Chapter 20: Sleep

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. The primary care pediatric nurse practitioner is performing a well child examination on a 4-
year-old child. The parent reports that the child snores frequently, often awakens during the
night, and seems cranky during the day. What will the nurse practitioner tell this parent?
a. Most sleep disorders are benign and will be outgrown.
b. Sleep disorders are symptomatic of underlying behavior problems.
c. Sleep disorders at this age can have long-term impacts on learning.
d. The child will need longer daytime naps to compensate for lost sleep.
ANS: C
Behavioral sleep disorders and sleep-disordered breathing before age 5 can result in increased
special education needs in children by 8 years of age. Sleep disorders are not usually benign
or outgrown. Sleep disorders can result in behavioral difficulties but are not symptomatic of
behavioral problems. Sleep-disordered breathing disrupts all sleep; napping will not produce
adequate quality sleep.

2. The parent of a school-age child who is overweight tells the primary care pediatric nurse
practitioner that the child seems to crave high-calorie, high-carbohydrate foods, even when
full. The nurse practitioner learns that the child is often irritable and sleepy at school in spite
of sleeping 9 or 10 hours each night. What will the nurse practitioner recommend?
a. Assessment of leptin and ghrelin hormone levels
b. Consultation with a dietician to develop an appropriate diet
c. Referral to a sleep disorder clinic for a sleep study
d. Taking one or two naps each day to increase the amount of sleep
ANS: C
Obstructive sleep apnea has been suggested to be a contributing factor to the pathogenesis of
obesity by inducing leptin resistance and increasing ghrelin levels, two hormones that regulate
satiety. The child shows symptoms of these abnormalities by craving high-calorie comfort
foods. The child should be evaluated for this underlying cause. Assessment of these hormone
levels is not routinely done. Consultation with a dietician may be necessary at some point but
does not get at the underlying problem. Increasing sleep time with naps has not been shown to
counteract the obesity effect.

3. The primary care pediatric nurse practitioner is performing a well baby examination on a 2-
week-old infant. The parent is concerned that the infant sleeps too much. The nurse
practitioner asks the parent to keep a sleep log and will teach the parent that which amount of
sleep per day is optimal for this infant?
a. 10 to 12 hours
b. 12 to 15 hours
c. 15 to 18 hours
d. 18 to 20 hours
ANS: C
Newborns sleep up to 8.25 at night and 8.25 hours during the day.
4. The primary care pediatric nurse practitioner is counseling a new parent about ways to reduce
the risk of sudden infant death syndrome (SIDS). What will the nurse practitioner include
when discussing SIDS?
a. Bed-sharing with infants greatly increases the risk of SIDS.
b. Breastfeeding does not appear to have any influence on SIDS risk.
c. Infants who attend day care have a higher than usual incidence of SIDS.
d. There is no difference in SIDS rates in immunized versus non-immunized infants.
ANS: A
Bed-sharing with infants has been shown to have a five-fold increase in the incidence of
SIDS, even with non-drug using and non-smoking parents; smoking, alcohol, and drug use
increase this risk even further. Breastfeeding is recommended and is associated with a reduced
risk of SIDS. Day care is not mentioned as increasing SIDS risk. Infants who are immunized
have a 50% reduction in SIDS risk, according to research evidence.

5. The primary care pediatric nurse practitioner is counseling the parents of a toddler about
sleep. The parents report that the toddler has recently begun resisting sleep and is often more
irritable during the day. What will the nurse practitioner recommend?
a. Co-sleeping with the child to help alleviate possible nighttime fears
b. Referral to a sleep disorders clinic for evaluation of sleep-disordered breathing
c. Reintroducing a second, morning nap time to compensate for lost sleep
d. Understanding that sleep resistance is a common developmental problem
ANS: D
Toddlers may develop sleep resistance as a normal part of their behaviors associated with
increased autonomy or may have nighttime fears or night terrors. Parents should understand
that this is common and transient. Co-sleeping may be practiced in some cultures but is not
recommended. It is not necessary to refer to a sleep disorders clinic unless there are specific
symptoms, such as snoring or restless sleep or sleepiness in spite of adequate sleep.

