ATI: RN Comfort, Rest, and Sleep
Assessment 2.0
A client is caring for a client who takes OTC sleep aid medication every evening. Which
of the following findings should the nurse identify as a potential adverse effect of OTC
sleep aid medications?
a. Hyperactivity
b. Diarrhea
c. Excessive salivation
d. Urinary retention - ansd. Urinary retention
-The nurse should identify that OTC sleep aid medications can cause urinary retention,
as well as daytime drowsiness, dry mouth, visual disturbances, and constipation.
A nurse is assessing a client who reports difficulty staying awake during the day and
experiencing involuntary episodes of lost muscle tone. The nurse should identify that
these are manifestations of which of the following conditions?
a. Hypersomnia
b. Narcolepsy (NT2)
c. Narcolepsy (NT1)
d. Insomnia - ansc. Narcolepsy (NT1)
-The nurse should identify that the client is exhibiting manifestations of narcolepsy
(NT1). Narcolepsy (NT1) is a chronic sleep condition that is characterized by sudden
sleepiness and sudden periods of sleep accompanied by cataplexy, or episodes of
involuntary loss of muscle tone brought on by strong emotions, such as laughter. Clients
who have narcolepsy (NT1) with cataplexy lack hypocretin in their central nervous
system. Clients who have both NT1 and NT2 narcolepsy might experience nocturnal
hallucinations, paralysis while asleep, and vivid dreams.
A nurse is caring for a client who has a history of migraines. The client tells the nurse, "I
have not been sleeping well. My migraine headaches have returned after not having
one for over a year." The nurse should identify that which of the following are potential
contributing factors to the client's migraines? Select all that apply.
a. Sleep-wake homeostasis
b. Sensory overload
c. Sleep deprivation
d. Increased melatonin
e. Decreased hypocretin levels - ansb. Sensory overload
c. Sleep deprivation
, A nurse is caring for a client who has a new prescription for a nonbenzodiazepine
hypnotic to promote sleep. For which of the following adverse effects should the nurse
monitor the client?
a. Retrograde amnesia
b. Urinary discomfort
c. Dry mouth
d. Hallucinations - ansd. Hallucinations
-The nurse should monitor the client for hallucinations, which can be an adverse effect
of nonbenzodiazepine hypnotics.
A nurse is caring for a client who has narcolepsy (NT1) with cataplexy. The nurse
should identify that this condition is caused by a lack of which of the following
hormones?
a. Hypocretin
b. Melatonin
c. Estrogen
d. Insulin - ansa. Hypocretin
-Hypocretin is a hormone produced in the hypothalamus and is responsible for
maintaining alertness. Narcolepsy (NT1) with cataplexy is caused by a lack of
hypocretin.
A nurse is caring for a client who is being evaluated for obstructive sleep apnea. Which
of the following findings should the nurse identify as a risk factor for OSA?
a. Hypersomnia
b. Obesity
c. Active glossal muscle
d. History of tonsillectomy - ansb. Obesity
A nurse is caring for a client who is having difficulty falling asleep. Which of the following
interventions should the nurse implement to promote sleep for the client?
a. Offer the client a caffeinated beverage 3 hr before their bedtime.
b. Turn on client's tv before they go to bed.
c. Warm the temperature of the client's room before they go to bed.
d. Dim the lights in the client's room at bedtime. - ansd. Dim the lights in the client's
room at bedtime.
-The nurse should dim the lights in the client's room at bedtime to promote sleep for the
client. Dimming the lights in the client's room improves relaxation and makes it easier
for the client to fall asleep.
Assessment 2.0
A client is caring for a client who takes OTC sleep aid medication every evening. Which
of the following findings should the nurse identify as a potential adverse effect of OTC
sleep aid medications?
a. Hyperactivity
b. Diarrhea
c. Excessive salivation
d. Urinary retention - ansd. Urinary retention
-The nurse should identify that OTC sleep aid medications can cause urinary retention,
as well as daytime drowsiness, dry mouth, visual disturbances, and constipation.
A nurse is assessing a client who reports difficulty staying awake during the day and
experiencing involuntary episodes of lost muscle tone. The nurse should identify that
these are manifestations of which of the following conditions?
a. Hypersomnia
b. Narcolepsy (NT2)
c. Narcolepsy (NT1)
d. Insomnia - ansc. Narcolepsy (NT1)
-The nurse should identify that the client is exhibiting manifestations of narcolepsy
(NT1). Narcolepsy (NT1) is a chronic sleep condition that is characterized by sudden
sleepiness and sudden periods of sleep accompanied by cataplexy, or episodes of
involuntary loss of muscle tone brought on by strong emotions, such as laughter. Clients
who have narcolepsy (NT1) with cataplexy lack hypocretin in their central nervous
system. Clients who have both NT1 and NT2 narcolepsy might experience nocturnal
hallucinations, paralysis while asleep, and vivid dreams.
A nurse is caring for a client who has a history of migraines. The client tells the nurse, "I
have not been sleeping well. My migraine headaches have returned after not having
one for over a year." The nurse should identify that which of the following are potential
contributing factors to the client's migraines? Select all that apply.
a. Sleep-wake homeostasis
b. Sensory overload
c. Sleep deprivation
d. Increased melatonin
e. Decreased hypocretin levels - ansb. Sensory overload
c. Sleep deprivation
, A nurse is caring for a client who has a new prescription for a nonbenzodiazepine
hypnotic to promote sleep. For which of the following adverse effects should the nurse
monitor the client?
a. Retrograde amnesia
b. Urinary discomfort
c. Dry mouth
d. Hallucinations - ansd. Hallucinations
-The nurse should monitor the client for hallucinations, which can be an adverse effect
of nonbenzodiazepine hypnotics.
A nurse is caring for a client who has narcolepsy (NT1) with cataplexy. The nurse
should identify that this condition is caused by a lack of which of the following
hormones?
a. Hypocretin
b. Melatonin
c. Estrogen
d. Insulin - ansa. Hypocretin
-Hypocretin is a hormone produced in the hypothalamus and is responsible for
maintaining alertness. Narcolepsy (NT1) with cataplexy is caused by a lack of
hypocretin.
A nurse is caring for a client who is being evaluated for obstructive sleep apnea. Which
of the following findings should the nurse identify as a risk factor for OSA?
a. Hypersomnia
b. Obesity
c. Active glossal muscle
d. History of tonsillectomy - ansb. Obesity
A nurse is caring for a client who is having difficulty falling asleep. Which of the following
interventions should the nurse implement to promote sleep for the client?
a. Offer the client a caffeinated beverage 3 hr before their bedtime.
b. Turn on client's tv before they go to bed.
c. Warm the temperature of the client's room before they go to bed.
d. Dim the lights in the client's room at bedtime. - ansd. Dim the lights in the client's
room at bedtime.
-The nurse should dim the lights in the client's room at bedtime to promote sleep for the
client. Dimming the lights in the client's room improves relaxation and makes it easier
for the client to fall asleep.
