The nurse and a client are discussing possible behaviors that might be

The nurse and a client are discussing possible behaviors that might be interfering with the client’s ability to fall asleep.

Which of the following assessment questions is most likely to identify possible problems with the client’s sleep routine that possibly are contributing to the difficulty?
1. “When do you usually retire for the night?”
2. “What do you do to help yourself fall asleep?”
3. “How much time does it usually take for you to fall asleep?”
4. “Have you changed anything about your presleep ritual lately?”

ANSWER

ANS: 2
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.