Answer to Question 1
B
Polypharmacy contributes to sleep problems as a result of medication side effects and drug inte-ractions. Decreased exposure to sunlight contributes to sleep problems. Sleep aids may assist with sleep issues. Decreased fluid intake may lead to dehydration, which may result in lethargy.
Answer to Question 2
D
Feedback
A Incorrect. This is a reasonable approach to communicating the risk of falls, but it cannot take the place of instructing the patient directly about prevention.
B Incorrect. Needs of an older adult can contribute to the risk of falls as an indi-vidual leans and reaches for something; thus, call bell instructions are a reason-able approach for preventing falls. However, before providing the call bell in-structions, the nurse needed to tell him to call for help.
C Incorrect. A urinal for a man and drinking water are common items older adults need, but reaching for them can contribute to falls.
D Correct. The nurse accomplished the most important aspect of fall prevention with the assessment, but in an attempt to communicate the fall risk to other staff members, the nurse failed to communicate properly to the patient about fall prevention before leaving the room.
Evidence-based practice: skin assessment
Nursing history for rectal and anal assessment
Scheduling patient appointments by telephone.
Giger and Davidhizar’s Transcultural Assessment Model.
Prioritization of Admission, Discharge, and Triage of Acutely III Patients in an ICU