The nurse completes an admission assessment on an older adult ...

[tiara099]

The nurse completes an admission assessment on an older adult patient. The nurse identifies which factor that may contribute to sleep problems?
 
  a. Exposure to sun-light c. Use of a sleep aid
  b. Polypharmacy d. Decreased fluid in-take

Question 2

After assessing the older male adult in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help.
 
  Which was the most important intervention the nurse should have implemented to prevent this event? a. Call for someone to bring the sign.
  b. Show him how to use the call bell.
  c. Provide a urinal and drinking water.
  d. Instruct the patient to call for help.

[Chou]

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.

[tiara099]

Thank you

[Chou]

Happy to help you