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A nurse working the night shift is watching the monitors on a telemetry unit and observes a slight increase in a patient's vital signs during sleep. Which of these points will the nurse correlate to changes in vital signs?
- A. They are aware of his surroundings at this point.
- B. They are in delta sleep at this time.
- C. It would be most difficult to awaken them at this time.
- D. This is most likely an NREM stage.
- E. This stage constitutes around 20% to 25% of total sleep.
- F. The muscles are relaxed in this stage.
Correct Answer: C,E
Rationale: This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. In stage IV NREM sleep (delta sleep), the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.
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A nurse caring for patients on a surgical unit should implement which recommendation to promote sleep?
- A. Keep the room light dimmed during the day.
- B. Maintain a cool temperature in the room for sleep.
- C. Keep the door of the room open for fresh air.
- D. Offer a hypnotic to patients on a regular basis.
- E. Offer pain medication prior to sleep, as needed.
- F. Provide earplugs if the patient agrees.
Correct Answer: B,E,F
Rationale: The nurse should keep the room cool and provide earplugs and eye masks if desired. The nurse should maintain a bright room environment during daylight hours and dim lights in the evening, keeping the door of the room closed to keep out extraneous noise. Sleep aid medications should only be offered as prescribed with the knowledge that they can become habit forming.
A nurse is providing education in a senior center on sleep and sleep hygiene in older adults. What teaching point will the nurse include?
- A. Drinking a cup of regular tea at night induces sleep.
- B. Using alcohol moderately promotes a deep sleep.
- C. Eating a bedtime snack high in tryptophan and carbohydrates improves sleep.
- D. Exercising right before bedtime can hinder sleep.
Correct Answer: C
Rationale: The nurse would teach that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.
A nurse observes involuntary muscle jerking in a sleeping patient. What action will the nurse take next?
- A. No action is necessary; this is normal in stage 1 sleep.
- B. Report the neurologic deficit to the health care provider.
- C. Lower the temperature in the patient's room.
- D. Awaken the patient, as this is an indication of night terrors.
Correct Answer: A
Rationale: Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. No further actions are needed for this patient.
A patient experiencing menopause tells the nurse at the medical clinic that she would like to try a CAH hormonal sleep aid like her friend uses. What information can the nurse give the patient?
- A. Melatonin, an over-the-counter hormonal sleep aid, has varied effectiveness.
- B. Lavender is a hormonal scented sleep aid.
- C. Lorazepam, a naturally occurring benzodiazepine, is recommended for sleep.
- D. Valerian is a natural hormonal sleep aid.
Correct Answer: A
Rationale: Melatonin, used as a complementary or alternate to traditional pharmacologic agents, is a hormone thought to regulate the sleep-wake cycle. Valerian is an herb; lavender is a plant used for aromatherapy and relaxation. Benzodiazepines are pharmacologic medications used to decrease anxiety and promote sleep and relaxation.
A nurse recommends that a patient with a sleep disorder keep a sleep diary. Which data will the nurse ask the patient to document?
- A. Daily mental activities
- B. Daily physical activities
- C. Morning and evening body temperature
- D. Daily measurement of fluid intake and output
- E. Presence of anxiety or worries affecting sleep
- F. Morning and evening blood pressure readings
Correct Answer: A,B,E
Rationale: A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is typically kept in the graphic record.