Chapter 19- Sleep Wake Disorders

Question 1

1. A nurse cares for these four patients. Which patient has the highest risk for problems with sleep physiology?
   a.
   Retiree who volunteers twice a week at Habitat for Humanity
   b.
   Corporate accountant who travels frequently
   c.
   Parent with three teenagers
   d.
   Lawn care worker

Answer 1

ANS: B
The corporate accountant is likely to work long hours and have significant stress associated with work demands. Compounded by travel, these factors are likely to precipitate unstable sleep patterns and inadequate sleep time. The retiree and lawn care worker engage in physical activity during the day, which will promote natural fatigue and sleep. The parent’s sleep is unlikely to be disturbed; teenagers sleep through the night.

Question 2

2. Which comment is most likely from a patient with chronic sleep deprivation?
   a.
   “I turn on the television every night to get to sleep. I set the timer so it goes off in 30 minutes.”
   b.
   “I have diarrhea frequently and not much energy, so I stay at home most of the time.”
   c.
   “I only sleep about 7 hours a night, but I know I should sleep 8 or 9 hours.”
   d.
   “When my alarm clock goes off every morning, it seems like I am dreaming.”

Answer 2

ANS: B
A discrepancy between hours of sleep obtained and hours required leads to sleep deprivation. Adults with less than 6 hours of sleep per night often suffer from chronic sleep deprivation. Common complaints include poor general health, physical and mental distress, limitations in ADLs, depressive or anxious symptoms, and pain. One distracter indicates a problem with sleep hygiene (television). The remaining distracters do not indicate a problem.

Question 3

3. The nurse provides health education for an adult experiencing sleep deprivation. Which instruction has the highest priority?
   a.
   “It’s important to limit your driving to short periods. Sleep deprivation increases your risks for serious accidents.”
   b.
   “Sleep deprivation is usually self-limiting. See your health care provider if it lasts more than a year.”
   c.
   “Turn the radio on with a soft volume as you prepare for bed each evening. It will help you relax.”
   d.
   “Three glasses of wine each evening helps many patients who suffer from sleep deprivation.”

Answer 3

ANS: A
Safety is the highest priority for this patient. Sleep deprivation causes psychomotor deficits. Driver drowsiness and fatigue lead to many automobile injuries and fatalities. Alcohol compounds problems associated with sleep deprivation. Sleep deprivation should be evaluated and treated; a 1-year delay is too long.

Question 4

4.	A nurse provides health education for an adult with sleep deprivation. It is most important for the nurse to encourage caution when the patient engages in
a.
using a vacuum cleaner.
b.
cooking a meal.
c.
driving a car.
d.
bathing.

Answer 4

ANS: C
Safety is the highest priority for this patient. Sleep deprivation causes psychomotor deficits. Driver drowsiness and fatigue lead to many automobile injuries and fatalities. The distracters are less likely to be associated with serious injury.

Question 5

5.	A patient needs diagnostic evaluation of sleep problems. Which test will evaluate the patient for possible sleep-related problems?
a.
Skull x-rays
b.
Electroencephalogram (EEG)
c.
Positron emission tomography (PET)
d.
Single photon emission computed tomography (SPECT)

Answer 5

ANS: B
EEG measures nonrapid eye movement (NREM) and rapid eye movement (REM) sleep. The distracters represent ways to diagnose structural and metabolic problems.

Question 6

6.	A patient says, “It takes me about 15 minutes to go to sleep each night.” This comment describes
a.
delta sleep.
b.
parasomnia.
c.
sleep latency.
d.
REM sleep.

Answer 6

ANS: C
Sleep latency refers to the amount of time it takes a person to fall asleep. The distracters represent other phases of the sleep cycle.

Question 7

7. A person says, “I often feel like I have been dreaming just before I awake in the morning.” Which rationale correctly explains the comment?
   a.
   Sleep architecture changes during the sleep period, resulting in increased slow-wave sleep at the end of the cycle.
   b.
   Cycles of REM sleep increase in the second half of sleep and occupy longer periods.
   c.
   Dreams occur more frequently when a person is experiencing unresolved conflicts or depression.
   d.
   Dream content relates directly to developmental tasks. The person is likely feeling autonomous.

Answer 7

ANS: B
Cycles of REM sleep increase in the second half of sleep and occupy longer periods, up to 1 hour. Dreaming occurs during REM sleep. The question relates to sleep architecture rather than dream content.

