Question 1

The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient?

Accepted Answer

Older adults and other individuals who experience depressive mood problems experience delays in falling asleep, earlier appearance of REM sleep, frequent awakening, feelings of sleeping poorly, and daytime sleepiness. A person who is moderately fatigued usually achieves restful sleep, especially if the fatigue is the result of enjoyable work or exercise. Hypertension often causes early-morning awakening and fatigue. Alcohol speeds the onset of sleep. Hypothyroidism decreases stage 4 sleep.

Question 2

The patient has just been diagnosed with narcolepsy. The nurse teaches the patient about management of the condition. Which information from the patient will cause the nurse to intervene?

Accepted Answer

The nurse will intervene about sitting in a hot, stuffy room as this will make the narcolepsy worse so this needs to be corrected. Patients with narcolepsy need to avoid factors that increase drowsiness (e.g., 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.

Question 3

The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate?

Accepted Answer

Discontinuing the soda and chocolate nightly snack will be most beneficial for this patient since it has two factors that will cause difficulty falling asleep. Coffee, tea, colas, and chocolate act as stimulants, causing a person to stay awake or to awaken throughout the night. 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.

Question 4

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's experiencing sleep deprivation. Which action will be best for the nurse to take?

Accepted Answer

The most effective treatment for sleep deprivation is elimination or correction of factors that disrupt the sleep pattern. Obtaining a private room in the medical-surgical 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.

Question 5

The patient presents to the clinic with reports of irritability, being sleepy during the day, chronically not being able to fall asleep, and being tired. Which nursing diagnosis will the nurse document in the plan of care?

Accepted Answer

Insomnia is experienced when the patient has chronic 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.

Question 6

The nurse is caring for a patient who is having trouble sleeping. Which action will the nurse take?

Accepted Answer

Relaxation exercises such as slow, deep breathing for 1 or 2 minutes relieve tension and prepare the body for rest. Instruct patients to wear loose-fitting nightwear. Walking and drinking a favorite beverage would not necessarily encourage sleep.

Question 7

A single parent is discussing the sleep needs of a preschooler with the nurse. Which information will the nurse share with the parent?

Accepted Answer

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 awaken during the night. On average, a preschooler needs about 12 hours of sleep.

Question 8

Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep?

Accepted Answer

During NREM sleep, biological functions slow. During sleep, the heart rate decreases to 60 beats/min or less. The patient experiences decreased respirations, blood pressure, and muscle tone. Heart rates above 60 are too high and respirations of 22 are too high to indicate comfortable NREM sleep.

Question 9

The nurse is completing a sleep assessment on a patient. Which tool will the nurse use to complete the assessment?

Accepted Answer

The visual analog scale is utilized for assessing sleep quality. Cataplexy, or sudden muscle weakness during intense emotions such as anger, sadness, or laughter, occurs at any time during the day; there is no cataplexy scale for sleep assessment. A polysomnogram involves the use of EEG, EMG, and EOG to monitor stages of sleep and wakefulness during nighttime sleep; this is used in a sleep laboratory study. Researchers believe that the ascending reticular activating system (RAS) located in the upper brainstem contains special cells that maintain alertness and wakefulness; however, there is no assessment tool called the RAS scale.

Question 10

The nurse is discussing lack of sleep with a middle-aged adult. Which area should the nurse most likely assess to determine a possible cause of the lack of sleep?

Accepted Answer

During middle adulthood, the total time spent sleeping at night begins to decline. Anxiety, depression, and certain physical illnesses 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.

Question 11

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 action should the nurse take next?

Accepted Answer

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. The nurse will address the adolescent, not the parents. Addressing alcohol abuse problems is not the next step but may be required later. While staying up late may be a normal occurrence for this adolescent, action is required.

Question 12

The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which statement by the nurses will best indicate that the teaching is effective?

Accepted Answer

Sleep involves a sequence of physiological states maintained by the central nervous system. It is associated with changes in the peripheral nervous, endocrine, cardiovascular, respiratory, and muscular systems. A disease process associated with the cranial nerves, urinary pathway, or spinal reflexes may influence a person's ability to sleep, but the best ans is the central nervous system.

Question 13

A patient has obstructive sleep apnea. Which assessment is the $\bold{priority}$?

Accepted Answer

In obstructive sleep apnea, the upper airway becomes partially or completely blocked, diminishing nasal airflow or 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 takes priority over gastrointestinal, circulatory, and neurologic functioning.

Question 14

The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching?

Accepted Answer

The patient indicates an understanding when asking the mother to come after the first week. The neonate up to the age of 3 months averages about 16 hours of sleep a day, sleeping almost constantly during the first week. The baby will sleep rather than play. The baby will not be on a sleeping schedule the first week home. The mother will be able to nap since the baby sleeps 16 hours a day.

Question 15

The nurse is caring for a postpartum patient. The patient's labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. Which nursing diagnosis will the nurse document in the patient's care plan?

Accepted Answer

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, there is 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, clear evidence shows 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.

