Sleep Patterns Case Study

Which statement is the best description of the sleep pattern for a normal adult?
A) Sleep is an unconscious state in which an individual’s reaction to environmental stimuli is decreased.

B) Most of the sleep cycle is made up of rapid eye movement (REM) sleep.

C) An adult has four to six sleep cycles, each with NREM sleep and REM sleep during a normal night’s sleep.

D) A middle-aged adult requires less sleep than the elderly adult.

C) An adult has four to six sleep cycles, each with NREM sleep and REM sleep during a normal night’s sleep.
CORRECT
About every 90 minutes, REM sleep recurs. When a sleeper awakens at any stage of the sleep cycle, the cycle must start again at Stage

A) Sleep is an unconscious state in which an individual’s reaction to environmental stimuli is decreased.
INCORRECT
Sleep is actually a conscious state in which an individual’s perception and reaction to the environment are decreased.
B) Most of the sleep cycle is made up of rapid eye movement (REM) sleep.
INCORRECT
The sleep cycle primarily consists of non-rapid eye movement (NREM) sleep. There are four stages of NREM or slow wave sleep: Stage I, very light sleep, to Stage IV, very deep sleep.
D) A middle-aged adult requires less sleep than the elderly adult.
INCORRECT
Although sleep patterns vary for each developmental age group, middle-aged adults usually require about 7 hours of sleep while the elderly require about 6 hours of sleep. Stage IV sleep is sometimes markedly decreased or absent in the elderly.

The nurse obtains a health history that reveals Mr. Owens is worried about the pressures of his new job. He has been unable to maintain his normal exercise routine and has gained 15 lbs. in the last 6 months. Mr. Owens admits he frequently smokes when he cannot sleep. His wife, who has accompanied him on the visit to the clinic, states his snoring has worsened in both frequency and noise level over the last 3 months. Mr. Owens has even resorted to taking one of his wife’s diazepam (Valium) tablets before bedtime.

The nurse recognizes Mr. Owens’ anxiety should be based on what information?
A) Antianxiety medications have proven to enhance the quality of sleep.

B) Anxiety stimulates the sympathetic nervous system resulting in less sleep.

C) There is no relationship between anxiety and weight gain.

D) Vigorous exercise before bedtime is usually conducive to the quality and quantity of sleep.

B) Anxiety stimulates the sympathetic nervous system resulting in less sleep.
CORRECT
This chemical change causes increasing norepinephrine levels in the blood, lessens Stage IV NREM and REM sleep, and results in more awakenings.

A) Antianxiety medications have proven to enhance the quality of sleep.
INCORRECT
Although many antianxiety medications hasten the onset of sleep, they can interfere with NREM and REM sleep.
C) There is no relationship between anxiety and weight gain.
INCORRECT
Anxiety is a known cause of weight fluctuations, either gain or loss.
D) Vigorous exercise before bedtime is usually conducive to the quality and quantity of sleep.
INCORRECT
While moderate exercise releases endorphins, which is usually conducive to sleep, vigorous exercise can inhibit sleep by reducing the individual’s ability to relax.

Mr. Owens reports that a few years ago he took temazepam (Restoril) for sleep, and it worked for a while.

In which drug classification is temazepam (Restoril) found?
A) Hypnotic.
B) Antianxiety.
C) Muscle Relaxant.
D) Antidepressant.

A) Hypnotic.
CORRECT
Temazepam (Restoril) is classified as a hypnotic medication: it is a benzodiazepine derivative with sedative effects.

B) Antianxiety.
INCORRECT
Temazepam (Restoril) is not classified as an antianxiety medication.
C) Muscle Relaxant.
INCORRECT
Temazepam (Restoril) is not classified as a muscle relaxant.
D) Antidepressant.
INCORRECT
Temazepam (Restoril) is not classified as an antidepressant.

Mr. Owens asks the nurse if he can start taking Restoril again.

4.
How should the nurse respond?
A) “You may resume the temazepam (Restoril) if you still have the prescription.”

B) “You really don’t need a medication like this, do you?”

C) “You should be re-evaluated by a healthcare provider before resuming this medication.”

D) “Absolutely not! This type of drug is very addictive and should be avoided whenever possible.”

C) “You should be re-evaluated by a healthcare provider before resuming this medication.”
CORRECT
The client should always be re-evaluated before resuming any medication. A new prescription needs to be filled if indicated. Continued evaluation is also needed if temazepam (Restoril) is used for more than 2 weeks or in high doses, both of which put the client at risk for tolerance and/or physical dependence.

