C HAPTER 43: S LEEP
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. A client is discussing his recent restlessness and increased irritabilit y.
Which of the following assessment questions is likel y to be most helping
in determining the cause of these complaints?
A. When did you start noticing these changes?
B. Has anything caused you to change your usual routine latel y?
C. Do you have any idea what might be causing these problems?
D. What makes you think that you are more irritable than is normal for
you?
ANS: B
When the sleep -wake cycle becomes disrupted (e.g., by working
rotating shifts), other physiological functions usuall y change as well.
For example, the person experiences a decreased appetite and loses
weight. Anxiet y, rest lessness, irritabilit y, and impaired judgment are
other common symptoms of sleep cycle disturbances. Failure to
maintain the individuals usual sleep - wake cycle negativel y influences
the clients overall health. Although the other options are not
inappropri ate, they are not as directl y aimed at determining the cause
of the changes.
, DIF: C REF: 1030 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Physiological
Integrit y/Basic Care and Comfort/Rest and Sleep
2. The nurse and a client are discussing possible behaviors that might be
interfering with the clients abilit y to fall asleep. Which of the following
assessment questions is most likel y to identify possible problems with the
clients sleep routine that possibl y are contribut ing to the difficult y?
A. When do you usuall y retire for the night?
B. What do you do to help yourself fall asleep?
C. How much time does it usuall y take for you to fall asleep?
D. Have you changed anything about your presleep ritual latel y?
ANS: B
As people try to fall asleep, they close their eyes and assume relaxed
positions. Stimuli to the RAS decline. If the room is dark and quiet,
activation of the RAS further declines. At some point the BSR takes
over, causing sleep. If the client engages in activities such as reading
or watching television as a means of falling asleep, this could be
causing the problem. Although the other questions are not
inappropriate, they are not as directed toward the cause of the problem.
DIF: C REF: 1029 OBJ: Anal ysis TOP: Nursing Pro cess:
Assessment MSC: NC LEX test plan designation: Physiological
Integrit y/Basic Care and Comfort/Rest and Sleep
3. An older adult client diagnosed as being in the earl y stage of Alzheimers
disease shares with the nurse that her sleep is interrupted by the noises I
, hear all through the night. The nurse explains that the most likel y reason
for this problem is:
A. The clients age
B. A lack of presleep relaxation
C. The amount of noise entering into the clients environment
D. A manifestation of the disease process causing the brain disorder
ANS: A
With aging, sleep becomes more fragmented, and a person spends more
time in lighter stages that are easil y disturbed by noise. The remaining
options may be a factor but not to the degree of normal aging.
DIF: C REF: 1035 OBJ: A nal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation:
Physiological Integrity/Basic Care and Comfort/Rest and Sleep
4. A 9-year-old client asks the nurse, Why do I need to sleep? The nurses
most age-appropriate, informative respons e is:
A. Everyone needs to sleep to feel rested.
B. It gives your body a chance to reall y rest.
C. You’ll be able to do so much better in school if you ’re rested.
D. Your body needs to rest in order to grow and be reall y healthy.
ANS: D
Sleep contributes to physiolo gical and psychological restoration,
maintenance, and growth of the body at any age. The remaining options
are not as effective at providing a thorough answer to the childs
, question. The body needs sleep to routinely restore biological
processes.
DIF: C REF: 1030 OBJ: Anal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation:
Physiological Integrity/Basic Care and Comfort/Rest and Sleep
5. A client has reported to the nurse that his sprained ankle resulted from a
careless accident. I s eem so clumsy and unfocused latel y. Which of the
following assessment questions is most likel y to reveal information
regarding the cause of these symptoms?
A. How many accidents have you had latel y?
B. Have the accidents resulted in serious injuries?
C. Have there been any changes in your daily routine latel y?
D. Do you have any idea what is responsible for this lack of focus?
ANS: D
A loss of REM sleep leads to feelings of confusion and suspicion.
Various body functions (e.g., mood, motor performance, memory, and
equilibrium) are altered when prolonged sleep loss occurs. Research
estimates that traffic, home, and work -related accidents caused by
falling asleep are often a result of sleep loss. This answer is the best
question because it directl y opens up the opportu nit y for the client to
discuss possible sleep problems if they exist. The other questions are
not inappropriate but are less likel y to reveal the possible cause of the
accidents.
