Sleep NCLEX Practice – Flashcards
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The nurse is caring for a young adult patient on the medical-surgical unit. When doing midnight checks, she sees that the patient is awake and is doing a puzzle. What is the best explanation for the patient being awake? A. The patient was waiting to talk with the nurse B. The patient misses his family and is lonely C. The patients sleep-wake cycle preference is late evening D. The patient has been kept up by the noise on the unit
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ANS: C All persons have biological clocks that synchronize their sleep-wake cycle. This explains why some individuals fall asleep in the early evening and some late evening or early morning. This patient is awake and alert enough to do a puzzle. The individual's sleep-wake preference is probably late evening. Waiting to talk with the nurse, being lonely, and noise on the unit may contribute to lack of sleep, but the best explanation for the patient being awake is the biological clock.
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The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which of these statements by the nurses would best indicate that learning has occurred? a. "If the patient has a disease process in the central nervous system, it can influence the functions of sleep." b. "If the patient has a disease process in the cranial nerves, it can influence the functions of sleep." c. "If the patient has an interruption in the motor pathways, it can influence the functions of sleep." d. "If the patient has an interruption in the spinal reflexes, it can influence the functions of sleep."
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ANS: A Sleep involves a sequence of physiological states maintained by the central nervous system. Current theory indicates that it is an active multiphase process that involves many parts of the brain and hormone and chemical secretion. A disease process associated with the cranial nerves, motor pathway, or spinal reflexes may influence a person's ability to sleep, but the best answer is the central nervous system.
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The nurse is caring for a patient who is having trouble sleeping. To encourage decreased stimulus to the reticular activating system and activation of the bulbar synchronizing region, which actions would the nurse implement? a. Encourage television for distraction. b. Encourage relaxed positions. c. Walk with the patient. d. Provide a favorite beverage.
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ANS: B Researchers believe that the ascending reticular activating system (RAS) located in the upper brainstem contains special cells that maintain alertness and wakefulness. Researchers also hypothesize that the release of serotonin from specialized cells in the bulbar synchronizing region (BSR) produces sleep. As the patient closes his eyes and assumes relaxed positions, stimuli to the RAS decrease, and at some point the BSR takes over. Television, walking, and drinking a favorite beverage would not necessarily encourage sleep.
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4. The nurse is caring for a patient in the sleep lab. The nurse recognizes that the patient is in stage 4 NREM from which of the following assessments? a. The patient awakens easily. b. Body functions slow. c. The patient is difficult to awaken. d. Eyes rapidly move.
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ANS: C Stage 4 NREM is the deepest stage of sleep. The patient is difficult to arouse, vital signs are significantly lower, and this stage lasts about 15 to 30 minutes. Sleep walking and enuresis sometimes occur. Lighter sleep is seen in stages 1 and 2, where the patient awakens easily. In stage 2, body functions slow and REM sleep is characterized by rapid eye movement.
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5. The patient shares with the nurse the vivid, full color dreams experienced by the patient last night. These data would indicate that the patient has reached what stage of sleep? a. Stage 1 NREM b. Stage 2 NREM c. Stage 3 NREM d. REM
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ANS: D Vivid, full color dreaming occurs during REM sleep. This stage usually begins about 90 minutes after sleep has begun. The eyes move rapidly, and heart rate, respiratory rate, and blood pressure fluctuate; loss of skeletal muscle tone occurs. The patient has an increase in gastric secretions and is difficult to arouse.
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6. Which nursing observation of the patient in intensive care indicates that the patient is sleeping comfortably? a. Eyes closed, lying quietly, respirations 12, heart rate 60 b. Eyes closed, tossing in bed, respirations 18, heart rate 80 c. Eyes closed, mumbling to self, respirations 16, heart rate 68 d. Eyes closed, lying straight in bed, respirations 22, heart rate 66
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ANS: A During NREM sleep, biological functions slow. During sleep, the heart rate decreases to 60 beats per minute or less. The patient experiences decreased respirations, blood pressure, and muscle tone.
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7. The nurse is discussing with a new mother the sleep requirements of a neonate. Which of these comments would indicate that the patient has an understanding of the neonate's sleeping pattern? a. "I can't wait to get the baby home to play with the brothers and sisters." b. "I will ask my mom to come after the first week, when the baby is more alert." c. "I will get the baby on a sleeping schedule the first week while my mom is here." d. "I won't be able to nap during the day because the baby will be awake."
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ANS: B The neonate averages about 16 hours of sleep. During the first week of life, the child sleeps almost constantly.
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8. The nurse is discussing lack of sleep with a middle-aged adult. The nurse recognizes that insomnia in this age group is commonly due to a. Anxiety. b. Teenagers keeping them awake. c. Caring for pets. d. Late night television.
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ANS: A During middle adulthood, the total time spent sleeping at night begins to decline. Anxiety, depression, and illness can affect sleep, and women can experience menopausal symptoms. Insomnia is common because of the changes and stresses associated with middle age. Teenagers, caring for pets, and late night television can influence the amount of sleep; however, these are not the most common causes of insomnia in this age group.
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9. A single dad is discussing with the nurse the sleep needs of a preschooler. Which of the following directions would be most helpful to the parent? a. "It is important that the 5-year-old get a nap every day." b. "Preschoolers sleep soundly all night long." c. "On average, the preschooler needs to sleep 10 hours a night." d. "The preschooler may have trouble settling down after a busy day."
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ANS: D The preschooler usually has difficulty relaxing or settling down after long, active days. By the age of 5, naps are rare for children, except those for whom a siesta is a custom. Preschoolers frequently partially awaken during the night. On average, a preschooler needs 12 hours of sleep.
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10. The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which nursing action should the nurse take? a. Discuss with the adolescent's parent staying up with friends and the need for sleep. b. Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness. c. This is a normal occurrence for adolescents and action is not required. d. Explore the reason for staying up late with friends several nights a week.
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ANS: B On average, a teenager needs about 71/2 hours of sleep per night. Many activities at school, social activities, and jobs can reduce the number of sleep hours, resulting in excessive daytime sleepiness. This can lead to decreased performance at school, vulnerability to accidents, behavior and mood problems, and increased use of alcohol. Discussion regarding adolescent sleep needs should first occur with the adolescent. Although it may be common for this adolescent to want to visit with friends and experience activities that go late into the night, these activities can and do impact the hours of sleep and the physical needs of the adolescent, no matter the reason for the late nights, and they do need to be addressed.
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11. The nurse is completing an assessment on an older patient who is having difficulty falling asleep. Which factor has the potential to contribute to this difficulty? a. Depression b. Smoking c. Alcohol d. Fatigue
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ANS: A Older adults and other individuals who experience depressive mood problems experience delays in falling asleep, earlier appearance of REM sleep, frequent awakening, increased total bed time, feelings of sleeping poorly, and early awakening. Smoking (nicotine) decreases the total sleep time and REM and causes awakening or difficulty staying asleep. Alcohol speeds the onset of sleep. A person who is moderately fatigued usually achieves restful sleep.
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12. The nurse is caring for an adolescent who is complaining of difficulty falling asleep. Which intervention would be most appropriate? a. Adjust the temperature in the patient's room to 21° C (70° F). b. Ensure that the night light in the patient's room is working. c. Encourage the discontinuation of soda and chocolate nightly snack. d. Close the door to decrease noise from unit activities.
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ANS: C Cola and chocolate contain caffeine, which interferes with the ability to fall asleep. Personal preference influences the temperature of the room, as well as the lighting of the room. Noise can be a factor in the unit and can awaken the patient, but caffeine can make it difficult to fall asleep.
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13. Which of the following would be most important for the nurse to monitor in a patient who has obstructive sleep apnea? a. Gastrointestinal function b. Circulatory status c. Respiratory status d. Neurological function
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ANS: C In obstructive sleep apnea, the upper airway becomes partially or completely blocked, diminishing airflow and stopping it. The person still attempts to breathe because the chest and abdominal movement continue, which results in loud snoring and snorting sounds. According to the ABCs of prioritizing care, airway and respiratory status take priority.
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14. The patient has just been diagnosed with narcolepsy. The nurse provides an educational session and teaches the patient to avoid a. Antidepressant medications. b. Naps shorter than 20 minutes. c. Sitting in hot, stuffy rooms. d. Chewing gum
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ANS: C Patients with narcolepsy need to avoid factors that increase drowsiness such as alcohol, heavy meals, exhausting activities, long-distance driving, and long periods of sitting in hot, stuffy rooms. Patients are treated with antidepressants, and management techniques involve scheduling naps no longer than 20 minutes and chewing gum. Additional management techniques include exercise, light high-protein meals, deep breathing, and taking vitamins.
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15. The nurse is caring for a patient who has been in holding in the emergency department for 24 hours. The nurse is concerned about the patient experiencing sleep deprivation. What would be the best action for the nurse to take? a. Expedite the process of obtaining a medical-surgical room for the patient. b. Pull the curtains shut, dim the lights, and decrease the number of visitors. c. Obtain an order for a medication to help the patient sleep. d. Ask everyone in the unit to try to be quiet so the patient can sleep.
