HESI P EDIATRICS PROCTORED EXAM
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patient has sleep deprivation. Which statement by the patient will indicate tot he
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nurse that outcomes are being met?
a. “I wake up only once a night to go to 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.”
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 a goal for insomnia. Waking up only once may indicate
nocturia is improving but does not relate to sleep deprivation.
26. An older-adult patient is visiting the clinic after a fall during the
night. The nurse obtains information on what medications the patient takes.
Which medication mostlikely contributed to the patient’s fall?
a. Melatonin
b. L-tryptophan
c. Benzodiazepine
d. Iron supplement
ANS: C
The most likely cause is a benzodiazepine. If older patients who were
recently continent, ambulatory, and alert become incontinent or
confused and/or demonstrate impaired mobility, the use of
benzodiazepines needs to be considered as a possible cause. This can
contribute to a fall in an older adult. Short-term use of melatonin has
been found to be safe, with mild side effects of nausea, headache, and
dizziness being infrequent. Iron supplements may be given to patients
with restless legs syndrome. Some substances such as L-tryptophan, a
natural protein found in foods such as milk, cheese, and meats,
promote sleep; while it does promote sleep, it is not the most likely to
, cause mobility problems.
MULTIPLERESPONSE
1. The nurse is caring for a patient who has not been able to sleep well
while in the hospital, leading to a disrupted sleep-wake cycle. Which
assessment findings will the nurse monitor for in this patient? (Select all
that apply.)
a. Changes in physiological function such as temperature
b. Decreased appetite and weight loss
c. Anxiety, irritability, andrestlessness
d. Shortness of breath and chest pain
e. Nausea, vomiting, and diarrhea
f. Impaired judgment
ANS:A, B, C, F
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.
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.
Which information will the nurse include in the teaching session? (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.
ANS:A, C, D
Sleep contributes to physiological and psychological restoration. NREM
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patient has sleep deprivation. Which statement by the patient will indicate tot he
i
nurse that outcomes are being met?
a. “I wake up only once a night to go to 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.”
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 a goal for insomnia. Waking up only once may indicate
nocturia is improving but does not relate to sleep deprivation.
26. An older-adult patient is visiting the clinic after a fall during the
night. The nurse obtains information on what medications the patient takes.
Which medication mostlikely contributed to the patient’s fall?
a. Melatonin
b. L-tryptophan
c. Benzodiazepine
d. Iron supplement
ANS: C
The most likely cause is a benzodiazepine. If older patients who were
recently continent, ambulatory, and alert become incontinent or
confused and/or demonstrate impaired mobility, the use of
benzodiazepines needs to be considered as a possible cause. This can
contribute to a fall in an older adult. Short-term use of melatonin has
been found to be safe, with mild side effects of nausea, headache, and
dizziness being infrequent. Iron supplements may be given to patients
with restless legs syndrome. Some substances such as L-tryptophan, a
natural protein found in foods such as milk, cheese, and meats,
promote sleep; while it does promote sleep, it is not the most likely to
, cause mobility problems.
MULTIPLERESPONSE
1. The nurse is caring for a patient who has not been able to sleep well
while in the hospital, leading to a disrupted sleep-wake cycle. Which
assessment findings will the nurse monitor for in this patient? (Select all
that apply.)
a. Changes in physiological function such as temperature
b. Decreased appetite and weight loss
c. Anxiety, irritability, andrestlessness
d. Shortness of breath and chest pain
e. Nausea, vomiting, and diarrhea
f. Impaired judgment
ANS:A, B, C, F
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.
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.
Which information will the nurse include in the teaching session? (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.
ANS:A, C, D
Sleep contributes to physiological and psychological restoration. NREM