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. A client is discussing his recent restlessness and increased irritabilit y.
Which of the following assessment questions is likel y to be most helping
in determining the cause of these complaints?
A. When did you start noticing these changes?
B. Has anything caused you to change your usual routine latel y?
C. Do you have any idea what might be causing these problems?
D. What makes you think that you are more irritable than is normal for
you?
ANS: B
When the sleep -wake cycle becomes disrupted (e.g., by working
rotating shifts), other physiological functions usuall y change as well.
For example, the person experiences a decreased appetite and loses
weight. Anxiet y, rest lessness, irritabilit y, and impaired judgment are
other common symptoms of sleep cycle disturbances. Failure to
maintain the individuals usual sleep - wake cycle negativel y influences
the clients overall health. Although the other options are not
inappropri ate, they are not as directl y aimed at determining the cause
of the changes.
, DIF: C REF: 1030 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Physiological
Integrit y/Basic Care and Comfort/Rest and Sleep
2. The nurse and a client are discussing possible behaviors that might be
interfering with the clients abilit y to fall asleep. Which of the following
assessment questions is most likel y to identify possible problems with the
clients sleep routine that possibl y are contribut ing to the difficult y?
A. When do you usuall y retire for the night?
B. What do you do to help yourself fall asleep?
C. How much time does it usuall y take for you to fall asleep?
D. Have you changed anything about your presleep ritual latel y?
ANS: B
As people try to fall asleep, they close their eyes and assume relaxed
positions. Stimuli to the RAS decline. If the room is dark and quiet,
activation of the RAS further declines. At some point the BSR takes
over, causing sleep. If the client engages in activities such as reading
or watching television as a means of falling asleep, this could be
causing the problem. Although the other questions are not
inappropriate, they are not as directed toward the cause of the problem.
DIF: C REF: 1029 OBJ: Anal ysis TOP: Nursing Pro cess:
Assessment MSC: NC LEX test plan designation: Physiological
Integrit y/Basic Care and Comfort/Rest and Sleep
3. An older adult client diagnosed as being in the earl y stage of Alzheimers
disease shares with the nurse that her sleep is interrupted by the noises I
, hear all through the night. The nurse explains that the most likel y reason
for this problem is:
A. The clients age
B. A lack of presleep relaxation
C. The amount of noise entering into the clients environment
D. A manifestation of the disease process causing the brain disorder
ANS: A
With aging, sleep becomes more fragmented, and a person spends more
time in lighter stages that are easil y disturbed by noise. The remaining
options may be a factor but not to the degree of normal aging.
DIF: C REF: 1035 OBJ: A nal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation:
Physiological Integrity/Basic Care and Comfort/Rest and Sleep
4. A 9-year-old client asks the nurse, Why do I need to sleep? The nurses
most age-appropriate, informative respons e is:
A. Everyone needs to sleep to feel rested.
B. It gives your body a chance to reall y rest.
C. You’ll be able to do so much better in school if you ’re rested.
D. Your body needs to rest in order to grow and be reall y healthy.
ANS: D
Sleep contributes to physiolo gical and psychological restoration,
maintenance, and growth of the body at any age. The remaining options
are not as effective at providing a thorough answer to the childs
, question. The body needs sleep to routinely restore biological
processes.
DIF: C REF: 1030 OBJ: Anal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation:
Physiological Integrity/Basic Care and Comfort/Rest and Sleep
5. A client has reported to the nurse that his sprained ankle resulted from a
careless accident. I s eem so clumsy and unfocused latel y. Which of the
following assessment questions is most likel y to reveal information
regarding the cause of these symptoms?
A. How many accidents have you had latel y?
B. Have the accidents resulted in serious injuries?
C. Have there been any changes in your daily routine latel y?
D. Do you have any idea what is responsible for this lack of focus?
ANS: D
A loss of REM sleep leads to feelings of confusion and suspicion.
Various body functions (e.g., mood, motor performance, memory, and
equilibrium) are altered when prolonged sleep loss occurs. Research
estimates that traffic, home, and work -related accidents caused by
falling asleep are often a result of sleep loss. This answer is the best
question because it directl y opens up the opportu nit y for the client to
discuss possible sleep problems if they exist. The other questions are
not inappropriate but are less likel y to reveal the possible cause of the
accidents.