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ANS: A The most effective treatment for sleep deprivation is elimination or correction of factors that disrupt the sleep pattern. Nurses play an important role in identifying treatable sleep deprivation problems. Obtaining a private room in the designated unit for the patient will help with decreasing stimuli and promoting more rest than an individual can obtain in an emergency department even with the interventions mentioned.
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16. The nurse is completing a sleep assessment on a patient. The nurse utilizes which of the following tools to complete the assessment? a. Visual Analogue Scale b. OUCHER scale c. FACES scale d. Glasgow Coma Scale
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ANS: A The Visual Analogue Scale is utilized for assessing sleep quality. The OUCHER and FACES scales are used to measure pain, and the Glasgow Coma Scale is used to measure level of consciousness.
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17. The nurse is beginning a sleep assessment on a patient. Which of the following would be the most appropriate question to ask? a. "What is going on?" b. "How are you sleeping?" c. "Are you taking any medications?" d. "What did you have for dinner last night?"
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ANS: B Asking patients how they are sleeping is an introductory question. After this beginning question is asked, problems with sleep such as the nature of the problem, signs and symptoms, onset and duration of the issue, severity, predisposing factors, and the effect on the patient can be assessed. What is going on is too broad and open ended for information about sleep to be obtained specifically. Medications and food intake can be part of the detailed assessment of sleep issues.
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18. The nurse assigns a nursing diagnosis of ineffective breathing pattern. Which of the following sleep conditions would support this diagnosis? a. Insomnia b. Narcolepsy c. Obstructive sleep apnea d. Sleep deprivation
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ANS: C Obstructive sleep apnea (OSA) occurs when the muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing airflow or stopping it for as long as 30 seconds. The person still attempts to breathe because chest and abdominal movements continue, resulting in snoring or snorting sounds. With narcolepsy, the person feels an overwhelming wave of sleepiness and falls asleep. Insomnia is characterized by chronic difficulty falling asleep. Sleep deprivation is a condition caused by dyssomnia. OSA is the only one of these conditions that results in blockage of the airway and impacts the ability to breathe.
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19. The nurse is caring for a postpartum patient. The patient's labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. What is the most appropriate nursing diagnosis? a. Impaired parenting b. Insomnia c. Ineffective coping d. Sleep deprivation
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ANS: D This patient has been deprived of sleep by staying awake during a 28-hour labor. Disorientation is one potential sign of sleep deprivation. In this scenario, we have a clear cause for the patient's lack of sleep, and it is a one-time episode. Insomnia, on the other hand, is a chronic disorder whereby patients have difficulty falling asleep, awaken frequently, or sleep only for a short time. This scenario does not indicate that this has been a chronic problem for this patient. Although ineffective coping can manifest as a sleep disturbance, we have clear evidence that it was labor that deprived this patient of sleep, not an inability to cope. It could be difficult to care for an infant when sleep deprived; however, this scenario gives no evidence that this mother displays impaired parenting and is not caring adequately for her child or lacks the skills to do so.
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20. The patient presents to the clinic with reports of irritability, being sleepy during the day, not being able to fall asleep, and being tired. Select the most appropriate nursing diagnosis. a. Anxiety b. Fatigue c. Sleep deprivation d. Insomnia
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ANS: D Insomnia is experienced when the patient has difficulty falling asleep, frequent awakenings from sleep, and/or short sleep or nonrestorative sleep. It is the most common sleep-related complaint and includes symptoms such as irritability, excessive daytime sleepiness, not being able to fall asleep, and fatigue. Anxiety is a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. Fatigue is an overwhelming sustained sense of exhaustion with decreased capacity for physical and mental work at a usual level. Sleep deprivation is a condition caused by dyssomnia and includes symptoms caused by illness, emotional distress, or medications.
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21. The nurse is preparing an older patient's evening medications. Which of the following does the nurse recognize as relatively safe for difficulty sleeping? a. Benadryl (diphenhydramine) b. Melatonin c. Valerian d. Lorazepam
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ANS: D One group of medications that are relatively safe are the benzodiazepines such as lorazepam. These medications cause relaxation and antianxiety and hypnotic effects. Caution older adults about using over-the-counter antihistamines because their long duration of action can cause confusion, constipation, and urinary retention. Use of nonprescription sleeping aids is not advisable. Patients need to learn the risks associated with these drugs and should be aware that the U.S. Food and Drug Administration does not regulate herbal products.
