ATI Engage Fundamentals (Physiologic Concepts for Nursing Practice): Comfort, Rest, and Sleep (With Rationale)

ATI Engage Fundamentals (Physiologic Concepts for Nursing Practice): Comfort, Rest, and Sleep (With Rationale) A nurse is contributing to a presentation about non pharmacological interventions used to promote sleep. Which of the following information should the nurse recommend including in the presentation? a. Non pharmacological interventions should only be practiced in the clients home setting. b. Massage is a non pharmacological intervention that should be used to promote sleep for clients who are taking anticoagulants. c. Non-pharmacological interventions used to help promote sleep include acupuncture and thermotherapy. d. Before implementing nonpharmalogical interventions, clients should be evaluated by a sleep specialist for sleep apnea and chronic lung disease. c. Non-pharmacological interventions used to help promote sleep include acupuncture and thermotherapy. Nonpharmacological interventions should only be practiced in the client's home setting.Nonpharmacological interventions can be practiced in medical facilities, as long as they are not contraindicated. Massage is a nonpharmacological intervention that should be used to promote sleep for clients who are taking anticoagulants.Massage is contraindicated for clients who are taking anticoagulants, as well as clients who have burns and wounds. Nonpharmacological interventions used to help promote sleep include acupuncture and thermotherapy.MY ANSWERThe nurse should recommend including in the presentation that massage, acupuncture, and thermotherapy have been found to be effective nonpharmacological interventions for sleep. Before implementing nonpharmacological interventions, clients should be evaluated by a sleep specialist for sleep apnea and chronic lung disease.Clients will need to be educated on nonpharmacological interventions to promote sleep. Clients who require pharmacological therapy for promotion of sleep should be evaluated by a sleep specialist for sleep apnea and chronic lung disease A nurse is caring for a client who takes an over-the-counter (OTC) sleep aid medication every evening. Which of the following findings should the nurse identify as a potential adverse effect of OTC sleep aid medications? a. Hyperactivity b. Diarrhea c. Excessive salivation d. Urinary retention d. Urinary retention HyperactivityOTC sleep aid medications can cause daytime drowsiness, not hyperactivity. DiarrheaOTC sleep aid medications can cause constipation, not diarrhea. Excessive salivationOTC sleep aid medications can cause dry mouth, not excessive salivation. Urinary retentionMY ANSWERThe nurse should identify that OTC sleep aid medications can cause urinary retention, as well as daytime drowsiness, dry mouth, visual disturbances, and constipation. 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 clients breathing was irregular and their heart rate was elevated c. The client experiences mental cloudiness for 30 to 60 min. The client was easily awakened.The nurse should identify that a client who was easily awakened was most likely in stage 1 of the sleep cycle, rather than stage 3. During stage 1 of the sleep cycle, the client begins to relax and body and eye movements begin to decrease. If left uninterrupted, the client will progress quickly to stage 2 of sleep, where awakening becomes more difficult. The client states that they were having a pleasant dream.Stage 4 of the sleep cycle, also known as rapid eye movement (REM) sleep, is the dreaming stage of sleep. If a client is awakened during this stage, their dreams will be interrupted. The client experiences mental cloudiness for 30 to 60 min.MY ANSWERStage 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. Prior to being awakened, the client's breathing was irregular and their heart rate was elevated.Irregular breathing and increased heart rate are an indication that the client is in stage 4 of the sleep cycle, also known as rapid eye movement (REM) sleep. A nurse is caring for a client who has a history of migraines. The client tells the nurse, "I have not been sleeping well. My migraine headaches have returned after not having one for over a year." The nurse should identify that which of the following are potential contributing factors to the client's migraines? (Select all that apply) Sleep-wake homeostasis Sensory overlad Sleep deprivation Increased melatonin Decreased hypocretin levels Sensory overload Sleep deprivation MY ANSWER Sleep-wake homeostasis is incorrect. Sleep-wake homeostasis is the second biological mechanism that assists the body to remember to sleep after a given time. It is not a likely contributing factor to the client's new onset of migraine headaches. Sensory overload is correct. Sensory overload can lead to sleep deprivation and is a possible contributing factor to the client's new onset of migraine headaches. Sleep deprivation is correct. Sleep deprivation has been known to trigger migraines. Therefore, the nurse should identify that sleep deprivation is a potential contributing factor to the client's new onset of migraine headaches. Increased melatonin is incorrect. Melatonin can assist with sleep and relaxation. It is not a likely contributing factor to the client's new onset of migraine headaches. Decreased hypocretin levels is incorrect. Hypocretin is a hormone responsible for maintaining alertness that is produced in the hypothalamus. It is not a likely contributing factor to the client's new onset of migraine headaches. 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 effects should the nurse monitor the client? a. Retrograde amnesia b. Urinary discomfort c. Dry mouth d. Hallucinations d. Hallucinations Retrograde amnesiaBenzodiazepines, rather than nonbenzodiazapine hypnotics, can cause retrograde amnesia. Urinary discomfortGastric discomfort, rather than urinary discomfort, is an adverse effect of nonbenzodiazapine hypnotics. Dry mouthOver-the-counter sleep aids, rather than nonbenzodiazapine hypnotics, can cause dry mouth. HallucinationsMY ANSWERThe nurse should monitor the client for hallucinations, which can be an adverse effect of nonbenzodiazepine hypnotics. A nurse is caring for a client who is being evaluated for obstructive sleep apnea. Which of the following findings should the nurse identify as a risk factor for obstructive sleep apnea? a. Hypersomnia b. Obesity c. Active glossal muscle d. History of tonsillectomy b. Obesity HypersomniaHypersomnia occurs when a client experiences excessive