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MSC: Client Needs: Health Promotion and Maintenance

9. A person is prescribed lorazepam 2 mg PO bid as needed for anxiety. When the person takes this medication, which change in sleep is anticipated? The patient will a. have fewer dreams. b. have less slow-wave sleep. c. experience extended sleep latency. d. enter sleep through REM sleep.

ANS: B

Lorazepam is a benzodiazepine, which reduces slow-wave sleep. REM sleep would likely increase. Persons with narcolepsy often enter sleep through REM.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 19-7 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity

10. A person is prescribed sertraline 100 mg PO daily. Which change in sleep is likely secondary to this medication? The patient will have a. more dreams. b. excessive sleepiness. c. less slow-wave sleep. d. less REM sleep.

ANS: D

Sertraline (Zoloft) is an SSRI antidepressant medication, which suppresses REM sleep. Dreams would decrease because they occur during REM. Benzodiazepines reduce slow-wave sleep. SSRIs have a side effect of insomnia.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 19-13 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. Summer b. Winter c. Spring d. Fall

11. Which season would be most associated with increased periods of wakefulness in the general population?

ANS: A

Circadian drive is associated with physiology. Light is the main exogenous factor that drives wakefulness. Days are longest in summer.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 19-7, 8 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. The master biological clock responds to darkness with sleep. b. Darkness stimulates histamine release, which promotes sleep. c. Cooler environmental temperatures stimulate retinal messages. d. Stimulation of the sympathetic nervous system promotes sleep.

12. Normally, most people sleep at night. What is the physiological rationale?

ANS: A

The master biological clock in the suprachiasmatic nucleus (SCN) of the hypothalamus regulates sleep as well as other physiological processes. Darkness cues the clock for sleep. Light cues it for wakefulness. Light stimulates retinal messages. Histamine release is associated with wakefulness. Stimulation of the sympathetic nervous system promotes alertness.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 19-7 to 9 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. “For 1 full week, record what you remember about your dream content and related feelings as soon as you wake up. Bring the record to your next appointment.” b. “While off work for 1 week, go to bed at your usual time and wake up without an alarm. Record how many hours you sleep and then average the findings.” c. “For 2 full weeks, record how much time you sleep each night and rate your daytime alertness on a scale of 1 to 10. Calculate your average alertness score.” d. “All adults need 7 or 8 hours of sleep to function properly. Let’s design ways to help you reach that goal.”

13. A nurse counsels a patient on ways to determine the person’s total sleep requirement. Which instruction would produce the most accurate results?

ANS: B

Sleep requirements are most accurately determined by going to bed at the usual time and waking up without an alarm for several nights, ideally on vacation. The average of these findings indicates the estimated requirements. Two distracters relate to dream content and daytime alertness. Some adults are long sleepers or short sleepers with different requirements for sleep from the general population.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 19-8, 9 TOP: Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance a. “It sounds like you are very devoted to your spouse.” b. “I noticed you fell asleep while I was assessing your spouse. I’m concerned about you.” c. “Your spouse is lucky to have you to provide care rather than being placed in a nursing home.” d. “If you keep going like this, your health will be impaired also. Then who will take care of both of you?”

14. A home care nurse assesses a very demanding patient with chronic obstructive pulmonary disease (COPD). Afterward, the nurse talks with the spouse who has provided this patient’s care for 6 years. The spouse says, “I don’t need much sleep anymore. I might need to help him during the night.” Select the nurse’s most therapeutic response.

ANS: B

Sleep deprivation can cause accidents. The correct answer makes an observation, gives important information about safety, and communicates care and compassion for the spouse. The distracters do not invite further dialogue with the spouse.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 19-2 (Health Policy), 3, 4, 24

TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment a. “What have you done to try to improve your sleep?” b. “What would be a good sleep pattern for you?” c. “How much exercise are you getting?” d. “Do you have pain at night?”

15. A patient with rheumatoid arthritis reports, “For the past month I’ve had trouble falling asleep. When I finally get to sleep, I wake up several times during the night.” Which information should the nurse seek initially?