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22. The nurse is caring for a patient on the medical-surgical unit who is experiencing an exacerbation of asthma. Which of the following interventions would be most appropriate to help the patient sleep? a. Bed placed in semi-Fowler's position b. Increased BNC oxygen to 5 L a minute c. A snack provided before bedtime d. Encouraging the patient to read
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ANS: A For patients with a physical illness, the nurse helps control symptoms that disrupt sleep. Placing the patient in an upright position eases the work of breathing. Increasing the oxygen provided would require a reason to do so, and a physician's order is required. Providing a snack and encouraging the patient to read may be good interventions for patients, but the most appropriate would be raising the head of the bed.
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23. A young mother has been hospitalized for an irregular heartbeat (arrhythmia). The night nurse comes in to see the patient awake. What would be the most appropriate nursing intervention? a. Inform the patient that it is late and time to go to sleep. b. Ask the patient if she would like medication to help her sleep. c. Recommend the great movie that is on television tonight. d. Take time to sit and talk with the patient about her inability to sleep.
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ANS: D Assessment is the first step of the nursing process; therefore assessment needs to be done first and involves ascertaining the cause of the patient's inability to sleep. Patients who are admitted to the hospital for uncertain diagnoses can be stressed and worried about the testing and outcomes. In addition, a young mother can be worried about the care of the children and those caring for the children. This uncertainty and change in routine can cause difficulty in resting or falling asleep. Take the time to talk with the patient to determine the cause of the inability to sleep. A distraction such as a television may or may not work for the patient. After assessment is completed, a sedative may or may not be in order. Telling the patient that it is late and time to go to sleep is not a therapeutic response for an adult who is under stress.
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24. The nurse is evaluating outcomes for the patient with the nursing diagnosis of Insomnia. During this process, the nurse recognizes that a. The patient is the best evaluator of sleep. b. Interventions will need to be adjusted. c. Medical conditions will not influence outcomes. d. Observations of the patient provide needed data.
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ANS: A The patient is the source for evaluating outcomes. The patient is the only one who knows whether sleep problems have improved and what has been successful. Interventions may or may not need to be adjusted. Observations do provide needed data, but in the case of insomnia, the patient is the source for evaluating the restfulness of sleep. Sometimes, the nurse has to work with the patient to redefine sleep expectations associated with medical conditions.
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25. A patient has received a nursing diagnosis of sleep deprivation. Which of the following statements by the patient would indicate that outcomes are being met? a. "I wake up only once a night to go the bathroom." b. "I feel rested when I wake up in the morning." c. "I go to sleep within 30 minutes of lying down." d. "I only take a 20-minute nap during the day."
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ANS: B Being able to sleep and feeling rested would indicate that outcomes are being met for sleep deprivation. Limiting a nap to 20 minutes is an intervention to promote sleep. Going to sleep within 30 minutes indicates that the patient may not be experiencing insomnia. Waking up during the night may indicate insomnia, and decreasing fluids in the evening is an intervention to help prevent this situation.
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26. The older patient is visiting the clinic after a fall during the night. Which of the following data points obtained most likely would contribute to this fall? a. The patient has been taking glucosamine. b. The patient has been taking a fish oil. c. The patient has been taking Benadryl (diphenhydramine). d. The patient has been taking vitamin C.
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ANS: C When older adults are using Benadryl (diphenhydramine), an over-the-counter medication for sleep, caution them that they may experience dizziness, drowsiness, confusion, constipation, and urinary retention because of the long duration of action of the medication. This can contribute to a fall in an older adult. Fish oil given for the treatment of cholesterol, although an issue after a fall with potential bleeding, is not a cause for the fall, nor is glucosamine, which is used in the treatment of joint issues. Neither of these substances are utilized for sleep. Vitamin C is used to support the immune system; it is not used for sleep and does not cause falls.
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1. The nurse is caring for a patient who has not been able to sleep well while in the hospital. The nurse recognizes that lack of sleep can manifest in which of the following signs and symptoms? (Select all that apply.) a. Changes in physiological function such as temperature b. Decreased appetite and weight loss c. Anxiety, irritability, and restlessness d. Impaired judgment e. Nausea, vomiting, and diarrhea f. Shortness of breath and chest pain
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ANS: A, B, C, D The biological rhythm of sleep frequently becomes synchronized with other body functions. Changes in body temperature correlate with sleep pattern. When the sleep-wake cycle becomes disrupted, changes in physiological function such as temperature can occur. Patients can experience decreased appetite, loss of weight, anxiety, restlessness, irritability, and impaired judgment. Gastrointestinal and respiratory/cardiovascular symptoms such as shortness of breath and chest pain are not symptoms of a disrupted sleep cycle.
