ch 11 Flashcards
A patient tells the nurse that he experiences daytime fatigue even after 7–8 hours of sleep each night. What is the best assessment question for the nurse to ask?
a. Have you tried getting 10 hours of sleep instead of 8 hours?
b. How long are you in the rapid eye movement (REM) stage?
c. Do you also have any recent lifestyle or behavior changes?
d. Do any of your close relatives have any sleep disorders?
ANS: C
The best question to elicit the most pertinent information is “Do you also have any recent lifestyle or behavior changes?” The patient is getting 7–9 hours/sleep each night, which is expected for the average adult. The patient will not be able to recall an unconscious state such as REM sleep. The patient may have close relatives with sleep disorders but this does not necessarily affect the patient’s own sleep habits.
The nurse is making rounds on the hospital unit and observes a patient sleeping. The patient’s pulse and respiratory rates are slower than baseline. The nurse realizes the patient has most likely just entered which stage of non-rapid eye movement sleep?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
ANS: B
In Stage 2 (N2), eye movement ceases; brain waves become even slower with the exception of an occasional burst or more rapid brain waves. Pulse rate and respirations slow and body temperature decreases as the individual moves toward deeper stages of sleep. Stage 3 (N3) and Stage 4 (N4) are the periods of deep sleep.
The nurse enters a patient’s room and the patient startles easily and appears to jerk his arms and legs before awakening. Which stage of non-rapid eye movement sleep did the patient most likely awaken from?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
ANS: A
In Stage 1 (N1 or Non-REM Stage 1), referred to as light sleep, the individual can be awakened easily. In this stage, brain waves slow and, on EEG, the slower wave pattern known as alpha waves appears. The individual at this point is likely to drift in and out of sleep and can be awakened easily. Sensations known as hypnagogic hallucinations can occur during this stage. A common sensation of this type is the feeling of falling. Uncontrolled muscle jerks sometimes occur at this stage along with sudden movements that can startle the individual and restore wakefulness.
The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse’s best action?
a. Notify the healthcare provider.
b. Re-assess the patient’s orientation.
c. Administer an anti-anxiety medication.
d. Cancel the patient’s procedure.
ANS: B
Stage 3 (N3) and Stage 4 (N4) are the periods of deep sleep. N3 is characterized by very slow brain waves called delta waves interspersed with smaller, faster waves. In Stage 4 (N4), the EEG shows almost exclusively delta waves. In this type of sleep it is difficult to awaken the individual and muscle activity is very limited or may be completely absent. A person awakened from Stage 3 or 4 of sleep could be disoriented for a brief period of time before regaining awareness.
A patient complains of not being able to fall asleep at night and asks the nurse if there is a safe, non-prescription medication he can try. After consulting the healthcare provider, the nurse should recommend which naturally occurring hormone?
a. Melatonin
b. Cortisol
c. Luteinizing hormone
d. Estrogen
ANS: A
A rise in the hormone melatonin at the onset of sleep helps to promote and maintain sleep, and a drop in levels leads to eventual awakening. The immune system is enhanced as well during sleep as proteins associated with fighting illness are produced. The circadian rhythm, or the typical 24 hour (more or less) cycle through which the body passes, including both awake and sleep cycles, is responsible for regulating all of the physiologic processes in the body. An adequate amount and quality of sleep, therefore, is essential to all of the regulatory mechanisms that take place in the body.
A mother tells the nurse she is concerned because her 8-month-old infant sleeps all day and night and is only awake about 2–3 hours per day. What is the nurse’s best response?
a. “This sleep pattern is very normal for an infant at this age.”
b. “Adding an additional feeding will keep the child awake more.”
c. “I recommend that you notify the child’s pediatrician.”
d. “Be sure you are laying the child on his back to sleep at night.”
ANS: C
By approximately 6 months of age, the infant should sleep through the night with at least one nap during the day. 2–3 hours of wakefulness per day is not an expected finding at age 8 months and should be reported to the pediatrician to determine the underlying cause. An additional feeding may be warranted; however the pediatrician should be notified first. Lying on infant on the back to sleep is recommended to prevent sudden infant death syndrome; however the priority concern is the length of time the child is sleeping.
The nurse is caring for a child with tonsillar enlargement. What is the nurse’s priority concern?
a. Low oxygen saturation
b. Daytime fatigue
c. Increased temperature
d. Antibiotic administration
ANS: A
Tonsillar enlargement in children often leads to obstructive sleep apnea which can cause decreased oxygen saturation levels. Low oxygen is a priority concern which carries the highest safety risk to the child. Obstructive sleep apnea occurs in an estimated 1–3% of children, though the causative factors may differ with tonsillar enlargement being a significant component in children. Infection that leads to an increased temperature and requires antibiotic therapy is a concern, but the priority health concern is low oxygen levels. Obstructive sleep apnea can interfere with sleep patterns and lead to daytime fatigue, but the highest priority of care is low oxygen.