Question 8

8. Which person would be most likely to experience sleep fragmentation?
   a.
   An obese adult
   b.
   A toddler who attends day care
   c.
   A person diagnosed with mild osteoarthritis
   d.
   An adolescent diagnosed with anorexia nervosa

Answer 8

ANS: A
Obese adults experience more disruption of sleep stages, resulting in fragmentation. Obesity is the leading factor for obstructive sleep apnea, which causes sleep fragmentation. These changes are also associated with illness and some medications. The changes are evident on a hypnogram. An adolescent with anorexia nervosa would have a low body weight and therefore decreased risk for sleep fragmentation. Persons with arthritis have pain that may sometimes interrupt sleep, but it would not have as high risk as would obesity. Toddlers do not generally experience sleep fragmentation.

Question 9

9.	A person is prescribed lorazepam 2 mg PO bid as needed for anxiety. When the person takes this medication, which change in sleep is anticipated? The patient will
a.
have fewer dreams.
b.
have less slow-wave sleep.
c.
experience extended sleep latency.
d.
enter sleep through REM sleep.

Answer 9

ANS: B
Lorazepam is a benzodiazepine, which reduces slow-wave sleep. REM sleep would likely increase. Persons with narcolepsy often enter sleep through REM.

Question 10

10.	A person is prescribed sertraline 100 mg PO daily. Which change in sleep is likely secondary to this medication? The patient will have
a.
more dreams.
b.
excessive sleepiness.
c.
less slow-wave sleep.
d.
less REM sleep.

Answer 10

ANS: D
Sertraline (Zoloft) is an SSRI antidepressant medication, which suppresses REM sleep. Dreams would decrease because they occur during REM. Benzodiazepines reduce slow-wave sleep. SSRIs have a side effect of insomnia.

Question 11

11.	Which season would be most associated with increased periods of wakefulness in the general population?
a.
Summer
b.
Winter
c.
Spring
d.
Fall

Answer 11

ANS: A
Circadian drive is associated with physiology. Light is the main exogenous factor that drives wakefulness. Days are longest in summer.

Question 12

12. Normally, most people sleep at night. What is the physiological rationale?
    a.
    The master biological clock responds to darkness with sleep.
    b.
    Darkness stimulates histamine release, which promotes sleep.
    c.
    Cooler environmental temperatures stimulate retinal messages.
    d.
    Stimulation of the sympathetic nervous system promotes sleep.

Answer 12

ANS: A
The master biological clock in the suprachiasmatic nucleus (SCN) of the hypothalamus regulates sleep as well as other physiological processes. Darkness cues the clock for sleep. Light cues it for wakefulness. Light stimulates retinal messages. Histamine release is associated with wakefulness. Stimulation of the sympathetic nervous system promotes alertness.

Question 13

13. A nurse counsels a patient on ways to determine the person’s total sleep requirement. Which instruction would produce the most accurate results?
    a.
    “For 1 full week, record what you remember about your dream content and related feelings as soon as you wake up. Bring the record to your next appointment.”
    b.
    “While off work for 1 week, go to bed at your usual time and wake up without an alarm. Record how many hours you sleep and then average the findings.”
    c.
    “For 2 full weeks, record how much time you sleep each night and rate your daytime alertness on a scale of 1 to 10. Calculate your average alertness score.”
    d.
    “All adults need 7 or 8 hours of sleep to function properly. Let’s design ways to help you reach that goal.”

Answer 13

ANS: B
Sleep requirements are most accurately determined by going to bed at the usual time and waking up without an alarm for several nights, ideally on vacation. The average of these findings indicates the estimated requirements. Two distracters relate to dream content and daytime alertness. Some adults are long sleepers or short sleepers with different requirements for sleep from the general population.

Question 14

14. A home care nurse assesses a very demanding patient with chronic obstructive pulmonary disease (COPD). Afterward, the nurse talks with the spouse who has provided this patient’s care for 6 years. The spouse says, “I don’t need much sleep anymore. I might need to help him during the night.” Select the nurse’s most therapeutic response.
    a.
    “It sounds like you are very devoted to your spouse.”
    b.
    “I noticed you fell asleep while I was assessing your spouse. I’m concerned about you.”
    c.
    “Your spouse is lucky to have you to provide care rather than being placed in a nursing home.”
    d.
    “If you keep going like this, your health will be impaired also. Then who will take care of both of you?”