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2. The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. What points should the nurse include in her teaching? (Select all that apply.) a. NREM sleep contributes to body tissue restoration. b. During NREM sleep, biological functions increase. c. Restful sleep preserves cardiac function. d. Sleep contributes to cognitive restoration. e. REM sleep decreases cortical activity. f. REM sleep assists with memory storage and learning
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ANS: A, C, D, E Sleep contributes to physiological and psychological restoration. NREM sleep contributes to body tissue restoration. It allows the body to rest and conserve energy. This is beneficial for the cardiac system by allowing the heart to beat fewer times each minute. During stage 4, the body releases growth hormone for renewal and repair of specialized cells such as the brain. REM sleep is necessary for brain tissue restoration and cognitive restoration and is associated with a change in cerebral blood flow and increased cortical activity. Sleep assists with memory storage and learning
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3. The patient and the nurse discuss the need for sleep. After the discussion, the patient is able to state factors that hinder sleep. Which statements indicate that the patient has a good understanding of sleep? (Select all that apply.) a. "Drinking coffee at 7 PM could interrupt my sleep." b. "Worry about work can disrupt my sleep." c. "Exercising 2 hours before bedtime can decrease relaxation." d. "Changing the time of day that I eat dinner can disrupt sleep." e. "Taking an antacid can decrease sleep." f. "Staying up late for a party can interrupt sleep patterns."
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ANS: A, B, C, F Caffeine, alcohol, and nicotine consumed late in the evening produce insomnia. Worry over personal problems or situations frequently disrupts sleep. Alterations in routines, including changing mealtimes and staying up late at night for social activities, can disrupt sleep. Exercising 2 hours before bedtime actually increases a sense of fatigue and promotes relaxation. Taking an antacid does not decrease sleep
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4. A community health nurse is providing an educational session at the senior center on how to promote sleep. Which practices should the nurse recommend? (Select all that apply.) a. Take a nap in the afternoon. b. Sleep where you sleep best. c. Use sedatives as a last resort. d. Decrease fluids 2 to 4 hours before sleep. e. Watch television right before sleep. f. Get up if unable to fall asleep in 15 to 30 minutes.
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ANS: B, C, D, F The nurse should instruct the patient to sleep where she sleeps best, to use sedatives as a last resort, to decrease fluid intake to cut down on bathroom trips, and, if unable to sleep in 15 to 30 minutes, to get up out of bed. Naps should be eliminated if not part of the individual's routine schedule, and if naps are taken, they should be limited to 20 minutes or less a day. Television can stimulate and disrupt sleep patterns
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To validate the suspicion that a married male client has sleep apnea the nurse first: 1) asks the client if he experiences apnea in the middle of the night 2) Questions the spouse if she is awakened by her husband's snoring 3) Places the client on a continuous positive airway pressure (CPAP) device 4) Schedules the client for a sleep test
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2) Questions the spouse if she is awakened by her husband's snoring
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When analgesics are ordered for a client with obstructive sleep apnea (OSA) following surgery, the nurse is most concerned about: 1) Nonsteroidal antiinflammatory drugs (NSAIDs) 2) Opioids 3) Anticonvulsants 4) Antidepressants 5) Adjuvants
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2) Opioids
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The nurse finds a client sleepwalking down the unit hallway. An appropriate intervention the nurse implements is: 1) Asking the client what he or she is doing and call for help 2) Quietly approaching the client and then loudly calling his or her name 3) Lightly tapping the client on the shoulder and leading him or her back to bed 4) Blocking the hallway with chairs and seating the client
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3) Lightly tapping the client on the shoulder and leading him or her back to bed
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Which of the following medications are the safest to administer to adults needing assistance in falling asleep? 1) Sedatives 2) Hypnotics 3) Benzodiazepines 4) Anti-anxiety agents
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3)Benzodiazepines
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To assist an adult client to sleep better the nurse recommends which of the following? (Select all that apply.) 1)Drinking a glass of wine just before retiring to bed 2)Eating a large meal 1 hour before bedtime 3)Consuming a small glass of warm milk at bedtime 4)Performing mild exercises 30 minutes before going to bed
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3)Consuming a small glass of warm milk at bedtime
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The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply): 1)Extended time to fall asleep 2)Falling asleep at inappropriate times 3)Difficulty staying asleep 4)Feeling tired after a night's sleep
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1, 3, 4
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When assessing a client for obstructive sleep apnea (OSA), the nurse understands the most common symptom is: 1)Headache 2)Early awakening 3)Impaired reasoning 4)Excessive daytime sleepiness
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4) Excessive daytime sleepiness
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A client taking a beta adrenergic blockers for hypertension can experience interference with sleep patterns such as: 1)Nocturia 2)Increased daytime sleepiness 3)Increased awakening from sleep 4)Increased difficulty falling asleep
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2) Increased daytime sleepiness Beta Blockers can cause nightmares, insomnia, and awakenings from sleep.