A) “You may resume the temazepam (Restoril) if you still have the prescription.”
INCORRECT
The client indicated the prescription was a few years old. This is not a safe option.
B) “You really don’t need a medication like this, do you?”
INCORRECT
This response does not answer the client’s question and may be perceived as judgmental.
D) “Absolutely not! This type of drug is very addictive and should be avoided whenever possible.”
INCORRECT
While alternative measures should be explored, this type of drug therapy is often a valid treatment option.

The nurse assesses Mr. Owens for which other symptom that is commonly associated with sleep deprivation?
A) Nocturia.
B) Tachycardia.
C) Euphoria.
D) Paresthesia.
A) Nocturia.
CORRECT
Urination during the night disrupts the sleep cycle and contributes to sleep deprivation.

B) Tachycardia.
INCORRECT
An increase in heart rate and is not typically associated with sleep deprivation.
C) Euphoria.
INCORRECT
A feeling of well-being or good health is not typically associated with sleep deprivation.
D) Paresthesia.
INCORRECT
A burning or tingling sensation, usually in the hands, arms, legs, or feet is not typically associated with sleep deprivation.

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The nurse formulates a plan of care for Mr. Owens.

Which statement reflects an expected outcome for the nursing diagnosis, “Disturbed sleep pattern related to stress from new job.”?
A) Assist client in identifying ways to relieve stress during the day and before bedtime.

B) Client will report a 50% decrease in night awakenings within one week.

C) Encourage client to establish bedtime rituals and avoid alcohol and caffeine.

D) Assess client’s sleep pattern by reviewing client’s sleep/wake log for one week.

B) Client will report a 50% decrease in night awakenings within one week.
CORRECT
This outcome is directly related to the nursing diagnosis, is specific and measurable, and is realistically timed.

A) Assist client in identifying ways to relieve stress during the day and before bedtime.
INCORRECT
This is an important intervention, but it is not stated as an expected outcome.
C) Encourage client to establish bedtime rituals and avoid alcohol and caffeine.
INCORRECT
These are important interventions, but they are not stated as expected outcomes.
D) Assess client’s sleep pattern by reviewing client’s sleep/wake log for one week.
INCORRECT
Although having the client keep a log is recommended, this is an evaluation method, not an expected outcome.

Which intervention should the nurse add to Mr. Owens’ plan of care?

A) Encourage an increase in carbohydrates and move the evening meal to one hour before bedtime to promote sleep.

B) Instruct the client to keep reading material from work at the bedside to review when he awakens.

C) Suggest the use of a soft, conforming mattress and pillow set for better body alignment.

D) Instruct the client to get out of bed if unable to fall back to sleep within 30 minutes and do a quiet activity until becoming sleepy.

D) Instruct the client to get out of bed if unable to fall back to sleep within 30 minutes and do a quiet activity until becoming sleepy.
CORRECT
Lying in bed awake for more than 30 minutes may increase anxiety and inhibit the onset of sleep. A quiet activity such as reading or muscle relaxation can be helpful.

A) Encourage an increase in carbohydrates and move the evening meal to one hour before bedtime to promote sleep.
INCORRECT
A carbohydrate snack is associated with inducing sleep, but meals should be avoided for 3 to 4 hours before bedtime.
B) Instruct the client to keep reading material from work at the bedside to review when he awakens.
INCORRECT
Activities associated with work may increase the client’s stress and inhibit sleep.
C) Suggest the use of a soft, conforming mattress and pillow set for better body alignment.
INCORRECT
The client has not expressed any physical discomforts related to his bed.

The nurse educates Mr. Owens on the effects that diet, exercise, stress reduction medications, and the environment have on sleep patterns.
What information reflects correct client teaching?

A) Dispelling diet myths such as drinking warm milk before bedtime to induce sleep.

B) Cigarette smoking works as a depressant, and smokers find smoking before bedtime helps them relax.

C) Encourage the client to make up for missed sleep during the day if possible.

D) The presence of unusual stimuli or the absence of familiar stimuli may inhibit sleep.

D) The presence of unusual stimuli or the absence of familiar stimuli may inhibit sleep.
CORRECT
Any change in the environment can inhibit sleep, including a quiet, peaceful environment when the client is accustomed to noise.

