CHAPTER 8: Sleep and Sleep Disorders 1. Which statement about sleep is accurate? a. Lack of sleep causes medical and psychiatric disorders. b. Adults generally require at least 5 hours of sleep every 24 hours. c. During sleep an individual is not consciously aware of his or her environment. d. Less than 10% of adults report at least one sleep problem, such as difficulty falling asleep. Explain: Lack of sleep does not cause medical and psychiatric disorders, although people with these diagnoses may have fragmented sleep. Most adults need 7 to 8 hours of sleep per day. In 2011, 87% of Americans reported sleep problems. 2. What are clinical manifestations of insomnia (select all that apply)? a. Narcolepsy b. Fragmented sleep c. Long sleep latency d. Morning headache e. Daytime sleepiness f. Difficulty concentrating explain: Manifestations of insomnia include difficulty falling asleep, frequent awakenings, prolonged nighttime awakening or awakening too early and not being able to fall back to sleep, and feeling unrefreshed on awakening and having daytime sleepiness and difficulty concentrating. 3. What is a typical parasomnia? a. Cataplexy b. Hypopnea c. Sleep apnea d. Sleep terrors explain: Parasomnias are unusual and often undesirable behaviors that occur while falling asleep, transitioning between sleep stages, or arousing from sleep. Cataplexy is brief and sudden loss of skeletal muscle tone and is experienced with narcolepsy episodes. Hypopnea is shallow respirations and sleep apnea is the cessation of spontaneous respirations for longer than 10 seconds. 4. What controls the cyclic changes between waking and sleep? a. Fluctuating levels of melatonin b. The environmental light-dark cycles c. Key nuclei in the brainstem, hypothalamus, and thalamus d. A variety of neuropeptides released from the nervous system explain: The nervous system controls the cyclic changes of wake and sleep through a complex arrangement of structures with key nuclei in the brainstem, hypothalamus, and thalamus. Melatonin is an endogenous hormone that increases sleep efficiency and is released in the evening. The light-dark cycles influence our circadian rhythms and neuropeptides influence wake behavior. These all play a role in the sleep/wake cycle and are components of the nervous system. 5. Match the descriptions to the stages of sleep. Some descriptions may have more than one stage and some stages may be used more than once. 1. NREM stage 1: Person easily awakened; Slow eye movements 2. NREM stage 2: Associated with specific EEG waveforms; Most of the night of sleep; Slowed heart rate, decreased body temperature. 3. NREM stage 3: Deepest sleep, lasting 20 to 40 minutes; Associated with specific EEG waveforms; Most vivid dreaming occurs; Decreased occurrence in older adults. 4. REM: Brain waves resemble wakefulness; 20% to 25% of sleep. 6. List at least three behaviors or practices that can contribute to insomnia: Any three of these can contribute to insomnia: • Consumption of stimulants (caffeine, nicotine, methamphetamine) close to bedtime • Side effect of medications (antidepressants, antihypertensives, corticosteroids, psychostimulants, analgesics) • Drinking alcohol or using over-the-counter medications as a sleep aid • Long naps in the afternoon • Sleeping in late • Exercise near bedtime • Jet lag • Nightmares • Stressful life event • Medical conditions or psychiatric illnesses • Irregular sleep/wake schedules • Worry about getting enough sleep 7. A clinical polysomnography (PSG) may be performed on a patient with signs and symptoms of a sleep disorder. What measures and observations does this study include (select all that apply)? a. Heart rate monitoring b. Noninvasive oxygen saturation (SpO2 ) c. Surface body temperature fluctuations d. Blood pressure monitoring (noninvasive) e. Airflow measured at the nose and mouth f. Muscle tone measured by electromyogram (EMG) g. Respiratory effort around the chest and abdomen h. Eye movements recorded by electrooculogram (EOG) i. Brain activity recorded by electroencephalogram (EEG) j. Actigraph watch worn on the wrist to monitor motor activity k. Gross body movements monitored via audio and visual recordings 8. What is first-line therapy for insomnia? a. Complementary therapies such as melatonin b. Cognitive-behavioral therapies such as relaxation therapy