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Narcolepsy can be best explained as: 1)A sudden muscle weakness during exercise 2)Stopping breathing for short intervals during sleep 3)Frequent awakenings during the night 4)An overwhelming wave of sleepiness and falling asleep
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4) An overwhelming wave of sleepiness and falling asleep
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A nursing measure to promote sleep in school-age children is to: 1)Make sure the room is dark and quiet 2)Encourage evening exercise 3)Encourage television watching 4)Encourage quiet activities prior to bed time.
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4) Encourage quiet activities prior to bed time.
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A female client verbalizes that she has been having trouble sleeping and feels wide awake as soon as getting into bed. The nurse recognizes that there are many interventions the promote sleep. Check all that apply. 1)Eat a heavy snack before bedtime 2)Read in bed before shutting out the light 3)Leave the bedroom if you are unable to sleep 4)Drink a cup of warm tea with milk at bedtime 5)Exercise in the afternoon rather than the evening 6)Count backwards from 100 to 0 when your mind is racing.
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3, 5, 6
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A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder. Select all that apply: 1) Chronic stress 2) Severe anxiety 3) Generalized pain 4) Excessive caffeine 5) Chronic depression 6) Environmental noise
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1, 4, 6
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Select all that apply to the use of barbiturates in treating insomnia: 1)Barbiturates deprive people of NREM sleep 2)Barbiturates deprive people of REM sleep 3)When the barbiturates are discontinued, the NREM sleep increases. 4)When the barbiturates are discontinued, the REM sleep increases. 5)Nightmares are often an adverse effect when discontinuing barbiturates.
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2, 4, 5
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Select all that apply that is appropriate when there is a benzodiazepine overdose: 1)Administration of syrup of ipecac 2)Gastric lavage 3)Activated charcoal and a saline cathartic 4)Hemodialysis 5)Administration of Flumazenil
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2, 3, 5
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Older adults who take long-acting sedatives or hypnotics are likely to experience: 1)Hallucinations 2)Ataxia 3)Alertness 4)Dyspnea
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2)Ataxia
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Which nursing diagnosis is appropriate for a patient who has received a sedative-hypnotic agent? 1) Alteration in tissue 2) perfusion 3) Fluid volume excess 4) Risk for injury 5) Risk for infection
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4) Risk for injury
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During patient teaching, the nurse explains the difference between a sedative and hypnotic by stating: 1)"Sedatives are much stronger than hypnotic drugs and should only be used for short periods of time." 2)"Sedative drugs induce sleep, whereas hypnotic drugs induce a state of hypnosis." 3)"Most drugs produce sedation at low doses and sleep (the hypnotic effect) at higher doses." 4)"There really is no difference; the terms are used interchangeably."
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3) "Most drugs produce sedation at low doses and sleep (the hypnotic effect) at higher doses."
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Which of the following is an important nursing action for the administration of a benzodiazepine as a sedative-hypnotic agent? 1)Use IM dosage forms for longer duration 2)Administer safely with other CNS depressants for insomnia 3)Monitor geriatric patients for the common occurrence of paradoxical reactions. 4)Evaluate for physical dependence that occurs within 48 hours of beginning the drug.
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3)Monitor geriatric patients for the common occurrence of paradoxical reactions.
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Which of the following is an appropriate nursing intervention for patients who are receiving CNS depressants? 1)Prevent any activity within the hospital setting while on oral muscle relaxants 2)Make sure that the patient knows that sedation should be minimal with these agents. 3)Cardiovascular stimulation, a common side effect, would lead to hypertension 4)Make sure the patient's call light is close by in case of the need for assistance with activities.
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4) Make sure the patient's call light is close by in case of the need for assistance with activities.
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Which of the following conditions characterizes rapid eye movement (REM) sleep? 1)Disorientation and disorganized thinking 2)Jerky limb movements and position changes 3)Pulse rate slowed by 5 to 10 beats/minute 4)Highly active brain and physiological activity levels.
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4) Highly active brain and physiological activity levels.