A) Dispelling diet myths such as drinking warm milk before bedtime to induce sleep.
INCORRECT
This is not a myth. L-tryptophan, an amino acid, which is thought to affect sleep, is found in milk and other dairy products, as well as beef, turkey, fish, brown rice, and peanuts.
B) Cigarette smoking works as a depressant, and smokers find smoking before bedtime helps them relax.
INCORRECT
Nicotine works as a stimulant on the body and can hinder sleep.
C) Encourage the client to make up for missed sleep during the day if possible.
INCORRECT
Daytime sleeping in clients with disturbed sleep pattern may compound the problem, making it more difficult for them to fall asleep and stay asleep at night.

When teaching the client and his wife about actions to promote rest and sleep, the nurse demonstrates by administering a back massage on Mr. Owens.

Which statement describes correct teaching?
A) Effleurage the entire back using slow movement and light pressure.

B) Petrissage the small muscles of the lower back using slow movement and light pressure.

C) Client grimacing confirms effective kneading pressure is being used.

D) Warmed oil should be used after massage to sustain relaxation.

A) Effleurage the entire back using slow movement and light pressure.
CORRECT
Effleurage is a French term meaning “to touch lightly.” This type of massage typically uses a gentle, sweeping, relaxing stroke that glides over the skin.

B) Petrissage the small muscles of the lower back using slow movement and light pressure.
INCORRECT
Petrissage is a French term meaning “to knead or rub with force.” It is used to break down tightness and tension in large muscles, not small ones.
C) Client grimacing confirms effective kneading pressure is being used.
INCORRECT
Facial grimacing may indicate pain or discomfort and confirm that too much pressure is being used.
D) Warmed oil should be used after massage to sustain relaxation.
INCORRECT
Warmed oil is most effective when applied prior to the massage. The oil decreases friction between the hands and the area being massaged and the warmth itself promotes relaxation.

The Nurse Practitioner conducts a physical exam. While the practitioner agrees that job stress is exacerbating the disturbed sleep pattern, the wife’s report of increased snoring episodes is disturbing. Diagnostic testing is prescribed. A polysomnogram (sleep study) reveals over 200 episodes of sleep apnea during the night. A pulse oximeter is used during the testing, and Mr. Owens’ oxygen saturation level drops at times to 82%. Mr. Owens is diagnosed with obstructive sleep apnea, and he is prescribed a nasal continuous positive airway pressure (CPAP) device at night.

10.
Which statement describes the use of a pulse oximeter?

A) Invasively records arterial blood oxygen saturation, and is used to determine hypoxia.

B) Pulse oximetry measures cardiac output noninvasively.

C) Counts respirations and alarms when below 12.

D) Measures the arterial blood oxygen saturation using a noninvasive finger sensor.

D) Measures the arterial blood oxygen saturation using a noninvasive finger sensor.
CORRECT
Arterial blood oxygen is non-invasively measured, and the percentage of hemoglobin that is saturated with oxygen is reported.

A) Invasively records arterial blood oxygen saturation, and is used to determine hypoxia.
INCORRECT
A pulse oximeter is a noninvasive device.
B) Pulse oximetry measures cardiac output noninvasively.
INCORRECT
Cardiac output is not measured with pulse oximetry.
C) Counts respirations and alarms when below 12.
INCORRECT
Pulse oximetry does not measure respirations.

How should the nurse explain obstructive sleep apnea to Mr. Owens and his wife?

A) There is a lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep.
CORRECT
This describes obstructive sleep apnea. Efforts by the brain and respiratory muscles continue, but airflow is obstructed.

B) There is a dysfunction of mechanisms that regulate the sleep and wake states causing excessive sleepiness during the day.

C) The airway remains open, but the brain fails to send messages to the diaphragm and chest muscles to initiate respirations.

D) It is a syndrome characterized by chronic difficulty falling asleep with frequent awakenings at night.

A) There is a lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep.
CORRECT
This describes obstructive sleep apnea. Efforts by the brain and respiratory muscles continue, but airflow is obstructed.
After providing teaching about use of the CPAP machine, the nurse schedules Mr. Owens for a follow-up visit, and he is instructed to call if questions arise.
Mr. Owens returns to the clinic after using the CPAP machine at home for 3 months. He reports no improvement in his symptoms and appears disheveled and irritable. He describes sleeping only 3 or 4 hours each night and blames it on discomfort caused by the CPAP machine. The nurse records Mr. Owens’ appearance and complaints.

