NR 226 NCLEX QUIZ ANSWERS Ch. 42 Sleep

NR 226 NCLEX QUIZ ANSWERS Ch. 42 Sleep 1. The nurse is caring for a young adult patient on the medical-surgical unit. When doing midnight checks, she sees that the patient is awake and is doing a puzzle. What is the best explanation for the patient being awake? a) The patient was waiting to talk with the nurse. b) The patient misses his family and is lonely. c) The patient’s sleep-wake cycle preference is late evening. d) The patient has been kept up with the noise on the unit. 2. The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which of these statements by the nurses would best indicate that learning has occurred? a) “If the patient has a disease process in the central nervous system, it can influence the functions of sleep b) c) “If the patient has a disease process in the cranial nerves, it can influence the functions of sleep.” d) “If the patient has an interruption in the motor pathways, it can influence the functions of sleep.” e) “If the patient has an interruption in the spinal reflexes, it can influence the functions of sleep.” 3. The nurse is caring for a patient who is having trouble sleeping. To encourage decreased stimulus to the reticular activating system and activation of the bulbar synchronizing region, which actions would the nurse implement? a) Encourage television for distraction. b) Encourage relaxed positions c) Walk with the patient. d) Provide a favorite beverage. 4. The nurse is caring for a patient in the sleep lab. The nurse recognizes that the patient is in stage 4 NREM from which of the following assessments? a) The patient awakens easily. b) Body functions slow. c) The patient is difficult to awaken. d) Eyes rapidly move. 5. The patient shares with the nurse the vivid, full color dreams experienced by the patient last night. These data would indicate that the patient has reached what stage of sleep? a) Stage 1 NREM b) Stage 2 NREM c) Stage 3 NREM d) REM e) 6. Which nursing observation of the patient in intensive care indicates that the patient is sleeping comfortably? a) Eyes closed, lying quietly, respirations 12, heart rate 60 b) t c) Eyes closed, tossing in bed, respirations 18, heart rate 80 d) Eyes closed, mumbling to self, respirations 16, heart rate 68 e) Eyes closed, lying straight in bed, respirations 22, heart rate 66 7. The nurse is discussing with a new mother the sleep requirements of a neonate. Which of these comments would indicate that the patient has an understanding of the neonate’s sleeping pattern? a) “I can’t wait to get the baby home to play with the brothers and sisters.” b) “I will ask my mom to come after the first week, when the baby is more alert.” c) d) “I will get the baby on a sleeping schedule the first week while my mom is here.” e) “I won’t be able to nap during the day because the baby will be awake.” 8. The nurse is discussing lack of sleep with a middle-aged adult. The nurse recognizes that insomnia in this age group is commonly due to: a) Anxiety. Correct b) Teenagers keeping them awake. c) Caring for pets. d) Late night television. 9. A single dad is discussing with the nurse the sleep needs of a preschooler. Which of the following direction would be most helpful to the parent? a) “It is important that the 5-year-old get a nap every day.” b) “Preschoolers sleep soundly all night long.” c) “On average, the preschooler needs to sleep 10 hours a night.” d) “The preschooler may have trouble settling down after a busy day.” e) 10. The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which nursing action should the nurse take? a) Discuss with the adolescent’s parent staying up with friends and the need for sleep. b) Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness. c) d) This is a normal occurrence for adolescents and action is not required. e) Explore the reason for staying up late with friends several nights a week. 11. The nurse is completing an assessment on an older patient who is having difficulty falling asleep. Which factor has the potential to contribute to this difficulty? a) Depression Correct b) Smoking c) Alcohol d) Fatigue 12. The nurse is caring for an adolescent who is complaining of difficulty falling asleep. Which intervention Would be most appropriate? a) Adjust the temperature in the patient’s room to 21° C (70° F). b) Ensure that the night light in the patient’s room is working. c) Encourage the discontinuation of soda and chocolate nightly snack. Correct d) Close the door to decrease noise from unit activities. 13. Which of the following would be most important for the nurse to monitor in a patient who has obstructive sleep apnea? a) Gastrointestinal function b) Circulatory status c) Respiratory status Correct d) Neurological function 14. The patient has just been diagnosed with narcolepsy. The nurse provides an educational session and teaches the patient to avoid: a) Antidepressant medications. b) Naps shorter than 20 minutes. c) Sitting in hot, stuffy rooms. Correct d) Chewing gum. 15. The nurse is caring for a patient who has been in holding in the emergency department for 24 hours. The nurse is concerned about the patient experiencing sleep deprivation. What would be the best action for the nurse to take? a) Expedite the process of obtaining a medical-surgical room for the patient. Correct b) Pull the curtains shut, dim the lights, and decrease the number of visitors. c) Obtain an order for a medication to help the patient sleep. d) Ask everyone in the unit to try to be quiet so the patient can sleep. 