Answer 14

ANS: B
Sleep deprivation can cause accidents. The correct answer makes an observation, gives important information about safety, and communicates care and compassion for the spouse. The distracters do not invite further dialogue with the spouse.

Question 15

15. A patient with rheumatoid arthritis reports, “For the past month I’ve had trouble falling asleep. When I finally get to sleep, I wake up several times during the night.” Which information should the nurse seek initially?
    a.
    “What have you done to try to improve your sleep?”
    b.
    “What would be a good sleep pattern for you?”
    c.
    “How much exercise are you getting?”
    d.
    “Do you have pain at night?”

Answer 15

ANS: D
Patients with diseases such as arthritis may have sleep disturbance related to nightly pain. Because the pain is chronic, the patient may fail to realize it is the reason for the inability to sleep. The other options do not follow the patient’s lead or begin problem solving without an adequate baseline.

Question 16

16.	A 76-year-old man tells the nurse at the sleep disorder clinic, “I awaken almost nightly in the midst of violent dreams in which I am defending myself against multiple attackers. Then I realize I have been hitting and kicking my wife. She has bruises.” Which health problem is most likely?
a.
Sleep paralysis
b.
Night terror disorder
c.
Sleep-related bruxism
d.
REM Sleep Behavior Disorder

Answer 16

ANS: D
The scenario describes REM sleep behavior disorder in which the patient engages in violent and complex behaviors during REM sleep as though acting out his dreams. Older men have a higher incidence of this problem. Sleep paralysis refers to the sudden inability to perform voluntary movement at either sleep onset or awakening from sleep. Bruxism refers to grinding teeth during stage 2 sleep. Night terror disorder occurs as arousal in the first third of the night during NREM sleep, accompanied by feelings of panic.

Question 17

17.	A patient reports, “Nearly every night I awaken feeling frightened after a bad dream. The dream usually involves being hunted by people trying to hurt me. It usually happens between 4 and 5 AM.” The nurse assesses this disorder as most consistent with criteria for which problem?
a.
Sleep deprivation
b.
Nightmare disorder
c.
Night terror disorder
d.
REM sleep behavior disorder

Answer 17

ANS: B
Nightmares are long, frightening dreams from which people awaken in a frightened state. They occur during REM sleep late in the night. Night terror disorder occurs as arousal in the first third of the night during NREM sleep and is accompanied by feelings of panic. REM sleep behavior disorder involves acting out a violent dream during REM sleep. Nightmare disorder may lead to sleep deprivation.

Question 18

18. A nurse who works night shift says, “I am exhausted most of the time. I sleep through my alarm. Sometimes my brain does not seem to work right. I am worried that I might make a practice error.” Which question should the nursing supervisor ask first?
    a.
    “What stress are you experiencing in your life?”
    b.
    “How much sleep do you get in a 24-hour period?”
    c.
    “Would it help if you do some exercises just before going to bed?”
    d.
    “Have you considered using a hypnotic medication to help you sleep?”

Answer 18

ANS: B
Total sleep hours should be ascertained before seeking to correct a sleep disorder. In this case, the patient describes sleep deprivation symptoms rather than a sleep disorder. The correct response is the only option that addresses total sleep hours.

Question 19

19.	A patient reports, “The medicine prescribed to help me get to sleep worked well for about a month, but I don’t have any more of those pills. Now my insomnia is worse than ever. I had nightmares the last 2 nights.” Which type of medication did the health care provider most likely prescribe?
a.
Benzodiazepine
b.
Tricyclic antidepressant
c.
Conventional antipsychotic
d.
Central nervous system (CNS) stimulant

Answer 19

ANS:	A
Benzodiazepines, members of the hypnotic’s family of medications, can worsen existing sleep disturbances when they are discontinued. This class of medications produces tolerance. Once the drug is discontinued, the individual may have rebound insomnia and nightmares. CNS stimulants worsen insomnia while they are in use. Tricyclic antidepressants and atypical antipsychotics may help insomnia but would not be used for initial therapy.

Question 20

20. A patient experiencing primary insomnia asks the nurse, “I take a nap during the day. Doesn’t that make up for a lost night’s sleep?” Select the nurse’s best reply.
    a.
    “Circadian drives give daytime naps a structure different from nighttime sleep.”
    b.
    “The body clock operates on a 24-hour cycle, making nap effectiveness unpredictable.”
    c.
    “It is a matter of habit and expectation. We expect to be more refreshed from a night’s sleep.”
    d.
    “Sleep restores homeostasis but works more efficiently when aided by melatonin secreted at night.”

