A nurse is assessing the status of a patient who is sleeping.
Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?

Choice A rationale:

Using heavy pressure on the cold pack for greater effectiveness is not the correct approach when applying a cold pack to an injured area. Applying excessive pressure can lead to tissue damage, frostbite, and can be uncomfortable for the patient. Cold packs should be applied with gentle, even pressure to avoid complications.

Choice B rationale:

Leaving the cold pack in place for over 30 minutes at a time is not recommended. Prolonged exposure to cold can also cause tissue damage, including frostbite. It is generally advised to limit cold pack applications to 20-30 minutes at a time to prevent complications.

Choice C rationale:

Preparing to apply heat instead if cold is not effective is not the appropriate action in this scenario. When a healthcare provider orders a cold pack application, it is essential to follow the prescribed treatment plan. Heat should only be considered if it is specifically ordered as an alternative treatment.

Choice D rationale:

Placing a towel between the pack and the skin is the correct approach to prevent patient injury when applying a cold pack. This helps to protect the skin from direct contact with the cold pack, reducing the risk of frostbite or cold-related injuries. It ensures a barrier between the cold pack and the patient's skin, providing a safe and comfortable application.

Choice A rationale:

Excessive NREM sleep does not cause periodic pauses in breathing. NREM (Non-Rapid Eye Movement) sleep consists of stages 1 through 4 and is characterized by a decrease in physiological activity, including a decrease in muscle tone. There is no direct association with breathing interruptions in NREM sleep.

Choice B rationale:

Insomnia is a sleep disorder characterized by difficulty falling asleep or staying asleep, but it does not involve periodic pauses in breathing. It is unrelated to the symptoms described in the question.

Choice C rationale:

Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness and sudden episodes of muscle weakness (cataplexy). It is not associated with periodic pauses in breathing, as described in the question.

Choice D rationale:

Sleep apnea is the correct answer. Sleep apnea is a sleep disorder characterized by repeated episodes of paused or shallow breathing during sleep. The patient may stop breathing for brief periods, then start breathing again. This pattern is consistent with the symptoms described in the question. Sleep apnea can have serious health implications and is important to recognize and address.