daytime fatigue that is not relieved by additional sleep. Hypersomnia is not a risk factor for obstructive sleep apnea. ObesityMY ANSWERThe nurse should identify that a client who is obese is at risk for developing obstructive sleep apnea. Active glossal muscleThe nurse should identify that an inactive glossal muscle, the tongue muscle, places the client at increased risk for obstructive sleep apnea. History of tonsillectomyThe nurse should identify that enlarged tonsils, not a history of a tonsillectomy, places the client at risk for obstructive sleep apnea. A nurse is assessing 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) HypersomniaHypersomnia is excessive daytime fatigue that does not improve after receiving additional sleep. Hypersomnia is not accompanied by involuntary episodes of lost muscle tone. Narcolepsy (NT2)Narcolepsy is a chronic sleep condition that is characterized by sudden sleepiness and sudden periods of sleep. Clients who have narcolepsy (NT2) have difficulty staying awake. However, these clients do not experience involuntary episodes of lost muscle tone. Narcolepsy (NT1)MY ANSWERThe 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. InsomniaInsomnia is the inability to obtain adequate sleep despite having adequate opportunity to sleep. Clients who have insomnia might experience daytime fatigue and loss of energy, but they do not have trouble staying awake or experience involuntary loss of muscle tone. A nurse is caring for a client who has narcolepsy (Nt1) with cataplexy. The nurse should identify that this condition is caused by a lack of which of the following hormones? a. Hypocretin b Melatonin c. Estrogen d. Insulin a. Hypocretin HypocretinMY ANSWERHypocretin is a hormone produced in the hypothalamus and is responsible for maintaining alertness. Narcolepsy (NT1) with cataplexy is caused by a lack of hypocretin. MelatoninMelatonin is a sleep hormone that is produced in the pineal gland. A lack of melatonin does not cause narcolepsy. EstrogenEstrogen is produced in the ovaries. Menopause, which involves a reduction in estrogen production, can cause sleep disturbance but does not cause narcolepsy. InsulinInsulin is produced in the pancreas and controls blood glucose levels. A lack of insulin does not cause narcolepsy. A nurse is reviewing the concept of comfort with an assistive personal (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 clients care and creating routines for the client to become familiar with." d. "Providing comfort to a client requires staff members to smile and remain cheerful no matter the outcome the client is facing" b. "Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy." "Providing comfort for a client is achieved by the relief of physical pain through the administration of medication."Administering pain medication to a client helps to alleviate physical pain. However, providing comfort to a client involves alleviating not only the client's physical pain, but also the client's emotional and mental distress. "Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy."MY ANSWERProviding comfort to a client involves easement of mental distress, as well as physical distress. "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."Providing comfort to a client involves allowing the client to feel in control and to make informed choices concerning their care. These actions assist with promoting feelings of positivity and confidence. "Providing comfort to a client requires staff members to smile and remain cheerful no matter the outcome the client is facing."Providing comfort for a client requires staff to display empathy and honesty when needed. Therefore, smiling and remaining cheerful are not always suitable actions for staff to take. A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse plan to include 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. Encourage the client to verbalize their needs and concerns.MY ANSWERThe 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. Limit time spent with client.Limiting time spent with the client can make the client feel as though the nurse does not have time to adequately attend to their needs. Therefore, staff should be available to spend as much time as needed with the client to promote comfort and feelings of safety. Ask the client to splint the incision when coughing.Asking the client to splint the incision when coughing will promote physical comfort, not emotional comfort, for the client. Administer pain medications as prescribed.Administering pain medications as prescribed will promote physical comfort, not emotional comfort, for the client. A nurse is caring for a client who works overnight shifts. The nurse should identify that individuals who perform shift work are at an increased risk for developing which of the following conditions? a. Diabetes mellitus b. Central sleep apnea c. Hypersomnia d. Restless leg syndrome (RLS) a. Diabetes mellitus Diabetes mellitusMY ANSWERIndividuals who perform shift work are at an increased risk for developing health conditions, including diabetes mellitus, obesity, and cardiovascular disease. Central sleep apneaCentral sleep apnea, commonly caused by opioid toxicity and heart failure, is a neurological condition that prevents the brain from communicating with the respiratory muscles and results in cessation of breathing. Shift workers are not at an increased risk for developing central sleep apnea. HypersomniaHypersomnia is a condition that is characterized by excessive daytime fatigue, even after long periods of sleep. Although shift workers can experience drowsiness, they are not at increased risk for developing hypersomnia. Restless leg syndrome (RLS)RLS is a neurologic sensorimotor disorder. Shift workers are not at an increased risk for developing RLS. A nurse is caring for a client who reports that they use their phone at night while they are in bed. The nurse should identify that excessive smartphone use can increase the client's risk for which of the following? a. Depression b. Binge eating disorder c. Restless leg syndrome (RLS) d. Diminished circadian rhythm a. Depression DepressionMY ANSWERExcessive smartphone use is a risk factor for both depression and poor sleep. Binge eating disorderExcessive smartphone use is not associated with an increased risk for binge eating disorder. Restless leg syndrome (RLS)RLS is a neurologic sensorimotor disorder with manifestations that worsen in the evening and at bedtime. However, excessive smartphone use is not associated with an increased risk for RLS.