Answer 20

ANS: A
Regular sleep cycles occur with nighttime sleep, with progression through two distinct physiological states: four stages of NREM and a period of REM sleep. Naps often contain different amounts of REM sleep, thus changing the physiology of sleep as well as the psychological and behavioral effects of sleep.

Question 21

22.	A patient says, “I have trouble falling asleep at night and might lie awake until 3 or 4 AM before falling sleep.” Which medication would the nurse expect a health care provider to prescribe for this patient?
a.
zolpidem
b.
flurazepam
c.
risperidone
d.
methylphenidate

Answer 21

ANS: A
Zolpidem is a short-acting hypnotic that will help the patient initiate sleep and awaken without untoward symptoms of drowsiness. Methylphenidate is a CNS stimulant. Flurazepam is a long-acting hypnotic that will produce hangover drowsiness during the next day. Risperidone is an antipsychotic and not likely to be useful in this scenario. See relationship to audience response question.

Question 22

23. A young adult says to the nurse, “I go to sleep without any problem, but I often wake up during the night because it feels like there are rubber bands in my legs.” Which assessment question should the nurse ask to assess for restless legs syndrome (RLS)?
    a.
    “What type of birth control do you use?”
    b.
    “How much caffeine do you use every day?”
    c.
    “How much exercise do you get in a typical day?”
    d.
    “Does anyone else in your family have this problem?”

Answer 22

ANS: D
RLS is a sensory and movement disorder characterized by an unpleasant, uncomfortable sensation in the legs accompanied by an urge to move. Symptoms begin or worsen during periods of inactivity, such as sleep. Symptoms can have a significant impact on the individual’s ability to fall asleep and stay asleep. There is likely to be a strong genetic component, especially when seen in individuals less than 40 years old.

Question 23

1.	Which neurotransmitters are most responsible for wakefulness? (Select all that apply.)
a.
γ-aminobutyric acid (GABA)
b.
Norepinephrine
c.
Acetylcholine
d.
Dopamine
e.
Galanin

Answer 23

ANS: B, C, D
The neurotransmitters responsible for wakefulness are dopamine, norepinephrine, serotonin, acetylcholine, histamine, glutamate, and hypocretin. GABA and galanin are sleep-promoting neurotransmitters.

Question 24

2. A night shift worker reports, “I’m having trouble getting to sleep after a night’s work. I have a hearty breakfast with coffee, read the paper, do my exercises, and then go to bed. However, I just lie awake until it is nearly time to get up to be with my family for dinner.” What changes should the nurse suggest? (Select all that apply.)
   a.
   Drink juice with breakfast rather than coffee.
   b.
   Exercise after awakening rather than before.
   c.
   Turn on the television when going to bed.
   d.
   Do not read the paper.
   e.
   Eat a light breakfast.

Answer 24

ANS: A, B, E
Sleep can be disrupted by caffeine, a CNS stimulant, exercise performed just before trying to sleep, and eating a heavy meal before retiring. Reading the newspaper is not likely to be so stimulating that it disrupts the patient’s ability to sleep. Television will be disruptive to sleep.

Question 25

3. A new patient at the sleep disorders clinic tells the nurse, “I have not slept well in a year, so I never feel good. I do not expect things will ever improve or be any different.” Interventions the nurse should consider include (Select all that apply)
   a.
   suggesting use of alcohol as a sedative.
   b.
   providing instruction in relaxation techniques.
   c.
   counseling the patient to address cognitive distortions.
   d.
   health teaching regarding factors that influence sleep.
   e.
   teaching fatigue-producing activities to become overtired.
   f.
   encouraging long daytime naps to compensate for sleep deprivation.

Answer 25

ANS: B, C, D
Interventions that could be helpful include teaching relaxation techniques, such as meditation or progressive relaxation, to relieve the tension that sometimes prevents initiation of sleep. Reviewing factors that influence sleep can assist the patient to diagnose and remove barriers to sleep. Cognitive therapy could be helpful in combating the hopelessness verbalized by the patient. Alcohol consumption actually disrupts sleep. Becoming overtired may be a barrier to nighttime sleep. Naps may help replace lost sleep, but lengthy daytime sleep will prevent the patient from sleeping well at night.