Chapter 34: Sleep–Wake Disorders: Nursing Care of Persons with Insomnia and Sleep Problems

A nurse is giving a presentation to a community group about sleep and its

relationship to health. In explaining the relationship between rapid eye movement

(REM) sleep and body temperature, which statement by the nurse would be most

appropriate?

A) "There is no observable relationship between REM sleep and body temperature."

B) "With higher levels of REM sleep, we also experience higher body tempera-

tures."

C) "Our REM sleep and body temperature cycles are inversely related."

D) "

Ans: C

Feedback:

The greatest amount of REM sleep is seen when the body temperature cycle is at

its lowest. Temperature regulation is impaired; that is, people do not sweat or

shiver during REM sleep.

The nurse is assessing the sleep patterns of a 70-year-old client whose life

partner died 6 months ago. Based on the knowledge of circadian rhythms and the

influence of age, which statement would the nurse anticipate that the client would

report about a personal sleep pattern?

A) "When I was younger, I didn't notice any differences in how I felt in the

morning or evening."

B) "Now it seems like I have difficulty falling asleep or staying asleep even when

circumstances are adequate for sl

Ans: B

Feedback:

Insomnia has a greater prevalence among older people and among divorced,

separated, and widowed adults. Increasing age and comorbid disorders (e.g.,

medical, mental disorders, and substance use) are all risks for developing insomnia disorder.

A student nurse is preparing a nursing care plan for a client who has been

diagnosed with insomnia and is experiencing sleep deprivation. Which nursing

diagnosis would the nurse most likely identify as reflecting a priority care issue?

A) Risk for Injury

B) Ineffective Coping

C) Deficient Knowledge

D) Anxiety

Ans: A

Feedback:

Safety is a priority for people with insomnia. Sleep deprivation can lead to accidents, falls, and injuries, especially in older clients. Sedating medication could

potentially increase falls.

A client who is receiving counseling at a community health center has reported

being unable to sleep during the last three weekly sessions. A nurse interviews

the family members to determine the effect of the client's problem on them.

Which response would the nurse most likely expect to hear?

A) "It really hasn't seemed to be a problem for us."

B) "There's been little change in how she gets along with other family members."

C) "The not sleeping has really had a positive effect on

Ans: D

Feedback:

Living with a family member with insomnia is challenging. Irritability, complaints

of sleeplessness, and chronic fatigue interfere with quality interpersonal relationships. It would be highly unlikely that things are not problematic or that the

effects of the insomnia would be positive.

A nurse is discussing strategies to enhance sleep with a client who is experiencing insomnia. Which recommendation would be most appropriate for the nurse

to suggest?

A) "Eat right before you go to bed, as long as it is something rich that will make

you sleepy."

B) "Try exercising a bit right before your bedtime so you will feel tired and sleepy."

C) "Drinking a warm cup of tea right before bedtime will help to relax you."

D) "Establish a regular time for going to bed and getting u

Ans: D

Feedback:

Routines are important, especially when preparing the body to sleep. Therefore,

establishing and maintaining a regular time for bedtime and awakening is appropriate. Clients with insomnia should be counseled not to eat anything heavy

for several hours before retiring. Spicy foods, alcohol, and caffeine should be

avoided. Additionally, exercise promotes sleep, but regular exercise should be

planned for 3 hours before bedtime.

A nurse is working with a psychiatric client who is being discharged from an

inpatient facility. The client asks the nurse, "What should I do at home to promote

getting adequate sleep?" Which response by the nurse would be most appropriate?

A) "Go to bed at the same time every night and watch a television show that

relaxes you."

B) "Save your bedroom for sleeping; that means no work and no TV in the

bedroom."

C) "Why don't you ask your psychiatrist for a prescription for a sleepi

Ans: B

Feedback:

The nurse can help the client develop bedtime rituals and good sleep hygiene.

Bedtime should be at a regular hour, and the bedroom should be conducive to

sleep. Preferably, the bedroom should not be a place where the individual watches

television or does work-related activities. The bedroom should be viewed as a

room for sleeping and sex, and the environment should be cool, with minimal

lighting.

A client diagnosed with a mental disorder is being discharged from an inpatient

unit. During the hospital stay, the client eventually was able to get an adequate

night's sleep even though there was a history of chronic insomnia over the years.

The client's spouse asks the nurse what the family can do in the home environment to promote healthy sleep. Which response by the nurse would be most

appropriate?

A) "It is basically up to your spouse to focus on promoting personal sleep."

