ATI Engage Fundamentals: Comfort, Rest, and Sleep
(With Rationale)
A nurse is collecting data from a client who reports difficulty staying awake
during the day and experiencing involuntary episodes of lost muscle tone. The
nurse should identify that these are manifestations of which of the following
conditions?
A. Hypersomnia
B. Narcolepsy (NT2)
C. Narcolepsy (NT1)
D. Insomnia
C. Narcolepsy (NT1)
The nurse should identify that the client is exhibiting manifestations of narcolepsy (NT1).
Narcolepsy (NT1) is a chronic sleep condition that is characterized by sudden
sleepiness and sudden periods of sleep accompanied by cataplexy, or episodes of
involuntary loss of muscle tone brought on by strong emotions, such as laughter. Clients
who have narcolepsy (NT1) with cataplexy lack hypocretin in their central nervous
system. Clients who have both NT1 and NT2 narcolepsy might experience nocturnal
hallucinations, paralysis while asleep, and vivid dreams.
A nurse is contributing to the plan of care for a client who is postoperative. Which
of the following interventions should the nurse recommend including to promote
emotional comfort for the client?
A. Encourage the client to verbalize their needs and concerns.
B. Limit time spent with client.
C. Ask the client to splint the incision when coughing.
D. Administer pain medications as prescribed.
A. Encourage the client to verbalize their needs and concerns.
The nurse should encourage the client to verbalize their needs and concerns. Listening
to the client's concerns and incorporating those concerns into the plan of care promotes
client comfort by allowing the client to feel valued and that they are a vital part of the
process.
A nurse is caring for a client who has a new prescription for a nonbenzodiazepine
hypnotic to promote sleep. For which of the following adverse affects should the
nurse monitor the client?
A. Retrograde amnesia
B. Urinary discomfort
C. Dry mouth
D. Hallucinations
D. Hallucinations
The nurse should monitor the client for hallucinations, which can be an adverse effect of
nonbenzodiazepine hypnotics.
A nurse is caring for a client who needs to be awakened for the administration of
an oral medication. Which of the following findings should indicate to the nurse
, that the client was in stage 3 of the sleep cycle when awakened?
A. The client was easily awakened.
B. The client states that they were having a pleasant dream.
C. The client experiences mental cloudiness for 30 to 60 min.
D. Prior to being awakened, the client's breathing was irregular and their heart
rate was elevated.
C. The client experiences mental cloudiness for 30 to 60 min.
Stage 3 of the sleep cycle is the deepest stage of sleep in which muscle, tissue, and
bones regenerate and the immune system strengthens. If a client is awakened during
stage 3 of the sleep cycle, the nurse should expect the client to experience mental
cloudiness for 30 to 60 min.
A nurse is discussing the stages of the sleep cycle with a client. The nurse
should include that the immune system is strengthened and tissues and bones
are repaired during which of the following stages of sleep cycle?
A.Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
C. Stage 3
The nurse should include that the immune system is strengthened and tissues and
bones are repaired during stage 3 of the sleep cycle.
A nurse is caring for a client who was admitted following a report of lumbar pain.
In addition to administering pain medications, which of the following
interventions should the nurse implement to promote comfort?
A. Present information honestly.
B. Have another nurse present difficult information.
C. Do not include the client's concerns in the plan of care if they interfere with
treatment.
D. Perform cognitive behavioral therapy with the client.
A. Present information honestly.
Presenting information and answering questions honestly can help the client to feel
safe. The nurse should also be present to respond to client needs and should remain
supportive of the client's choices.
A nurse is reinforcing teaching about the concept of comfort with a newly hired
assistive personnel (AP). Which of the following statements by the AP indicates
an understanding of comfort?
A. "Providing comfort for a client is achieved by the relief of physical pain
through the administration of medication."
B. "Providing comfort to a client involves alleviating the client's physical, mental,
and emotional distress using warmth and empathy."
C. "Providing comfort for a client is achieved by taking control of the client's care
and creating routines for the client to become familiar with."
