NURS 6531: Insomnia Management in Primary
Care – 52-Year-Old with Sleep Maintenance &
Onset Insomnia
Complete Case Study with CBT-I,
Pharmacologic Update, and Exam Q&A |
2026/2027 latest Edition
SECTION 1: CASE PRESENTATION & INITIAL ASSESSMENT
(Questions 1-25)
Question 1:
A 52-year-old female teacher presents with a 4-month history of
difficulty falling asleep (30-45 minutes) and mid-nocturnal
awakening (2-3 AM, unable to return to sleep for >1 hour). Her
total sleep is ~4-5 hours/night, 4-5 nights/week. Which of the
following is the most appropriate next step?
A) Prescribe zolpidem 10 mg HS
B) Order polysomnography
C) Start CBT-I and sleep diary
D) Check TSH and ferritin
,Answer: C) Start CBT-I and sleep diary
Rationale: Insomnia is a clinical diagnosis. First-line management
is non-pharmacologic: Cognitive Behavioral Therapy for Insomnia
(CBT-I) and assessment via a 2-week sleep diary .
Polysomnography is only indicated if sleep-disordered breathing
or movement disorders are suspected . TSH and ferritin should be
checked only if suggested by ROS/PE (e.g., RLS symptoms) .
Question 2:
A 52-year-old female reports trouble falling asleep and staying
asleep for 4 months. Her Epworth Sleepiness Scale score is
12/24 (moderate daytime sleepiness). She denies snoring,
gasping, or restless legs. What is the most likely diagnosis?
A) Obstructive Sleep Apnea (OSA)
B) Generalized Anxiety Disorder (GAD)
C) Chronic Insomnia Disorder
D) Circadian Rhythm Disorder
Answer: C) Chronic Insomnia Disorder
Rationale: The patient meets criteria for chronic insomnia
disorder: difficulty initiating and maintaining sleep for >3 months
with daytime impairment . The absence of snoring/apneas rules
out OSA. While she has anxiety about sleep, the primary issue is
insomnia .
Question 3:
Which of the following findings would be a red flag for
secondary insomnia requiring further workup?
, A) Daytime fatigue
B) Difficulty initiating sleep
C) Nocturnal choking or gasping
D) Evening screen use
Answer: C) Nocturnal choking or gasping
Rationale: Red flags for secondary insomnia include symptoms
suggesting heart failure, COPD, thyroid disease, or substance use
. Nocturnal choking/gasping may indicate OSA or cardiac issues
. Daytime fatigue is expected with insomnia; evening screen use
is a behavioral contributor.
Question 4:
A patient with chronic insomnia has a normal physical exam (BMI
26.5, Mallampati II, no thyromegaly). Which diagnostic workup is
most appropriate?
A) Polysomnography
B) TSH, CBC, ferritin, B12, metabolic panel
C) Sleep diary and Insomnia Severity Index (ISI)
D) ECG and chest X-ray
Answer: C) Sleep diary and Insomnia Severity Index (ISI)
Rationale: The first-line assessment for chronic insomnia includes
a 2-week sleep diary and ISI to quantify severity . Labs (TSH,
CBC, ferritin, B12) are ordered only if suggested by
history/ROS . Polysomnography is not indicated unless OSA or
movement disorders are suspected .
Question 5:
Care – 52-Year-Old with Sleep Maintenance &
Onset Insomnia
Complete Case Study with CBT-I,
Pharmacologic Update, and Exam Q&A |
2026/2027 latest Edition
SECTION 1: CASE PRESENTATION & INITIAL ASSESSMENT
(Questions 1-25)
Question 1:
A 52-year-old female teacher presents with a 4-month history of
difficulty falling asleep (30-45 minutes) and mid-nocturnal
awakening (2-3 AM, unable to return to sleep for >1 hour). Her
total sleep is ~4-5 hours/night, 4-5 nights/week. Which of the
following is the most appropriate next step?
A) Prescribe zolpidem 10 mg HS
B) Order polysomnography
C) Start CBT-I and sleep diary
D) Check TSH and ferritin
,Answer: C) Start CBT-I and sleep diary
Rationale: Insomnia is a clinical diagnosis. First-line management
is non-pharmacologic: Cognitive Behavioral Therapy for Insomnia
(CBT-I) and assessment via a 2-week sleep diary .
Polysomnography is only indicated if sleep-disordered breathing
or movement disorders are suspected . TSH and ferritin should be
checked only if suggested by ROS/PE (e.g., RLS symptoms) .
Question 2:
A 52-year-old female reports trouble falling asleep and staying
asleep for 4 months. Her Epworth Sleepiness Scale score is
12/24 (moderate daytime sleepiness). She denies snoring,
gasping, or restless legs. What is the most likely diagnosis?
A) Obstructive Sleep Apnea (OSA)
B) Generalized Anxiety Disorder (GAD)
C) Chronic Insomnia Disorder
D) Circadian Rhythm Disorder
Answer: C) Chronic Insomnia Disorder
Rationale: The patient meets criteria for chronic insomnia
disorder: difficulty initiating and maintaining sleep for >3 months
with daytime impairment . The absence of snoring/apneas rules
out OSA. While she has anxiety about sleep, the primary issue is
insomnia .
Question 3:
Which of the following findings would be a red flag for
secondary insomnia requiring further workup?
, A) Daytime fatigue
B) Difficulty initiating sleep
C) Nocturnal choking or gasping
D) Evening screen use
Answer: C) Nocturnal choking or gasping
Rationale: Red flags for secondary insomnia include symptoms
suggesting heart failure, COPD, thyroid disease, or substance use
. Nocturnal choking/gasping may indicate OSA or cardiac issues
. Daytime fatigue is expected with insomnia; evening screen use
is a behavioral contributor.
Question 4:
A patient with chronic insomnia has a normal physical exam (BMI
26.5, Mallampati II, no thyromegaly). Which diagnostic workup is
most appropriate?
A) Polysomnography
B) TSH, CBC, ferritin, B12, metabolic panel
C) Sleep diary and Insomnia Severity Index (ISI)
D) ECG and chest X-ray
Answer: C) Sleep diary and Insomnia Severity Index (ISI)
Rationale: The first-line assessment for chronic insomnia includes
a 2-week sleep diary and ISI to quantify severity . Labs (TSH,
CBC, ferritin, B12) are ordered only if suggested by
history/ROS . Polysomnography is not indicated unless OSA or
movement disorders are suspected .
Question 5:
