ATI Engage Fundamentals: Comfort, Rest, and Sleep (With Rationale)

ATI Engage Fundamentals: Comfort, Rest, and Sleep (With Rationale) A nurse is collecting data from 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 C. 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 contributing to the plan of care for a client who is postoperative. Which of the following interventions should the nurse recommend including to promote emotional comfort for the client? A. Encourage the client to verbalize their needs and concerns. B. Limit time spent with client. C. Ask the client to splint the incision when coughing. D. Administer pain medications as prescribed. A. Encourage the client to verbalize their needs and concerns. The nurse should encourage the client to verbalize their needs and concerns. Listening to the client's concerns and incorporating those concerns into the plan of care promotes client comfort by allowing the client to feel valued and that they are a vital part of the process. 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 affects should the nurse monitor the client? A. Retrograde amnesia B. Urinary discomfort C. Dry mouth D. Hallucinations D. 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 needs to be awakened for the administration of an oral medication. Which of the following findings should indicate to the nurse that the client was in stage 3 of the sleep cycle when awakened? A. The client was easily awakened. B. The client states that they were having a pleasant dream. C. The client experiences mental cloudiness for 30 to 60 min. D. Prior to being awakened, the client's breathing was irregular and their heart rate was elevated. C. The client experiences mental cloudiness for 30 to 60 min. Stage 3 of the sleep cycle is the deepest stage of sleep in which muscle, tissue, and bones regenerate and the immune system strengthens. If a client is awakened during stage 3 of the sleep cycle, the nurse should expect the client to experience mental cloudiness for 30 to 60 min. A nurse is discussing the stages of the sleep cycle with a client. The nurse should include that the immune system is strengthened and tissues and bones are repaired during which of the following stages of sleep cycle? A.Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 C. Stage 3 The nurse should include that the immune system is strengthened and tissues and bones are repaired during stage 3 of the sleep cycle. A nurse is caring for a client who was admitted following a report of lumbar pain. In addition to administering pain medications, which of the following interventions should the nurse implement to promote comfort? A. Present information honestly. B. Have another nurse present difficult information. C. Do not include the client's concerns in the plan of care if they interfere with treatment. D. Perform cognitive behavioral therapy with the client. A. Present information honestly. Presenting information and answering questions honestly can help the client to feel safe. The nurse should also be present to respond to client needs and should remain supportive of the client's choices. A nurse is reinforcing teaching about the concept of comfort with a newly hired assistive personnel (AP). Which of the following statements by the AP indicates an understanding of comfort? A. "Providing comfort for a client is achieved by the relief of physical pain through the administration of medication." B. "Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy." C. "Providing comfort for a client is achieved by taking control of the client's care and creating routines for the client to become familiar with." D. "Providing comfort to a client requires staff members to smile and remain cheerful no matter the outcome the client is facing." B. "Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy." Providing comfort to a client involves easement of mental distress, as well as physical distress. 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 the client's television 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. D. 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. A nurse is caring for a client who takes an over-the-counter (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 D. 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 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 B. Sensory overload is correct. Sensory overload can lead to sleep deprivation and is a possible contributing factor to the client's new onset of migraine headaches. C. Sleep deprivation is correct. Sleep deprivation has been known to trigger migraines. Therefore, the nurse should identify that sleep deprivation is a potential contributing factor to the client's new onset of migraine headaches.