c. Benzodiazepine-receptor-like agents (e.g., zolpidem [Ambien]) d. Over-the-counter medication such as diphenhydramine (Benadryl) explain: Cognitive-behavioral therapies are effective therapies for insomnia and should be tried first. These include relaxation training, guided imagery, education about good sleep hygiene, and regular exercise several hours before bedtime. The other therapies are used to treat insomnia, with benzodiazepinereceptor-like agents being the first choice for drug therapy. Many patients will try over-the-counter medications such as diphenhydramine (Benadryl) but tolerance develops rapidly. Complementary and alternative therapies such as melatonin have been found to be useful to help individuals to fall asleep but they are not first-line therapy. 9. The nurse knows that a patient taught sleep hygiene practices needs further instruction when he says a. “Once I go to bed, I should get up if I am not asleep after 20 minutes.” b. “It’s okay to have my usual two glasses of wine in the evening before bed.” c. “A couple of crackers with cheese and a glass of milk may help to relax before bed.” d. “I should go to the gym earlier in the day so that I’m done at least 6 hours before bedtime.” Explain: It is not recommended that a person lie in bed awake. Alcohol should not be consumed within 6 hours of bedtime. The other statements represent strategies that may help the individual go to sleep. Exercise is good but not within 6 hours of bedtime; a light snack may help to relax the person 10. The patient is complaining of insomnia. Which bedtime snack would be the best option for this patient? a. Hershey’s bar b. 8 oz hot chocolate c. 8 oz Dannon coffee yogurt d. 1 cup Ben & Jerry’s nonfat coffee fudge frozen yogurt explain: Hot chocolate has 5 mg of caffeine. A Hershey’s bar has 10 mg of caffeine, Dannon coffee yogurt has 45 mg of caffeine, and Ben & Jerry’s nonfat coffee fudge frozen yogurt contains 85 mg of caffeine. 11. A nurse caring for a patient in the intensive care unit (ICU) implements strategies to create an environment conducive to sleep. Which strategy would be most effective? a. Turning off the lights in the room during the night b. Having the television on at all times for background noise c. Silencing the alarms on the bedside monitor and infusion pumps d. Administering ordered analgesics around the clock, even if the patient denies pain explain: Reducing the light and noise levels in the ICU can help to promote opportunities for sleep. Having the TV on at all times will only add to the noise level. Analgesics given for actual pain may help a patient to sleep or rest but they may also alter sleep. The alarms should not be silenced except for short periods to address why they were alarming. Silencing alarms to prevent them from making noise puts the patient at risk because the nurse may not be alerted to patient changes on the monitor or problems with the infusion device. 12. Which medication is a nonamphetamine wake-promotion drug? a. Modafinil (Provigil) b. Protriptyline (Vavactil) c. Desipramine (Norpramin) d. Methylphenidate (Concerta) explain: Desipramine and protriptyline are both tricyclic antidepressants used to treat cataplexy and methylphenidate is an amphetamine. 13. The nurse in a clinic is talking with a patient who will be traveling from the Midwest time zone to Moscow to attend a 4-day conference. The patient asks the nurse how he can minimize the effects of jet lag. What are at least two recommendations that the nurse could give to the patient? Any of these responses would be appropriate: • Start to get in harmony with the Moscow time zone several days before you travel. • Be sure to expose yourself to daytime daylight, which will assist with synchronizing your body’s clock to environmental time. • Melatonin has been shown to be an effective sleep aid to help synchronize the body’s rhythm. • Resynchronization of the body’s clock will occur at a rate of 1 hr/day if the patient travels eastward. 14. Place the events below in the order they occur in the patient with obstructive sleep apnea (beginning with 1). 