Which is the priority nursing diagnosis for a patient who has been diagnosed with Meniere’s disease?
Acute confusion related to delirium and disorientation
Nausea related to constant sensation of noxious taste
Autonomic dysreflexia related to distention of bowel or bladder
Risk for falls related to unsteadiness and loss of balance
The Correct Answer is D
Choice A reason: This is incorrect. Acute confusion related to delirium and disorientation is not the priority nursing diagnosis for a patient who has been diagnosed with Meniere’s disease. Meniere’s disease is a disorder of the inner ear that causes episodes of vertigo, hearing loss, tinnitus, and ear fullness. It does not typically cause acute confusion, delirium, or disorientation.
Choice B reason: This is incorrect. Nausea related to constant sensation of noxious taste is not the priority nursing diagnosis for a patient who has been diagnosed with Meniere’s disease. Meniere’s disease can cause nausea and vomiting during the attacks of vertigo, but not a constant sensation of noxious taste. Nausea is a symptom, not a nursing diagnosis.
Choice C reason: This is incorrect. Autonomic dysreflexia related to distention of bowel or bladder is not the priority nursing diagnosis for a patient who has been diagnosed with Meniere’s disease. Autonomic dysreflexia is a life-threatening condition that occurs in people with spinal cord injuries above the level of T6. It causes a sudden and severe increase in blood pressure, headache, sweating, and bradycardia. It is triggered by a stimulus below the level of injury, such as a distended bladder or bowel. It is not related to Meniere’s disease.
Choice D reason: This is correct. Risk for falls related to unsteadiness and loss of balance is the priority nursing diagnosis for a patient who has been diagnosed with Meniere’s disease. Meniere’s disease can cause severe vertigo, which is a sensation of spinning or moving when the person is still. This can impair the patient’s equilibrium and coordination, making them prone to falling and injuring themselves. The nurse should assess the patient’s risk for falls and implement interventions to prevent them, such as providing a safe environment, assisting with mobility, and educating the patient on self-care strategies.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because suggesting having warm milk with a shot of whisky before going to bed is not an appropriate intervention to treat ongoing insomnia for a middle-aged adult with a busy career. Warm milk may have some soothing effects on the patient, but adding whisky to it may counteract the benefits and worsen the insomnia. Alcohol is a depressant that can make the patient feel sleepy at first, but it can also disrupt the sleep cycle and cause frequent awakenings, nightmares, or hangovers.
Choice B reason: This is an incorrect choice because obtaining a prescription for zolpidem to be taken at bedtime is not an appropriate intervention to treat ongoing insomnia for a middle-aged adult with a busy career. Zolpidem is a hypnotic drug that can induce sleep and improve the sleep quality and quantity of the patient, but it can also have many side effects and interactions, and cause dependence, tolerance, or withdrawal. Zolpidem should be used only as a short-term treatment for insomnia, and only under the supervision of a physician.
Choice C reason: This is an incorrect choice because recommending the use of sleep aids such as triazolam is not an appropriate intervention to treat ongoing insomnia for a middle-aged adult with a busy career. Triazolam is a benzodiazepine drug that can enhance the activity of GABA, a neurotransmitter that inhibits brain activity and promotes sleep. However, it can also have many side effects and interactions, and cause dependence, tolerance, or withdrawal. Triazolam should be used only as a short-term treatment for insomnia, and only under the supervision of a physician.
Choice D reason: This is the correct choice because encouraging the patient to practice peaceful meditation before bedtime is an appropriate intervention to treat ongoing insomnia for a middle-aged adult with a busy career. Meditation is a relaxation technique that can reduce stress, anxiety, and negative emotions, and promote calmness, mindfulness, and well-being. Meditation can help the patient to fall asleep faster and sleep better, and it does not have any adverse effects or risks. The nurse should teach the patient how to meditate and encourage the patient to practice it regularly.
Correct Answer is B
Explanation
Choice A reason: This is incorrect. Cleaning the fixed IV pump and returning it to the floor can cause harm to the patient or the staff if the pump is used again.
Choice B reason: This is correct. Tagging the IV pump and removing it from the area prevents the pump from being used by mistake and alerts the maintenance staff to repair or replace it.
Choice C reason: This is incorrect. Contacting the IV pump manufacturer is not the role of the nurse. The nurse should report the malfunction to the appropriate person in the facility.
Choice D reason: This is incorrect. Initiating a work order on the IV pump is not enough to ensure the safety of the patient and the staff. The pump should be tagged and removed from the area as well.
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