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Which of the following sleep disorders is the most prevalent? 1)Hypersomnia 2)Insomnia 3)Parasomnia 4)Sleep-awake schedule disturbance.
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2) Insomnia
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Which of the following substances is a natural hormone produced by the pineal gland that induces sleep? 1)Amphetamine 2)Melatonin 3)Methylphenidate 4)Pemoline
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2)Melatonin
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The nurse in the hospital has a prescription to administer medication at 0400 to Mrs. Giovanni. Mrs. Giovanni is asleep when the nurse enters the room. She is difficult to arouse and confused. Identify the stage of sleep Mrs. Giovanni was likely in when the nurse awakened her. 1) Stage II 2) Stage III 3) Stage IV 4) REM
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Answer: 3) Stage IV Rationale: Stage IV is the deepest sleep and the most restorative. In this stage, the delta waves are highest in amplitude, slowest in frequency, and highly synchronized. The body, mind, and muscles are very relaxed. It is difficult to awaken someone in stage IV sleep, and if awakened, the person may appear confused and react slowly.
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The duration of sleep is regulated by the: 1) electrical impulses transmitted to the cerebellum. 2) person's innate biorhythms. 3) amount of sleep a person usually requires. 4) reticular activating system.
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Answer: 4) reticular activating system. Rationale: In the morning, with an increase in environmental light, the hypothalamus is signaled to induce gradual arousal from sleep. The reticular formation is then activated by the stimuli from the cerebral cortex. The reticular formation is responsible for maintaining wakefulness. Together, the reticular formation and cortical neurons are called the reticular activating system (RAS). The RAS regulates the duration of sleep.
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Depression, hyperthyroidism, hypothyroidism, pain, and sleep apnea are examples of: 1) disorders that are provoked by sleep. 2) conditions known as parasomnias. 3) conditions that cause secondary sleep disorders. 4) disorders associated with narcolepsy.
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Answer: 3) conditions that cause secondary sleep disorders. Rationale: Secondary sleep disorders occur when a disease causes alterations in sleep stages or in quantity of sleep. Depressed people may spend more time in bed; however, in general, they have difficulty falling asleep, experience less slow-wave (deep) sleep, spend less time in REM sleep, awaken early, and have less total sleep time. An increase in thyroid secretion causes an increase in stage III and IV sleep. Hypothyroidism causes a decrease in those stages. Hyperthyroidism creates increased metabolic rate, making it difficult to fall asleep. Acute pain and chronic pain interfere with sleep. They inhibit sleep, increase arousals during sleep, and cause longer awake intervals during the night. During periods of sleep apnea, O2 level in the blood drops, and the CO2 level rises, causing the person to wake up frequently.
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What is the hormone that promotes sleep? 1) Melatonin 2) L-tryptophan 3) Progesterone 4) Oxytocin
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Answer: 1) Melatonin Rationale: The levels of melatonin, which is the natural hormone that promotes sleep, decline in the latter decades of life. It is produced at night by the pineal gland in the brain.
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How would the nurse be able to identify the person with narcolepsy from one with seizures? 1) Episodes are short in duration. 2) Episodes come on suddenly. 3) The patient can be aroused from the episode. 4) The patient loses voluntary control of his muscles.
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Answer: 3) The patient can be aroused from the episode. Rationale: The patient with narcolepsy can be aroused from the sleep episode. A person with seizure activity is unresponsive to stimulus and does not resolve in relationship to arousing. Narcolepsy and seizures are triggered suddenly. Both involve involuntary control of motor function with paralysis and cataplexy. Typical seizures last less than 8 minutes. Most narcoleptic episodes are also brief with microactivity lasting only a few minutes. Infrequently, the uncontrollable urge to sleep goes on for up to an hour.
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Question: A nurse assesses a patient's body temperature in the late afternoon as 37.2°C (99°F). What would be the nurse's best action related to this slight elevation in temperature? a. Assess the patient for infection. b. Record the temperature as a normal finding. c. Call the physician for an order for antipyretics. d. Decrease the room temperature.
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Answer: b. A slight increase in body temperature in the late afternoon is the result of a normal circadian rhythm and does not need to be reported unless it becomes higher. This slight variation from normal does not necessarily mean an infection is present. A warm environment might cause an elevation in body temperature, but the most likely cause is normal circadian rhythm.
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Question: A nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep? a. Stage I NREM sleep b. Stage II NREM sleep c. Stage IV NREM sleep d. REM sleep
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Answer: a. Involuntary muscle jerking occurs in stage I NREM sleep. In the other stages, the muscles proceed from a relaxed state to large muscle immobility.