Which information is considered objective data by the nurse?
A) Client states he only sleeps 3 or 4 hours per night.

B) Client yells at his wife when she says he is irritable.

C) Client reports the CPAP apparatus is uncomfortable.

D) Client’s wife states he has been irritable at home.

B) Client yells at his wife when she says he is irritable.
CORRECT
Because this was observed by the nurse, it is objective data.
After further examination and testing by the healthcare provider, Mr. Owens is referred to a surgeon and is scheduled for removal of his tonsils and uvula to treat the obstructive sleep apnea. He is admitted to the hospital and an apnea monitor is prescribed.

The charge nurse should assign Mr. Owens to which room?
A) A semi-private room with another client.

B) A designated isolation room with a double door.

C) A private room near the nursing station and report room.

D) A private room at the end of the hall.

C) A private room near the nursing station and report room.
CORRECT
Due to the increased monitoring necessitated by the client’s sleep apnea, the room should be near the nursing station.
To promote sleep in a hospitalized client, which intervention should the nurse implement?
A) Instruct the night nurse not to perform the prescribed every 4 hour assessments during the night.

B) Withhold client’s pain medication during the day to decrease napping episodes.

C) Ensure that the client’s room is kept completely dark during the night with no outside lighting.

D) Close the door to the client’s room whenever possible to decrease the noise level and light coming into the room.

D) Close the door to the client’s room whenever possible to decrease the noise level and light coming into the room.
CORRECT
Reducing the amount of light and the noise of call lights, hallway traffic, and overhead paging are important nursing interventions to facilitate sleep for a hospitalized client.
Mr. Owens refuses to wear the CPAP mask while hospitalized. The night before his surgical procedure, the pulse oximeter alarms. The nurse enters his room and observes that Mr. Owens is sleeping and his oxygen saturation has decreased to 84%.

Which action should the nurse take?
A) Quietly place an oxygen mask on the client without waking him.

B) Gently shake the client to awaken him.

C) Document the observation as an expected finding.

D) Request the healthcare provider to reevaluate the client’s status.

B) Gently shake the client to awaken him.
CORRECT
Although the nurse wants to promote sleep, the client must be awakened to relieve the obstruction and increase oxygen saturation.
At 3:00 a.m. Mr. Owens awakes and requests a sleeping pill, stating he needs to make sure he gets some sleep the night before surgery. His prescriptions include zolpidem tartrate (Ambien) 5 mg PO at bedtime PRN for sleep. His last respiratory rate while sleeping was 12 with an oxygen saturation level of 89%. His current vital signs are: P 80, B/P 120/70, R 22, T 98.9° F, and oxygen saturation 95%.

Which data should the nurse consider when deciding whether or not to give this medication?
A) The client’s current respiratory rate and oxygen saturation.

B) Mr. Owens’ need to sleep prior to his surgical procedure.

C) The medication is prescribed PRN, and the client has requested it.

D) Respiratory rate and oxygen saturation level while sleeping.

D) Respiratory rate and oxygen saturation level while sleeping.
CORRECT
These data are most indicative of the client’s sleep oxygenation status, which may worsen when taking hypnotic medications.
Mr. Owens’ surgery is completed without complications. After a two hour stay in the post anesthesia unit, he returns to his room. The next day, the nurse notes a pattern in his vital signs. Mr. Owens’ heart rate drops from 80 bpm to 65 bpm while sleeping. His oxygen saturation remains greater than 95% with regular respirations of 16 to 20 per minute.
Which action should the nurse take?

A) Document this expected finding.

B) Page the healthcare provider about this abnormality.

C) Recommend the application of a cardiac monitor.

D) Increase vital sign monitoring from every 8 hours to every 4 hours.

A) Document this expected finding.
CORRECT
A decrease of up to 20 bpm during NREM sleep is considered a normal finding and a part of the body’s circadian rhythm.
In managing Mr. Owens’ postoperative care, which task should the nurse delegate to the unlicensed assistive personnel (UAP)?

A) Complete a focused respiratory assessment every four hours.

B) Obtain pulse oximetry and respiratory rate every 2 hours.

C) Take vital signs and complete body systems assessment every 8 hours.

D) Administer prescribed throat lozenges every 2 hours as needed.