16. The nurse is completing a sleep assessment on a patient. The nurse utilizes which of the following tools to complete the assessment? a) Visual Analogue Scale Correct b) OUCHER scale c) FACES scale d) Glasgow Coma Scale 17. The nurse is beginning a sleep assessment on a patient. Which of the following would be the most appropriate question to ask? a) “What is going on?” b) “How are you sleeping?” Correct c) “Are you taking any medications?” d) “What did you have for dinner last night?” 18. The nurse assigns a nursing diagnosis of ineffective breathing pattern. Which of the following sleep conditions would support this diagnosis? a) Insomnia b) Narcolepsy c) Obstructive sleep apnea Correct d) Sleep deprivation 19. The nurse is caring for a postpartum patient. The patient’s labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. What is the most appropriate nursing diagnosis? a) Impaired parenting b) Insomnia c) Ineffective coping d) Sleep deprivation Correct 20. The patient presents to the clinic with reports of irritability, being sleepy during the day, not being able to fall asleep, and being tired. Select the most appropriate nursing diagnosis. a) Anxiety b) Fatigue c) Sleep deprivation d) Insomnia Correct 21. The nurse is preparing an older patient’s evening medications. Which of the following does the nurse recognize as relatively safe for difficulty sleeping? a) Benadryl (diphenhydramine) b) Melatonin c) Valerian d) Lorazepam Correct 22. The nurse is caring for a patient on the medical-surgical unit who is experiencing an exacerbation of asthma. Which of the following interventions would be most appropriate to help the patient sleep? a) Bed placed in semi-Fowler’s position Correct b) Increased BNC oxygen to 5 L a minute c) A snack provided before bedtime d) Encouraging the patient to read 23. A young mother has been hospitalized for an irregular heartbeat (arrhythmia). The night nurse comes in to see the patient awake. What would be the most appropriate nursing intervention? a) Inform the patient that it is late and time to go to sleep. b) Ask the patient if she would like medication to help her sleep. c) Recommend the great movie that is on television tonight. d) Take time to sit and talk with the patient about her inability to sleep. Correct 24. The nurse is evaluating outcomes for the patient with the nursing diagnosis of Insomnia. During this process, the nurse recognizes that: a) The patient is the best evaluator of sleep. Correct b) Interventions will need to be adjusted. c) Medical conditions will not influence outcomes. d) Observations of the patient provide needed data. 25. A patient has received a nursing diagnosis of sleep deprivation. Which of the following statements by the patient would indicate that outcomes are being met? a) “I wake up only once a night to go the bathroom.” b) “I feel rested when I wake up in the morning.” Correct c) “I go to sleep within 30 minutes of lying down.” d) “I only take a 20-minute nap during the day.” 26. The older patient is visiting the clinic after a fall during the night. Which of the following data points obtained most likely would contribute to this fall? a) The patient has been taking glucosamine. b) The patient has been taking a fish oil. c) The patient has been taking Benadryl (diphenhydramine). Correct d) The patient has been taking vitamin C. 27. The nurse is caring for a patient who has not been able to sleep well while in the hospital. The nurse recognizes that lack of sleep can manifest in which of the following signs and symptoms? (Select all that apply) a) Changes in physiological function such as temperature Correct b) Decreased appetite and weight loss Correct c) Anxiety, irritability, and restlessness Correct d) Impaired judgment Correct e) Nausea, vomiting, and diarrhea f) Shortness of breath and chest pain 28. 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. What points should the nurse include in her teaching? (Select all that apply.) a) NREM sleep contributes to body tissue restoration. Correct b) During NREM sleep, biological functions increase. c) Restful sleep preserves cardiac function. Correct d) Sleep contributes to cognitive restoration. Correct e) REM sleep decreases cortical activity. Correct f) REM sleep assists with memory storage and learning. 29. The patient and the nurse discuss the need for sleep. After the discussion, the patient is able to state factors that hinder sleep. Which statements indicate that the patient has a good understanding of sleep? (Select all that apply.) a) “Drinking coffee at 7 PM could interrupt my sleep.” Correct b) “Worry about work can disrupt my sleep.” Correct c) “Exercising 2 hours before bedtime can decrease relaxation.” Correct d) “Changing the time of day that I eat dinner can disrupt sleep.” e) “Taking an antacid can decrease sleep.” f) “Staying up late for a party can interrupt sleep patterns.” Correct 30. A community health nurse is providing an educational session at the senior center on how to promote sleep. Which practices should the nurse recommend? (Select all that apply.) Take a nap in the afternoon. Sleep where you sleep best. Correct Use sedatives as a last resort. Correct Decrease fluids 2 to 4 hours before sleep. Correct Watch television right before sleep. Get up if unable to fall asleep in 15 to 30 minutes. Correct