleep apnea are instructed to decrease alcohol intake in the evening and not to sleep on the back. CPAP is not needed if lifestyle changes alleviate the occurrence of obstructive sleep apnea.
Your client with OSA has returned to the clinic after being on CPAP therapy for the past month. Before he began CPAP, his hypertension was not responding to antihypertensive medication, and he was very overweight. You - A. Ask whether his sleep partner reports less snoring and encourage continued use of the CPAP. B. Expect that regular use of the CPAP will result in an improvement of his hypertension C. Check his weight as part of the physical evaluation and encourage weight loss to achieve a normal weight D. All of the above
D. All of the above
Your 75 year old client has suffered a fall. Luckily, she did not fracture any bones or have a serious injury from the fall. Which of the following is correct? A. You explain that prevention of future falls is a priority. B. Evaluation should include a consideration of heart failure or other cardiac problems. C. A disturbed sleep pattern is a potential nursing diagnosis. D. All of the above.
D. All of the above.
You are discussing an upcoming plane flight with your 70 year old client, who will be visiting family. The travel plans include flying from the east coast of the United States (Florida) to the west coast (California). Your patient is concerned about the possibility of jet lag because he had a bad case of jet lag 15 years ago when he too a similar trip. Which of the following is an appropriate response? A. Jet lag occurs only with north to south travel, so you don't need to worry. B. There is not much you can do about jet lag. You'll just have to suffer through it. C. You are lucky. As one gets older, jet lag becomes less severe, and your symptoms won't be as bad as they were when you were younger. D. Spending time in the sunlight at your destination will help, and there are also medications that may be helpful.
D. Spending time in the sunlight at your destination will help, and there are also medications that may be helpful.
Your 35 year old patient complains that when her alarm clock awakens her in the morning on work days, she feels very sleepy for at least an hour and she has difficulty concentrating and getting ready for work. Drinking coffee helps her alertness somewhat. You suspect a diagnosis of - A. Narcolepsy B. RLS C. REM sleep behavior disorder (RBD) D. sleep inertia (sleep drunkenness)
D. sleep inertia (sleep drunkenness)
An older adult client who recently experienced the death of a parent is having difficulty maintaining sleep and asks the nurse how long sleep will be affected. How should the nurse respond? A. "Insomnia will resolve as soon as you start medication for it." B. "Insomnia is chronic and cannot be cured." C. "You have nothing to worry about." D. "Most episodes of insomnia last 3-4 weeks."
D. "Most episodes of insomnia last 3-4 weeks." Rationale: Most episodes of insomnia are acute and last only 3-4 weeks. Stating that there is nothing to worry about does not answer the client's question. Insomnia is not necessarily chronic unless there are perpetuating factors. Nonpharmacologic interventions for the older adult are suggested for the treatment of insomnia.
