Nokea
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 female client who is receiving counseling at a community health center has complained about being unable to sleep at each of the last three weekly sessions. The 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 her and us.
- D. It?s been exhausting living with her these past few weeks.
Correct Answer: D
Rationale: Chronic insomnia can strain family dynamics, leading to exhaustion (D) due to disrupted routines or irritability. Minimal impact (A), no change in relationships (B), or positive effects (C) are less likely given insomnia?s negative effects.
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.
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.
A nurse is preparing a presentation on sleep disorders for a community group. Which of the following would the nurse include when explaining the differences between 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 apnea syndrome can experience temporary paralysis with naps.
- D. Naps are not recommended for clients with narcolepsy because of their association with severe loss of muscle tone.
Correct Answer: B
Rationale: Narcolepsy involves refreshing naps (B), unlike obstructive sleep apnea (OSA), where naps are non-restorative due to fragmented sleep. Symptoms differ significantly (A), paralysis is specific to narcolepsy (C), and naps are beneficial for narcolepsy (D).
A client 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 behavior therapy
- D. Stimulus control
Correct Answer: D
Rationale: Avoiding non-sleep activities in the bedroom is a stimulus control technique (D), strengthening the bed-sleep association. Sleep restriction (A) limits time in bed, relaxation training (B) focuses on calming techniques, and cognitive behavior therapy (C) is broader.