ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 35 : Rest and Sleep Questions
Question 1 of 5
A nurse observes involuntary muscle jerking in a sleeping patient. What action will the nurse take next?
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.
Question 2 of 5
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?
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.
Question 3 of 5
A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations?
Correct Answer: D,E,F
Rationale: Many adolescents do not get enough sleep due to the demands of school, activities, and part-time employment.
Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.
Question 4 of 5
A nurse is providing education in a senior center on sleep and sleep hygiene in older adults. What teaching point will the nurse include?
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.
Question 5 of 5
As part of interprofessional rounds, a nurse in a skilled facility assesses for sleep deficits. Patients with which health problems would the team identify as higher risk for sleep disturbances?
Correct Answer: A,B,C
Rationale: A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. Worries and anxiety can interfere with sleep, as can pain. A patient who has GERD may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.