B) "Co

Ans: C

Feedback:

Family and friends should be encouraged to support the new habits that the client

is trying to establish. Avoiding stimulating activities and engaging in relaxing

activities before bedtime are crucial, and family and friends can help create an

environment conducive to sleep. Alcohol, spicy foods, and caffeine should be

avoided.

A client has been admitted to the psychiatric unit with a diagnosis of narcolepsy. Which client statement would the nurse interpret as reflecting this condition?

A) "Sometimes when I'm falling asleep, I see and hear things that others don't."

B) "I often have brief periods of intense excitement when going to sleep, and my

legs won't hold still."

C) "I lie there and worry all night, and it keeps me awake. I just can't relax."

D) "I think my sleep pattern is messed up because

Ans: A

Feedback:

The overwhelming urge to sleep is the primary symptom of narcolepsy. This ir-

resistible urge to sleep occurs at any time of the day, regardless of the amount of

sleep the client has had. Falling asleep often occurs in inappropriate situations,

such as while driving a car or reading a newspaper. These sleep episodes are

usually short, lasting 5 to 20 minutes, but may last up to an hour if sleep is not

interrupted. Individuals with narcolepsy may experience sleep attacks and report

frequent dreaming. They usually feel alert after a sleep attack, only to fall asleep

unintentionally again several hours later. Excitement with leg restlessness,

worrying, an inability to relax, and the use of sleeping pills are not associated with

narcolepsy.

A nurse is preparing a presentation on sleep disorders for a community group.

Which statement would the nurse include when explaining the differences be-

tween narcolepsy and obstructive sleep apnea syndrome?

A) "Symptoms of both disorders are essentially the same, so it is difficult to

differentiate between the two disorders."

B) "People with narcolepsy awaken from a nap feeling rested and replenished, but

those with obstructive sleep apnea do not."

C) "People with obstructive sleep a

Ans: B

Feedback:

Unlike narcolepsy, naps tend to be unrefreshing to those with obstructive sleep

apnea syndrome. The disorders are different. Individuals with narcolepsy may

experience cataplexy, a bilateral loss of muscle tone.

A nurse is working with a client diagnosed with insomnia. When developing an

education plan for the client, which sleep promotion intervention would the nurse

implement first?

A) Encouraging the client to stop smoking

B) Instructing the client to keep regular bedtimes and rising times

C) Encouraging the client to take frequent naps

D) Administering prescribed sleep medications

Ans: B

Feedback:

Nonpharmacologic, health-promoting interventions are the first choice before

administering pharmacologic agents. Sleep hygiene strategies, such as keeping

regular times for going to bed and rising, are effective and should be encouraged.

The goal is to normalize sleep patterns to improve well-being.

A nurse obtaining information about sleep patterns asks the client about the

total amount of sleep time, as compared to the amount of time spent in bed. The

nurse is assessing which aspect?

A) Sleep latency

B) Sleep architecture

C) Sleep efficiency

D) Sleep-wake cycle

Ans: C

Feedback:

Sleep efficiency refers to the ratio of total sleep time to time in bed. Sleep latency

is the time period measured from "lights out" or bedtime to the initiation of sleep.

Sleep architecture is the pattern of NREM and REM, which is in about a 90- to

110-minute cycle. The sleep-wake cycle is an endogenously generated rhythm

close to 24 to 25 hours, synchronized with the day-night cycle.

A group of nursing students is reviewing information about factors affecting

the pattern and quality of sleep. The students demonstrate a need for additional

review when they identify which factor?

A) Sleep patterns are relatively constant across the lifespan.

B) Women report more problems with sleep than men.

C) Working night shifts and sleeping during the day can affect sleep.

D) Environmental influences on sleep can be internal or external.

Ans: A

Feedback:

Sleep patterns change dramatically over the course of the lifespan. Sleep problems and poorer quality sleep are reported more often by women than men.

Lifestyle factors such as working the night shift and sleeping during the day can

affect normal sleep. The external and internal environment can affect sleep.

The sleep history of a client experiencing sleep problems reveals that the

client ingests a significant amount of caffeine each day. Which effect of caffeine on

sleep would the nurse incorporate into a discussion with the client?

A) Decreased sleep latency

B) Increased total sleep time

C) Decreased REM sleep

D) Increased slow-wave sleep

Ans: C

Feedback:

Caffeine causes increased sleep latency, decreased total sleep time, and de-

creased REM sleep. It does not affect slow-wave sleep.

A client diagnosed with insomnia is taught to avoid watching television,

eating, and doing work in the bedroom. Which technique is being used?

