FNP Sleep Disorder Practice Questions

Stimulant medications frequently cause sleep-onset insomnia especially when extended-release formulations are used. If sleep hygiene interventions fail, the most appropriate pharmacological step is to switch to a short-acting formulation to ensure the medication clears the system before bedtime. Option A introduces unnecessary polypharmacy to treat a side effect of another drug. Option C would likely worsen the insomnia by increasing the overall serum concentration of the stimulant. Option D does not solve the problem because extended-release amphetamines also last 10 to 12 hours and will continue to disrupt sleep.

This patient's new-onset hypertension, combined with unexplained weight gain, violaceous abdominal striae, proximal muscle weakness, and hyperglycemia, forms the classic clinical picture of a Cushing syndrome disorder. The excess cortisol promotes sodium retention, insulin resistance, and characteristic fat redistribution. Primary adrenal hyperaldosteronism causes hypertension and weakness due to hypokalemia, but it does not cause violaceous striae or rapid central weight gain. Obstructive sleep apnea is associated with obesity and hypertension but typically presents with snoring and daytime sleepiness rather than proximal muscle weakness and purple striae. Renal artery stenosis presents with an abdominal bruit and isolated hypertension, lacking the systemic metabolic and dermatologic changes seen in hypercortisolism.

When CPAP efficacy is objectively confirmed by excellent adherence and an apnea-hypopnea index under five, persistent symptoms like fatigue and morning headaches suggest a different underlying etiology. The APRN must evaluate for other conditions such as restless legs syndrome, narcolepsy, depression, or thyroid dysfunction. Increasing the airway pressure or switching to a bilevel machine is inappropriate because her sleep apnea is already well controlled based on the objective data. Recommending an analgesic merely masks the headache without identifying the root cause of her ongoing fatigue.

Masked hypertension occurs when office readings are normal but out-of-office readings are elevated. This patient's normal office blood pressure and elevated home blood pressure indicate masked hypertension, making Option C correct. Option B is the exact opposite scenario where office readings are high but home readings are normal. Option A is incorrect because both systolic and diastolic values are elevated at home. Option D refers to a normal physiologic drop in blood pressure during sleep, which does not apply to daytime home averages.

Amitriptyline is a tricyclic antidepressant that effectively prevents migraines while simultaneously treating her comorbid depression and insomnia. Topiramate is a strong preventive but often causes weight loss, which is undesirable given her low normal BMI. Propranolol and divalproex are effective for migraine prevention but do not optimally address her mood or sleep disturbances.

Stimulus control therapy aims to reassociate the bed exclusively with sleep. The patient should leave the bedroom if unable to sleep within 20 minutes to break the association between bed and wakefulness. Option A reinforces the negative association of lying awake and frustrated in bed. Option C still involves doing wakeful, engaging activities in bed, which directly violates stimulus control principles. Option D decreases the homeostatic sleep drive, which will only worsen her nighttime insomnia and perpetuate the cycle.

New onset congestive heart failure is the primary differential because exertional fatigue, nocturia, and trace pedal edema strongly suggest decreased cardiac output and fluid retention. Exacerbation of chronic pulmonary disease is unlikely given the clear lung fields and lack of cough or wheezing. Unrecognized major depressive disorder episode might cause generalized fatigue but does not explain the exertional nature of the exhaustion or the physical signs of edema. Undiagnosed obstructive sleep apnea syndrome causes fatigue and nocturia but typically presents with snoring and daytime sleepiness rather than specific exertional intolerance. Recognizing atypical heart failure symptoms prevents misattributing them to normal aging.

Symptoms of severe insomnia, psychomotor agitation, and delusional beliefs are hallmark signs of postpartum psychosis, which is a psychiatric emergency carrying a high risk of infanticide and suicide. The patient requires immediate emergency evaluation and likely inpatient stabilization. Option A is incorrect because the EPDS screens for depression, not acute psychosis. Option B is dangerous as it merely masks symptoms without treating the underlying life-threatening condition. Option D ignores glaring red flags for a severe psychotic break.

Evaluating the effectiveness of non-pharmacological interventions involves monitoring symptom progression over an adequate timeframe. After eight weeks of consistent therapy, this patient’s score has slightly worsened, and she is experiencing persistent anhedonia and insomnia. Option D is the correct choice because clinical guidelines recommend initiating a pharmacological intervention when moderate to severe symptoms do not improve with psychotherapy alone. Option A is incorrect; simply doing more of an ineffective therapy delays necessary medical treatment. Option B is a helpful lifestyle modification but is insufficient as a standalone step-up treatment for worsening clinical depression. Option C is an overreaction; while her symptoms are persistent and distressing, there is no indication of acute suicidality or psychosis that would justify an inpatient hospital admission. Stepping up to an antidepressant is the appropriate evidence-based next step.

This patient has a STOP-BANG score of 5 (age over 50, male, BMI over 35, hypertension, and snoring), which places him at high risk for OSA. A score of 5 to 8 warrants objective testing, making a home sleep apnea test the most appropriate next step. Recommending a cervical collar does not diagnose or treat obstructive sleep apnea. Prescribing modafinil inappropriately masks daytime symptoms without addressing the underlying airway obstruction. Advising sleep hygiene is generally helpful but entirely insufficient for a high-risk patient requiring formal diagnostic evaluation.