ANS: D

Patients with diseases such as arthritis may have sleep disturbance related to nightly pain. Because the pain is chronic, the patient may fail to realize it is the reason for the inability to sleep. The other options do not follow the patient’s lead or begin problem solving without an adequate baseline.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 19-4 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. Sleep paralysis b. Night terror disorder c. Sleep-related bruxism d. REM Sleep Behavior Disorder

16. A 76-year-old man tells the nurse at the sleep disorder clinic, “I awaken almost nightly in the midst of violent dreams in which I am defending myself against multiple attackers. Then I realize I have been hitting and kicking my wife. She has bruises.” Which health problem is most likely?

ANS: D

The scenario describes REM sleep behavior disorder in which the patient engages in violent and complex behaviors during REM sleep as though acting out his dreams. Older men have a higher incidence of this problem. Sleep paralysis refers to the sudden inability to perform voluntary movement at either sleep onset or awakening from sleep. Bruxism refers to grinding teeth during stage 2 sleep. Night terror disorder occurs as arousal in the first third of the night during NREM sleep, accompanied by feelings of panic.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 19-16, 17, 38 (Box 19-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. Sleep deprivation b. Nightmare disorder c. Night terror disorder d. REM sleep behavior disorder

17. A patient reports, “Nearly every night I awaken feeling frightened after a bad dream. The dream usually involves being hunted by people trying to hurt me. It usually happens between 4 and 5 AM.” The nurse assesses this disorder as most consistent with criteria for which problem?

ANS: B

Nightmares are long, frightening dreams from which people awaken in a frightened state. They occur during REM sleep late in the night. Night terror disorder occurs as arousal in the first third of the night during NREM sleep and is accompanied by feelings of panic. REM sleep behavior disorder involves acting out a violent dream during REM sleep. Nightmare disorder may lead to sleep deprivation.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 19-16, 38(Box 19-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. “What stress are you experiencing in your life?” b. “How much sleep do you get in a 24-hour period?” c. “Would it help if you do some exercises just before going to bed?” d. “Have you considered using a hypnotic medication to help you sleep?”

18. A nurse who works night shift says, “I am exhausted most of the time. I sleep through my alarm. Sometimes my brain does not seem to work right. I am worried that I might make a practice error.” Which question should the nursing supervisor ask first?

ANS: B

Total sleep hours should be ascertained before seeking to correct a sleep disorder. In this case, the patient describes sleep deprivation symptoms rather than a sleep disorder. The correct response is the only option that addresses total sleep hours.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 19-3, 4, 38 (Box 19-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. Benzodiazepine b. Tricyclic antidepressant c. Conventional antipsychotic d. Central nervous system (CNS) stimulant

19. A patient reports, “The medicine prescribed to help me get to sleep worked well for about a month, but I don’t have any more of those pills. Now my insomnia is worse than ever. I had nightmares the last 2 nights.” Which type of medication did the health care provider most likely prescribe?

ANS: A

Benzodiazepines, members of the hypnotic’s family of medications, can worsen existing sleep disturbances when they are discontinued. This class of medications produces tolerance. Once the drug is discontinued, the individual may have rebound insomnia and nightmares. CNS stimulants worsen insomnia while they are in use. Tricyclic antidepressants and atypical antipsychotics may help insomnia but would not be used for initial therapy.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 19-36 (Table 19-2) TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity a. “Circadian drives give daytime naps a structure different from nighttime sleep.” b. “The body clock operates on a 24-hour cycle, making nap effectiveness unpredictable.” c. “It is a matter of habit and expectation. We expect to be more refreshed from a night’s sleep.” d. “Sleep restores homeostasis but works more efficiently when aided by melatonin secreted at night.”

20. A patient experiencing primary insomnia asks the nurse, “I take a nap during the day. Doesn’t that make up for a lost night’s sleep?” Select the nurse’s best reply.

ANS: A

Regular sleep cycles occur with nighttime sleep, with progression through two distinct physiological states: four stages of NREM and a period of REM sleep. Naps often contain different amounts of REM sleep, thus changing the physiology of sleep as well as the psychological and behavioral effects of sleep.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 19-7, 8, 38 (Box 19-1) TOP: Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance a. “Tell me about strategies you have tried to increase your total sleep hours.” b. “Lack of sleep acts as a stressor on the body and can cause physical changes.” c. “If you have really tried to sleep more, maybe you should consult your health care provider.” d. “If you function well with 6 hours of sleep, you are a short sleeper. That’s normal for some people.”

21. A patient tells the nurse, “Everyone says we should sleep 8 hours a night. I can only sleep 6 hours, no matter how hard I try. Am I doing harm to my body?” Select the nurse’s best response.