6. The parent of a 3-year-old child tells the primary care pediatric nurse practitioner that the
child has never been able to fall asleep without a parent in the room. The child has a new
sibling and the parent is concerned that the toddler’s cries will awaken the infant. What will
the nurse practitioner counsel the parent?
a. Leaving the room as the child is falling asleep and returning at intervals to check
on the child
b. Offering a reward for each night the child falls asleep without the parent in the
room
c. Putting the child to bed at the same time every night and ignoring all sleep
interfering behaviors
d. Taking away a favorite activity or video for each night the child fusses about the
parent not being in the room
ANS: A
Leaving the room as the child becomes drowsy and checking on the child at intervals is called
graduated extinction and allows parents to ensure safety while helping the child to initiate and
maintain sleep independently. The other measures may result in the toddler becoming upset
and crying, which would awaken the baby. Rewards and punishments are not necessarily
successful.
 7. The parent of a 4-year-old who has difficulty initiating and maintaining sleep has tried several
nonpharmacological methods with variable success and asks about medications. What will the
primary care pediatric nurse practitioner recommend?
a. Diphenhydramine
b. Lorazepam
c. Melatonin
d. Zolpidem
ANS: C
Medications to treat dyssomnias are generally discouraged in children, since they have side
effects and since the mainstay of treatment is behavioral therapy and sleep hygiene. If
medications are used, melatonin is the most commonly prescribed. Diphenhydramine can lead
to parasomnias in some children. Benzodiazepines, such as lorazepam, can cause dependence.
Sedatives, such as zolpidem, have high levels of side effects.

8. The parent of a 3-year-old child tells the primary care pediatric nurse practitioner that after
falling asleep in the living room and being awakened to go to bed one evening, the child
appeared confused and disoriented for a period of time. What will the nurse practitioner
counsel this parent?
a. That if this occurs again, to question the child about nightmares
b. That this is a sign of sleep walking and could be dangerous
c. That this is a type of sleep terror which will resolve over time
d. That this is probably a benign, temporary type of a sleep disorder
ANS: D
This child most likely exhibits confusional arousal, which occurs when a child is awakened
from a deep sleep during the first part of the night. It is most likely benign and temporary,
usually diminishing by age 5 years. It is not a sign of nightmares or night terrors. It may be the
start of sleep walking but is less likely.

9. During a well child examination, the primary care pediatric nurse practitioner learns that a 5-
year-old child has had several episodes of walking out of the bedroom after falling asleep,
looking dazed, with open eyes, and saying things that don’t make sense. What will the nurse
practitioner recommend?
a. Establishing a graduated extinction program and good sleep hygiene
b. Making sure that stairs are blocked and doors are locked
c. Referral to a sleep disorder clinic for evaluation of a parasomnia
d. To awaken the child when these occur and asking about nightmares
ANS: B
Parents of children with sleep walking should be assured that this is relatively benign but
should make sure the house is secure so the child will not cause self-harm. Graduated
extinction and sleep hygiene are used for children who have difficulty initiating or
maintaining sleep. Referral to a sleep disorder clinic may be warranted if the child has an
episode of leaving the house or some other dangerous activity. The child should be guided
back to bed without awakening.

10. The parent of a school-age child tells the primary care pediatric nurse practitioner that the
child is restless most nights and complains often that bugs are in the bed. After consultation
with a sleep disorder specialist and subsequent evaluation of a ferritin level of 30, the nurse
practitioner may expect to treat this child with what?
 a. Clonazepam
b. Ferrous sulfate
c. Gabapentin
d. Sertraline
ANS: B
A ferritin level of less than 50 is associated with periodic limb movements (PLM). The
treatment for this is ferrous sulfate 3 mg/kg per day. Clonazepam and gabapentin may be
ordered if ferritin levels are normal and other organic causes of PLM have been ruled out.
Sertraline may make PLM worse.

11. An adolescent exhibits mild depressive symptoms and tells the primary care pediatric nurse
practitioner that he is most concerned about difficulty falling and staying asleep. The
adolescent does not want to take medication to treat the depressive symptoms. What will the
nurse practitioner recommend?
a. A program of sleep hygiene and gradual sleep extension
b. A sedative-narcotic will help both sleep and depression
c. Cognitive therapy can help the adolescent to sleep better
d. Using an antidepressant will improve sleep patterns
ANS: A
Depression is linked to sleep problems and both predict and are predicted by a diagnostic
cluster that includes ODD, GAD, and depression. One study found that gradual sleep
extension combined with sleep extension advice had a beneficial effect on depressive
symptoms of adolescents with chronic sleep reduction. Sedatives will not affect depression.
Cognitive therapy is useful for insomnia related to anxiety. Antidepressants do not necessarily
treat insomnia.

12. A child with Down syndrome who has sleep-disordered breathing with obstructive sleep
apnea continues to have symptoms in spite of tonsillectomy and adenoidectomy and treatment
with a leukotriene receptor antagonist medication and a nasal steroid spray. The primary care
pediatric nurse practitioner will refer the child to a sleep disorder clinic to discuss which
therapy?
a. Craniofacial surgery
b. Oral appliances
c. Positive airway pressure therapy
d. Supplemental oxygen
ANS: C
Positive airway pressure therapy can be used to treat sleep-disordered breathing in children
who have failed other therapies and even developmentally delayed children show
improvement in behaviors after this therapy. Craniofacial surgery may be used in the presence
of maxillofacial deformities that affect sleep-disordered breathing but is a last option. Oral
appliances may be used if deformities can be corrected in this manner. Supplemental oxygen
helps with oxygen saturations but not with disordered breathing patterns themselves.