1. Risk factors: obesity, large neck circumference, craniofacial abnormalities, acromegaly, smoking 2. Narrowing of air passages with muscle relaxation during sleep 3. Tongue and soft palate obstruct pharynx 4. Apnea lasting 10 to 90 seconds 5. Hypoxemia and hypercapnia 6. Generalized startle response, snorting, or gasping 7. Brief arousal and airway opened 8. Occurs 200 to 400 times during 6 to 8 hours of sleep Explain: Obstructive sleep apnea has the risk factors listed. Airflow obstruction occurs because of narrowing of the air passages with relaxation of muscle tone during sleep or when the tongue and soft palate fall backward and partially or completely obstruct the pharynx. With apnea lasting 10 to 90 seconds, hypoxemia and hypercapnia occur. The startle response causes a brief arousal, so the tongue and soft palate move forward and the airway opens. This cycle occurs 200 to 400 times during 6 to 8 hours of sleep. 15. The physician has ordered continuous positive airway pressure (CPAP) for a patient with serious obstructive sleep apnea. How will CPAP help the patient? a. Prevent airway occlusion by bringing the tongue forward b. Be easily tolerated by both the patient and the patient’s bed partner c. Provide enough positive pressure in the airway to prevent airway collapse d. Deliver a high inspiratory pressure and a low expiratory pressure to prevent airway collapse explain: CPAP is continuous positive airway pressure and is the treatment of choice for more serious sleep apnea. Bilevel positive airway pressure (BiPAP) is the therapy that delivers a high inspiratory pressure and a low expiratory pressure to prevent airway collapse. CPAP is not well tolerated and compliance is low. Compliance may be improved by involving the patient in the selection of the device and mask, showing the CPAP before therapy begins, and teaching troubleshooting to reduce anxiety. An oral appliance is used to prevent airway occlusion from the relaxed mandible and tongue. 16. While caring for a patient following an uvulopalatopharyngoplasty (UPPP), the nurse monitors the patient for which complications in the immediate postoperative period? a. Snoring and foul-smelling breath b. Infection and electrolyte imbalance c. Loss of voice and severe sore throat d. Airway obstruction and hemorrhage explain: The most common complications in the immediate postoperative period are airway obstruction and hemorrhage. The patient may experience a sore throat, foul-smelling breath, and snoring during the recovery but they will resolve. Infection is a potential complication of any surgery but is not common with this procedure. Loss of voice and electrolyte imbalance generally are not complications of this procedure. 17. An older patient asks the nurse why she has so much trouble sleeping. What is the most appropriate response by the nurse? a. “Disturbed sleep is a normal result of aging.” b. “Have you tried any over-the-counter medications to help you sleep?” c. “Don’t worry. You don’t need as much sleep as you did when you were younger.” d. “Tell me more about the trouble you are having. There may be some things we can do to help.” Explain: Assess the patient to determine what the problem is and then offer sleep hygiene instruction and collaborate with the physician to improve the patient’s sleep behavior. Disturbed sleep is not a normal result of aging and people need about the same amount of sleep throughout their life span. Overthe-counter and prescription sleep aids need to be used very cautiously in older adults and patient response must be monitored closely. 18. Nurses who rotate shifts or work nights are at risk for developing shift work sleep disorder characterized by insomnia, sleepiness, and fatigue. Identify at least three negative implications for the nurse. Any three of these would be correct: • Nurse is too sleepy to be fully awake at work • Nurse is too alert to sleep soundly the next day • Increased morbidity and mortality related to cardiovascular problems • Mood disorders are higher • Fatigue could result in errors and accidents, as perceptual skills, judgment, and decisionmaking abilities may be diminished 19. What strategies could decrease the distress of rotating shifts for nurses (select all that apply)? a. Take a brief onsite nap b. Use sleep hygiene practices c. Sleep just before going to work d. Maintain consistent sleep/wake schedules even on days off (if possible) e. Negotiate to control work schedule rather than having someone else impose the schedule explain: All of these measures can be used to help a nurse who works rotating shifts to get adequate sleep.