ANS: D

Some individuals require less sleep than others do. Those who need less are called “short sleepers,” compared with “long sleepers,” who require more than 8 hours. The distracters do not provide information the patient is seeking or are untrue.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 19-8, 9

TOP: Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance a. zolpidem b. flurazepam c. risperidone d. methylphenidate

22. A patient says, “I have trouble falling asleep at night and might lie awake until 3 or 4 AM before falling sleep.” Which medication would the nurse expect a health care provider to prescribe for this patient?

ANS: A

Zolpidem is a short-acting hypnotic that will help the patient initiate sleep and awaken without untoward symptoms of drowsiness. Methylphenidate is a CNS stimulant. Flurazepam is a long-acting hypnotic that will produce hangover drowsiness during the next day.

Risperidone is an antipsychotic and not likely to be useful in this scenario. See relationship to audience response question.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 19-36 (Table 19-2)

TOP: Nursing Process: Implementation

MSC: Client Needs: Physiological Integrity a. “What type of birth control do you use?” b. “How much caffeine do you use every day?” c. “How much exercise do you get in a typical day?” d. “Does anyone else in your family have this problem?”

23. A young adult says to the nurse, “I go to sleep without any problem, but I often wake up during the night because it feels like there are rubber bands in my legs.” Which assessment question should the nurse ask to assess for restless legs syndrome (RLS)?

ANS: D

RLS is a sensory and movement disorder characterized by an unpleasant, uncomfortable sensation in the legs accompanied by an urge to move. Symptoms begin or worsen during periods of inactivity, such as sleep. Symptoms can have a significant impact on the individual's ability to fall asleep and stay asleep. There is likely to be a strong genetic component, especially when seen in individuals less than 40 years old.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 19-17, 18, 38 (Box 19-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity

Multiple Response

1. Which neurotransmitters are most responsible for wakefulness? (Select all that apply.)

a. γ-aminobutyric acid (GABA) b. Norepinephrine c. Acetylcholine d. Dopamine e. Galanin

ANS: B, C, D

The neurotransmitters responsible for wakefulness are dopamine, norepinephrine, serotonin, acetylcholine, histamine, glutamate, and hypocretin. GABA and galanin are sleep-promoting neurotransmitters.

PTS: 1 DIF: Cognitive Level: Remember (Knowledge)

REF: Page 19-8 TOP: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance a. Drink juice with breakfast rather than coffee. b. Exercise after awakening rather than before. c. Turn on the television when going to bed. d. Do not read the paper. e. Eat a light breakfast.

2. A night shift worker reports, “I’m having trouble getting to sleep after a night’s work. I have a hearty breakfast with coffee, read the paper, do my exercises, and then go to bed. However, I just lie awake until it is nearly time to get up to be with my family for dinner.” What changes should the nurse suggest? (Select all that apply.)

ANS: A, B, E

Sleep can be disrupted by caffeine, a CNS stimulant, exercise performed just before trying to sleep, and eating a heavy meal before retiring. Reading the newspaper is not likely to be so stimulating that it disrupts the patient’s ability to sleep. Television will be disruptive to sleep.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 19-27, 28, 39 (Box 19-2) TOP: Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

3. A new patient at the sleep disorders clinic tells the nurse, “I have not slept well in a year, so I never feel good. I do not expect things will ever improve or be any different.” Interventions the nurse should consider include (Select all that apply) a. suggesting use of alcohol as a sedative. b. providing instruction in relaxation techniques. c. counseling the patient to address cognitive distortions. d. health teaching regarding factors that influence sleep. e. teaching fatigue-producing activities to become overtired. f. encouraging long daytime naps to compensate for sleep deprivation.

ANS: B, C, D

Interventions that could be helpful include teaching relaxation techniques, such as meditation or progressive relaxation, to relieve the tension that sometimes prevents initiation of sleep. Reviewing factors that influence sleep can assist the patient to diagnose and remove barriers to sleep. Cognitive therapy could be helpful in combating the hopelessness verbalized by the patient. Alcohol consumption actually disrupts sleep. Becoming overtired may be a barrier to nighttime sleep. Naps may help replace lost sleep, but lengthy daytime sleep will prevent the patient from sleeping well at night.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 19-27, 28, 39 (Box 19-2)

TOP: Nursing Process: Planning/Outcomes Identification

MSC: Client Needs: Psychosocial Integrity