Question 16

The nurse is caring for a young-adult patient on the medical-surgical unit. When doing midnight checks, the nurse observes the patient awake, putting a puzzle together. Which information will the nurse consider to best explain this finding?

Accepted Answer

This patient is awake and alert enough to do a puzzle. The individual's sleep-wake preference is probably late evening. All persons have biological clocks that synchronize their sleep-wake cycle. This explains why some individuals fall asleep in the early evening, whereas others go to bed at midnight or early morning. 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.

Question 17

The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM?

Accepted Answer

The patient is difficult to arouse, vital signs are significantly lower, and this stage lasts about 15 to 30 minutes. Stage 4 NREM is the deepest stage of sleep. Lighter sleep is seen in stages 1 and 2, where the patient awakens easily. REM sleep is characterized by rapid eye movement.

Question 18

The nurse is beginning a sleep assessment on a patient. Which question will be most appropriate for the nurse to ask initially?

Accepted Answer

Sleep is a subjective experience. Only the patient is able to report whether or not it is sufficient and restful. 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.

Question 19

A nurse is teaching the staff about the sleep cycle. Which sequence will the nurse include in the teaching session?

Accepted Answer

The cyclical pattern usually progresses from stage 1 through stage 4 of NREM, followed by a reversal from stages 4 to 3 to 2, ending with a period of REM sleep. The others are incorrect sequences.

Question 20

The nurse adds a nursing diagnosis of ineffective breathing pattern to a patient's care plan. Which sleep condition caused the nurse to assign this nursing diagnosis?

Accepted Answer

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.

Quiz 43: Sleep

The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient?

The patient has just been diagnosed with narcolepsy. The nurse teaches the patient about management of the condition. Which information from the patient will cause the nurse to intervene?

The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate?

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's experiencing sleep deprivation. Which action will be best for the nurse to take?

The patient presents to the clinic with reports of irritability, being sleepy during the day, chronically not being able to fall asleep, and being tired. Which nursing diagnosis will the nurse document in the plan of care?

The nurse is caring for a patient who is having trouble sleeping. Which action will the nurse take?

A single parent is discussing the sleep needs of a preschooler with the nurse. Which information will the nurse share with the parent?

Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep?

The nurse is completing a sleep assessment on a patient. Which tool will the nurse use to complete the assessment?

The nurse is discussing lack of sleep with a middle-aged adult. Which area should the nurse most likely assess to determine a possible cause of the lack of sleep?

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 action should the nurse take next?

The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which statement by the nurses will best indicate that the teaching is effective?

A patient has obstructive sleep apnea. Which assessment is the $\bold{priority}$ ?

The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching?

The nurse is caring for a postpartum patient. The patient's labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. Which nursing diagnosis will the nurse document in the patient's care plan?

The nurse is caring for a young-adult patient on the medical-surgical unit. When doing midnight checks, the nurse observes the patient awake, putting a puzzle together. Which information will the nurse consider to best explain this finding?

The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM?

The nurse is beginning a sleep assessment on a patient. Which question will be most appropriate for the nurse to ask initially?

A nurse is teaching the staff about the sleep cycle. Which sequence will the nurse include in the teaching session?

The nurse adds a nursing diagnosis of ineffective breathing pattern to a patient's care plan. Which sleep condition caused the nurse to assign this nursing diagnosis?

Quiz 43: Sleep

The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient?

The patient has just been diagnosed with narcolepsy. The nurse teaches the patient about management of the condition. Which information from the patient will cause the nurse to intervene?

The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate?

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's experiencing sleep deprivation. Which action will be best for the nurse to take?

The patient presents to the clinic with reports of irritability, being sleepy during the day, chronically not being able to fall asleep, and being tired. Which nursing diagnosis will the nurse document in the plan of care?

The nurse is caring for a patient who is having trouble sleeping. Which action will the nurse take?

A single parent is discussing the sleep needs of a preschooler with the nurse. Which information will the nurse share with the parent?

Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep?

The nurse is completing a sleep assessment on a patient. Which tool will the nurse use to complete the assessment?

The nurse is discussing lack of sleep with a middle-aged adult. Which area should the nurse most likely assess to determine a possible cause of the lack of sleep?

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 action should the nurse take next?

The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which statement by the nurses will best indicate that the teaching is effective?

A patient has obstructive sleep apnea. Which assessment is the priority\bold{priority}priority ?

The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching?

The nurse is caring for a postpartum patient. The patient's labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. Which nursing diagnosis will the nurse document in the patient's care plan?

The nurse is caring for a young-adult patient on the medical-surgical unit. When doing midnight checks, the nurse observes the patient awake, putting a puzzle together. Which information will the nurse consider to best explain this finding?

The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM?

The nurse is beginning a sleep assessment on a patient. Which question will be most appropriate for the nurse to ask initially?

A nurse is teaching the staff about the sleep cycle. Which sequence will the nurse include in the teaching session?

The nurse adds a nursing diagnosis of ineffective breathing pattern to a patient's care plan. Which sleep condition caused the nurse to assign this nursing diagnosis?

A patient has obstructive sleep apnea. Which assessment is the $\bold{priority}$ ?