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A student nurse is preparing a nursing care plan for a client who has 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
Correct Answer: A
Rationale: Sleep deprivation increases the risk for injury (A) due to impaired coordination and cognition, making it a priority. Ineffective coping (B), deficient knowledge (C), and anxiety (D) are secondary concerns compared to safety risks.
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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 of the following?
- 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.
Correct Answer: A
Rationale: Sleep patterns change across the lifespan (A), with aging affecting sleep duration and quality, indicating a need for review. Women reporting more sleep issues (B), night shifts (C), and environmental influences (D) are accurate.
The nurse is assessing the sleep patterns of a 70-year-old female client with a mental disorder. Based on the knowledge of circadian rhythms and the influence of age, which of the following would the nurse anticipate that the client would report about her 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 am sleepier at night and more alert in the morning.
- C. When I worked days, I?d always have trouble feeling sleepy in the morning.
- D. When I was younger, the amount of sleep I got didn?t seem to matter.
Correct Answer: B
Rationale: Aging shifts circadian rhythms, often leading to earlier sleepiness and morning alertness (B), a pattern known as advanced sleep phase syndrome. Options (A), (C), and (D) do not reflect typical age-related changes in circadian rhythms.
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 my wife doesn?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 I took sleeping pills when I was younger.
Correct Answer: A
Rationale: Hallucinations while falling asleep (A) are hypnagogic hallucinations, a hallmark of narcolepsy. Restless legs (B) suggest restless leg syndrome, worry (C) indicates insomnia, and past sleeping pill use (D) is unrelated to narcolepsy.
The nurse is discussing sleep enhancing strategies with a client who is experiencing insomnia. Which of the following 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 up in the morning.
Correct Answer: D
Rationale: Establishing a regular sleep schedule (D) promotes circadian rhythm stability, a key strategy for insomnia. Eating before bed (A) can disrupt sleep, exercise close to bedtime (B) may increase arousal, and tea (C) may contain caffeine, worsening insomnia.
After teaching a class about circadian rhythm disorders, a nursing instructor determines that the teaching was successful when the class identifies which of the following as a subtype? Select all that apply.
- A. Delayed sleep phase
- B. Nightmare
- C. Sleep terror
- D. Jet lag
- E. Shift work
Correct Answer: A,D,E
Rationale: Circadian rhythm disorders include delayed sleep phase (A), jet lag (D), and shift work (E) disorders, which disrupt sleep-wake timing. Nightmare (B) and sleep terror (C) are parasomnias, not circadian disorders.