(With Rationale)
A nurse is collecting data from a client who reports difficulty staying awake
during the day and experiencing involuntary episodes of lost muscle tone. The
nurse should identify that these are manifestations of which of the following
conditions?
A. Hypersomnia
B. Narcolepsy (NT2)
C. Narcolepsy (NT1)
D. Insomnia
C. Narcolepsy (NT1)
The nurse should identify that the client is exhibiting manifestations of narcolepsy (NT1).
Narcolepsy (NT1) is a chronic sleep condition that is characterized by sudden
sleepiness and sudden periods of sleep accompanied by cataplexy, or episodes of
involuntary loss of muscle tone brought on by strong emotions, such as laughter. Clients
who have narcolepsy (NT1) with cataplexy lack hypocretin in their central nervous
system. Clients who have both NT1 and NT2 narcolepsy might experience nocturnal
hallucinations, paralysis while asleep, and vivid dreams.
A nurse is contributing to the plan of care for a client who is postoperative. Which
of the following interventions should the nurse recommend including to promote
emotional comfort for the client?
A. Encourage the client to verbalize their needs and concerns.
B. Limit time spent with client.
C. Ask the client to splint the incision when coughing.
D. Administer pain medications as prescribed.
A. Encourage the client to verbalize their needs and concerns.
The nurse should encourage the client to verbalize their needs and concerns. Listening
to the client's concerns and incorporating those concerns into the plan of care promotes
client comfort by allowing the client to feel valued and that they are a vital part of the
process.
A nurse is caring for a client who has a new prescription for a nonbenzodiazepine
hypnotic to promote sleep. For which of the following adverse affects should the
nurse monitor the client?
A. Retrograde amnesia
B. Urinary discomfort
C. Dry mouth
D. Hallucinations
D. Hallucinations
The nurse should monitor the client for hallucinations, which can be an adverse effect of
nonbenzodiazepine hypnotics.
A nurse is caring for a client who needs to be awakened for the administration of
an oral medication. Which of the following findings should indicate to the nurse
, that the client was in stage 3 of the sleep cycle when awakened?
A. The client was easily awakened.
B. The client states that they were having a pleasant dream.
C. The client experiences mental cloudiness for 30 to 60 min.
D. Prior to being awakened, the client's breathing was irregular and their heart
rate was elevated.
C. The client experiences mental cloudiness for 30 to 60 min.
Stage 3 of the sleep cycle is the deepest stage of sleep in which muscle, tissue, and
bones regenerate and the immune system strengthens. If a client is awakened during
stage 3 of the sleep cycle, the nurse should expect the client to experience mental
cloudiness for 30 to 60 min.
A nurse is discussing the stages of the sleep cycle with a client. The nurse
should include that the immune system is strengthened and tissues and bones
are repaired during which of the following stages of sleep cycle?
A.Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
C. Stage 3
The nurse should include that the immune system is strengthened and tissues and
bones are repaired during stage 3 of the sleep cycle.
A nurse is caring for a client who was admitted following a report of lumbar pain.
In addition to administering pain medications, which of the following
interventions should the nurse implement to promote comfort?
A. Present information honestly.
B. Have another nurse present difficult information.
C. Do not include the client's concerns in the plan of care if they interfere with
treatment.
D. Perform cognitive behavioral therapy with the client.
A. Present information honestly.
Presenting information and answering questions honestly can help the client to feel
safe. The nurse should also be present to respond to client needs and should remain
supportive of the client's choices.
A nurse is reinforcing teaching about the concept of comfort with a newly hired
assistive personnel (AP). Which of the following statements by the AP indicates
an understanding of comfort?
A. "Providing comfort for a client is achieved by the relief of physical pain
through the administration of medication."
B. "Providing comfort to a client involves alleviating the client's physical, mental,
and emotional distress using warmth and empathy."
C. "Providing comfort for a client is achieved by taking control of the client's care
and creating routines for the client to become familiar with."