B) Obtain pulse oximetry and respiratory rate every 2 hours.
CORRECT
This task may be delegated. However, the nurse must then evaluate the data after it is obtained by the UAP.
The nurse monitors Mr. Owens’ postoperative lab values. The nurse notes that his white blood cell count (WBC) is 15,000 mm3.

What assessment should the nurse perform first?
A) Observe for excessive drainage.

B) Measure oxygen saturation.

C) Determine skin turgor.

D) Measure the tympanic temperature.

D) Measure the tympanic temperature.
CORRECT
The client’s WBC is elevated, indicating a possible infection. The client should be assessed for fever.
The nurse notifies the healthcare provider of the elevation in WBC and receives a prescription for an oral antibiotic. Mr. Owens is to receive the first dose prior to discharge. When entering his room with the medication, the nurse observes that Mr. Owens is asleep. His wife asks the nurse to leave the medication at the bedside for self-administration when he awakens.

Which is the correct nursing action?
A) Honor the wife’s request and leave the medication capsule at the bedside.

B) Let the client sleep for one more hour and return with the antibiotic.

C) Wake the client and administer the first dose of the antibiotic.

D) Allow the client to start the medication at home after discharge.

C) Wake the client and administer the first dose of the antibiotic.
CORRECT
Although the client may need sleep, his need for the antibiotic is greater.
Mr. Owens has been prescribed levoflloxacin (Levaquin) 500 mg PO daily. The nurse has received 250 mg tablets from the pharmacy.

Which nursing action should be taken?
A) Consult with the pharmacy to obtain one 500 mg tablet.

B) Administer two 250 mg tablets of the medication.

C) Give one 250 mg tablet in the morning and one 250 mg tablet in the evening.

D) Notify the healthcare provider and obtain a prescription for 500 mg tablets.

B) Administer two 250 mg tablets of the medication.
CORRECT
Two 250 mg tablets = 500 mg.
When leaving the hospital Mr. Owens states, “I really need to get back to work. All of this has caused a great strain on my job.”

How should the nurse respond to Mr. Owens’ statement?
A) “Right now you need to concentrate on getting better.”

B) “I will have a social worker call you to see if you need any financial help.”

C) “You seem concerned about missing work and the pressures of your job.”

D) “I know what you mean. I couldn’t afford to miss very much work either.”

C) “You seem concerned about missing work and the pressures of your job.”
CORRECT
The nurse is therapeutically restating the client’s feelings, which is likely to encourage the client to continue the conversation.
Mr. Owens is seen in the surgeon’s office for his follow-up evaluation two weeks after his surgery.

Which method effectively evaluates improvement of the client’s sleep apnea as it relates to respiration?

A) Ask the client how he has been sleeping for the last two weeks since his surgery.

B) Obtain current vital signs including a pulse oximetry reading.

C) Review the sleep log kept by Mrs. Owens with recorded respiratory rate and pattern at night.

D) Assess lung sounds in the sitting and supine position.

C) Review the sleep log kept by Mrs. Owens with recorded respiratory rate and pattern at night.
CORRECT
A log of nightly respiratory rate and pattern specifically evaluates the nursing diagnosis of ineffective respiratory patterns.
During the follow-up visit, Mr. Owens states, “I’m a little worried about my son. He is 16 and seems to be sleeping too much. If this keeps up, I’m afraid my sleep will be disturbed again!”

Which initial response by the nurse is best?
A) “Please tell me about your son’s sleep habits.”

B) “Don’t worry, it is normal for teenagers to sleep a lot. You are just hypersensitive about sleep.”

C) “Teens typically do not need as much sleep as adults, so there must be a problem.”

D) “You seem overly concerned about your son. You need to worry about yourself now.”

A) “Please tell me about your son’s sleep habits.”
CORRECT
This information is needed to determine what is “too much.” The response also invites the client to continue expressing his concerns.
Mr. Owens reports his son sleeps sometimes until noon in the summer, but he often stays up very late at night.

Which response by the nurse is best?
A) “Sleeping until noon is unhealthy for anyone no matter what age they are.”

B) “Many adolescents start developing this type of pattern as they develop independence.”

C) “I would try enforcing a strict, earlier bedtime routine so he does not sleep so late.”

D) “Excessive daytime sleepiness is symptomatic of the sleep disorder narcolepsy.”

B) “Many adolescents start developing this type of pattern as they develop independence.”
CORRECT
This is particularly common during the summer months, if there are no school obligations to make them rise earlier.
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