A) Sleep restriction

B) Relaxation training

C) Cognitive-behavioral therapy

D) Stimulus control

Ans: D

Feedback:

Stimulus control is a technique used when the bedroom environment no longer

provides cues for sleep but has become the cue for wakefulness. Clients are in-

structed to avoid behaviors in the bedroom that are incompatible with sleep,

including watching television, doing homework, and eating. This allows the

bedroom to be reestablished as a stimulus for sleep. Clients often increase their

time in bed to provide more opportunity for sleep, resulting in fragmented sleep

and irregular sleep schedules. With sleep restriction, clients are instructed to

spend less time in bed and to avoid napping. Relaxation training involves the use

of progressive relaxation, autogenic training, and biofeedback to relieve physical

or emotional distress affecting sleep. Cognitive-behavioral therapy identifies the

maladaptive behavior, bringing the distortions to the client's attention and extinguishing the association between effort to sleep and increased arousals.

A client with insomnia is prescribed zolpidem. When describing the action of

this medication to the client, the nurse would incorporate information related to

the medication's effect on which of the following?

A) Gamma-aminobutyric acid (GABA)

B) Serotonin

C) Dopamine

D) Norepinephrine

Ans: A

Feedback:

Zolpidem is a benzodiazepine receptor agonist that exerts its effects by facilitating GABA effects. Serotonin, dopamine, and norepinephrine are not involved.

A group of nursing students is reviewing the various agents used to treat

insomnia. The students demonstrate an understanding of the information when

they identify which agent as a melatonin receptor agonist?

A) Trazodone

B) Estazolam

C) Mirtazapine

D) Ramelteon

Ans: D

Feedback:

Ramelteon is a melatonin receptor agonist. Trazodone and mirtazapine are se-

dating antidepressants. Estazolam is a benzodiazepine classified as a benzodi-

azepine receptor agonist.

After educating a group of nursing students about the physiology of sleep, the

instructor determines that the education was successful when the group identifies

which of the following as responsible for maintaining wakefulness?

A) Reticular activating system

B) Gamma-aminobutyric acid (GABA)

C) Dopamine

D) Melatonin

Ans: A

Feedback:

From a physiologic perspective, dopamine, gamma-aminobutyric acid (GABA),

adenosine, histamine, hypocretin, melatonin, and cortisol appear to play roles in

changing sleep states (Monti, 2013). Wakefulness is maintained by the reticular

activating system in the brain. As the cycle of the reticular activating system

dwindles, neurotransmitters that promote sleep take over.

A nurse interviewing a client about sleep patterns is told that the client goes

to bed about 11 p.m. and usually falls asleep by 11:15 p.m. The nurse identifies

this as which time period?

A) Sleep latency

B) Sleep architecture

C) Sleep efficiency

D) Slow-wave sleep

Ans: A

Feedback:

Sleep latency is the time period measured from "lights out," or bedtime, to initiation of sleep. Sleep architecture is the pattern of non-rapid eye movement

(NREM) and rapid eye movement that are in approximately a 90- to 110-minute

cycle. Sleep occurs in stages, and the timing of sleep is regulated by circadian

rhythms. Sleep efficiency is the ratio of total sleep time to time in bed. Slow-wave

sleep is the deepest state of sleep occurring during stages 3 and 4 of NREM sleep.

A nursing instructor is describing the prevalence of sleep-wake disorders as

being greater among individuals with mental health disorders. Which disorders

would the instructor include as being associated with sleep-wake disorders?

Select all that apply.

A) Depression

B) Borderline personality disorder

C) Schizophrenia

D) Posttraumatic stress disorder

E) Anxiety

Ans: A, D

Feedback:

Sleep-wake disorders occur independent of a diagnosis of other mental disorders,

but they also occur in people with mental disorders. For example, a core feature

of posttraumatic stress disorder (PTSD) is sleep disturbance. Insomnia often

increases the risk for relapse of the mental disorder. Documented comorbid

conditions include cardiovascular disorders, diabetes, musculoskeletal disorders,

respiratory disorders, digestive disorders, pain conditions, and mental disorders

including depression, PTSD, and other sleep disorders such as sleep apnea and

restless legs syndrome. Obstructive sleep apnea is not associated with borderline

personality disorder or schizophrenia.

After teaching a class about circadian rhythm disorders, a nursing instructor

determines that the education was successful when the class identifies which subtype of this disorder according to the DSM-5. Select all that apply.

A) Delayed sleep phase

B) Nightmare

C) Sleep terror

D) Shift work type

E) Jet lag type

Ans: A, D

Feedback:

According to the DSM-5, subtypes of circadian rhythm disorders include a delayed

sleep phase and shift work type. Although jet lag type is a circadian rhythm

sleep-wake disorder, it is not included in the DSM-5. Nightmare and sleep terror

are separate disorders.