patient has sleep deprivation. Which statement by the patient will indicate to

the nurse that outcomes are being met?

a. “I wake up only once a night to go to the bathroom.”

b. “I feel rested when I wake up in the morning.”

c. “I go to sleep within 30 minutes of lying down.”

d. “I only take a 20-minute nap during the day.”

ANS: B

Being able to sleep and feeling rested would indicate that outcomes are

being met for sleep deprivation. Limiting a nap to 20 minutes is an

intervention to promote sleep. Going to sleep within 30 minutes

indicates a goal for insomnia. Waking up only once may indicate

nocturia is improving but does not relate to sleep deprivation.

26. An older-adult patient is visiting the clinic after a fall during the

night. The nurse obtains information on what medications the patient takes.

Which medication mostlikely contributed to the patient’s fall?

a. Melatonin

b. L-tryptophan

c. Benzodiazepine

d. Iron supplement

ANS: C

The most likely cause is a benzodiazepine. If older patients who were

recently continent, ambulatory, and alert become incontinent or

confused and/or demonstrate impaired mobility, the use of

benzodiazepines needs to be considered as a possible cause. This can

contribute to a fall in an older adult. Short-term use of melatonin has

been found to be safe, with mild side effects of nausea, headache, and

dizziness being infrequent. Iron supplements may be given to patients

with restless legs syndrome. Some substances such as L-tryptophan, a

natural protein found in foods such as milk, cheese, and meats,

promote sleep; while it does promote sleep, it is not the most likely to