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Question: A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. a. He is aware of his surroundings at this point. b. He is in delta sleep at this time. c. It would be most difficult to awaken him at this time. d. This is most likely an NREM stage. e. This stage constitutes around 20% to 25% of total sleep. f. The muscles are relaxed in this stage.
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Answer: c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.
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Question: A nurse working the night shift at a hospital observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By the age of 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d. Many adolescents do not get enough sleep. e. Total sleep decreases in adults with a decrease in stage IV sleep. f. Sleep is less sound in older adults and stage IV sleep may be absent.
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Answer: d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.
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Question: A nurse is discussing with an older female patient the factors that affect sleep. What fact does the nurse teach her? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Aging decreases the amount of REM sleep a person experiences. d. Exercising decreases REM and NREM sleep.
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Answer: c. The nurse would teach the patient that the amount of REM sleep decreases with age. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity increases both REM and NREM sleep.
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Question: A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. a. A patient who has uncontrolled hypothyroidism b. A patient with coronary artery disease c. A patient who has gastroesophageal reflux (GERD) d. A patient who is HIV positive e. A patient who is taking corticosteroids for arthritis f. A patient with a urinary tract infection
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Answer: a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has gastroesophageal reflux (GERD) may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.
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Question: A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. a. A patient who is taking iron supplements for anemia b. A patient with Parkinson disease who is taking dopamine c. An elderly patient taking diuretics for congestive heart failure d. A patient who is taking antibiotics for an ear infection e. A patient who is prescribed antidepressants f. A patient who is taking low-dose aspirin prophylactically
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Answer: b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.
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Question: A nurse working the night shift in a pediatric unit observes a 10-year-old male patient walking the hallway in a sleep state. The child is unaware of his environment and doesn't recall the incident in the morning. Which sleep disorder would the nurse expect? a. Bruxism b. Cataplexy c. Restless leg syndrome d. Somnambulism
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Answer: d. Somnambulism (sleepwalking) may range from sitting up in bed to walking around the room or the house to walking outside the house. The sleepwalker is unaware of the environment. Bruxism is grinding of one's teeth and frequently is an indicator of stress. Cataplexy is a sudden loss of motor tone that may cause the person to fall asleep; it is usually experienced during a period of strong emotion. People with restless leg syndrome (RLS) cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs.
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Question: A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? a. REM behavior disorder b. Narcolepsy c. Enuresis d. Sleep apnea
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Answer: b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. REM Behavior Disorder (RBD) is characterized by "acting out" dreams while asleep. Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.
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Question: A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. a. Daily mental activities b. Daily physical activities c. Morning and evening body temperature d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings
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Answer: a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.
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Question: To promote sleep in a patient, a nurse suggests what intervention? a. Follow the usual bedtime routine if possible. b. Drink two or three glasses of water at bedtime. c. Have a large snack at bedtime. d. Take a sedative-hypnotic every night at bedtime.
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Answer: a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.
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Question: A nurse formulates the following diagnosis for an elderly patient who is having trouble getting to sleep at night: Disturbed Sleep Pattern: Initiation of Sleep. Which of the following nursing interventions would the nurse perform related to this diagnosis? Select all that apply. a. Arrange for assessment for depression and treatment. b. Discourage napping during the day. c. Decrease fluids during the evening. d. Administer diuretics in the morning. e. Encourage patient to engage in some type of physical activity. f. Assess medication for side effects of sleep pattern disturbances.
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Answer: a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.
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Question: A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. Which diagnosis would be most appropriate for this patient? a. Ineffective Coping: Multiple Stressors of New Job b. Sleep Deprivation: Difficulty Falling Asleep c. Disturbed Sleep Pattern: Altered Sleep-Wake Pattern d. Risk for Injury: Activity Intolerance/Sleep Deprivation
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Answer: c. When assessment data point to a sleep problem that is amenable to nursing therapy, it receives the label Disturbed Sleep Pattern if the problem is time limited (such as changing shifts) or Sleep Deprivation if the problem is prolonged. The labels Ineffective Coping and Risk for Injury have not yet been determined.
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Question: A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? a. Keep the room light dimmed during the day. b. Keep the room cool. c .Keep the door of the room open. d. Offer a sleep aid medication to patients on a regular basis.
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Answer: b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.
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Question: A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in elderly patients. Which action is recommended for these patients? a. Increase physical activities during the day. b. Encourage short periods of napping during the day. c. Increase fluids during the evening. d. Dispense diuretics during the afternoon hours.
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Answer: a. In order to promote sleep in the elderly patient, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.
