The nurse is beginning a sleep assessment on a patient. Which ...

[CQXA]

The nurse is beginning a sleep assessment on a patient. Which question will be most appropriate for the nurse to ask initially?
 
  a. What is going on?
  b. How are you sleeping?
  c. Are you taking any medications?
  d. What did you have for dinner last night?

Question 2

The nurse adds a nursing diagnosis of ineffective breathing pattern to a patient's care plan. Which sleep condition caused the nurse to assign this nursing diagnosis?
 
  a. Insomnia
  b. Narcolepsy
  c. Sleep deprivation
  d. Obstructive sleep apnea

[bblaney]

Answer to Question 1

ANS: B
Sleep is a subjective experience. Only the patient is able to report whether or not it is sufficient and restful. Asking patients how they are sleeping is an introductory question. After this beginning question is asked, problems with sleep such as the nature of the problem, signs and symptoms, onset and duration of the issue, severity, predisposing factors, and the effect on the patient can be assessed. What is going on is too broad and open ended for information about sleep to be obtained specifically. Medications and food intake can be part of the detailed assessment of sleep issues.

Answer to Question 2

ANS: D
Obstructive sleep apnea (OSA) occurs when the muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing airflow or stopping it for as long as 30 seconds. The person still attempts to breathe because chest and abdominal movements continue, resulting in snoring or snorting sounds. With narcolepsy, the person feels an overwhelming wave of sleepiness and falls asleep. Insomnia is characterized by chronic difficulty falling asleep. Sleep deprivation is a condition caused by dyssomnia. OSA is the only one of these conditions that results in blockage of the airway and impacts the ability to breathe.

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