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 most likely contributed to the patient’s fall?

Melatonin

Benzodiazepine

L-tryptophan

Iron supplement

Answer and Explanation

The Correct Answer is B

Choice A reason: Melatonin, used for sleep regulation, may cause mild drowsiness but is not strongly linked to falls in older adults. Its side effects are minimal, and it does not significantly impair balance or coordination. This medication is unlikely to have caused the fall, making it an incorrect choice.

Choice B reason: Benzodiazepines, used for anxiety or insomnia, increase fall risk in older adults by causing sedation, dizziness, and impaired coordination. These effects, especially at night, can lead to balance issues and falls. Given their known association with falls in the elderly, this is the most likely medication contributing to the incident.

Choice C reason: L-tryptophan, an amino acid supplement for sleep or mood, has minimal side effects and is not associated with significant sedation or balance impairment. It is unlikely to cause falls in older adults, as it does not affect motor function or coordination, making this an incorrect choice.

Choice D reason: Iron supplements treat anemia but do not cause sedation, dizziness, or balance issues linked to falls. Side effects like gastrointestinal upset are unrelated to fall risk. This medication is not a likely contributor to the patient’s fall, making it an incorrect choice compared to benzodiazepines.

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Correct Answer is A

Explanation

Choice A reason: Expressive aphasia impairs speech production due to brain injury, but patients can often use nonverbal methods like gestures or facial expressions. Including a goal for nonverbal communication is realistic, promoting effective interaction while speech therapy progresses. This aligns with the patient’s current abilities and supports functional communication.

Choice B reason: Recovering full speech vocabulary in one day is unrealistic for expressive aphasia, which requires prolonged speech therapy due to neurological damage. This goal sets false expectations, ignoring the chronic nature of traumatic brain injury recovery, and is not appropriate for the care plan.

Choice C reason: Carrying a pen and pad may help some patients, but expressive aphasia does not guarantee writing ability, as written language can also be impaired. This goal is less broadly applicable than nonverbal communication, which leverages intact motor and emotional expression, making it a less suitable choice.

Choice D reason: Thickening drinks prevents aspiration in dysphagia, not aphasia. Expressive aphasia affects speech, not swallowing. This goal is irrelevant to the patient’s condition, as there is no indication of swallowing difficulty, making it an incorrect focus for the care plan.

A. During NREM sleep, biological functions increase. B. REM sleep decreases cortical activity. C. Restful sleep preserves cardiac function. D. NREM sleep contributes to body tissue restoration. E. Sleep contributes to cognitive restoration.

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: During NREM sleep, biological functions like heart rate and metabolism decrease, not increase, to promote restoration. Increased functions occur in REM sleep or wakefulness. This statement is incorrect, as it misrepresents NREM sleep’s physiological role, making it an inappropriate teaching point.

Choice B reason: REM sleep increases cortical activity, supporting dreaming and memory processing, not decreasing it. This statement is inaccurate, as REM is characterized by high brain activity similar to wakefulness. It does not align with sleep’s benefits, making it incorrect for the teaching session.

Choice C reason: Restful sleep preserves cardiac function by reducing heart rate, blood pressure, and stress hormones, lowering cardiovascular strain. Adequate sleep prevents arrhythmias and hypertension, making this a correct teaching point to highlight sleep’s protective role in heart health for ICU patients.

Choice D reason: NREM sleep, especially deep stages, promotes body tissue restoration by facilitating protein synthesis and growth hormone release, aiding tissue repair. This is a key benefit, particularly for ICU patients recovering from illness, making it a correct point for the nurse’s teaching session.

Choice E reason: Sleep, particularly REM and deep NREM, supports cognitive restoration by consolidating memories and clearing brain metabolites. This enhances alertness and decision-making, critical for ICU patients’ recovery. This is a correct teaching point, emphasizing sleep’s role in mental clarity and function.

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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 most likely contributed to the patient’s fall?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care?

Correct Answer is A

Explanation

The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. Which information will the nurse include in the teaching session? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

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A patient is diagnosed with obstructive sleep apnea. Which assessment is the priority?

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