The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended question will provide the nurse with helpful information about the patient’s health status?

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.

Choice A reason: This is the correct choice because melatonin is the safest sleep aid for the elderly patient with insomnia. Melatonin is a natural hormone that regulates the sleep-wake cycle. It has few side effects and interactions, and does not cause dependence or withdrawal. Melatonin can improve the quality and duration of sleep, and reduce the time to fall asleep.

Choice B reason: This is an incorrect choice because temazepam is not the safest sleep aid for the elderly patient with insomnia. Temazepam is a benzodiazepine that enhances the activity of GABA, a neurotransmitter that inhibits brain activity. It has many side effects and interactions, and can cause dependence, tolerance, or withdrawal. Temazepam can also impair cognitive and motor functions, and increase the risk of falls, fractures, and delirium.

Choice C reason: This is an incorrect choice because trazodone is not the safest sleep aid for the elderly patient with insomnia. Trazodone is an antidepressant that blocks the reuptake of serotonin, a neurotransmitter that regulates mood and sleep. It has many side effects and interactions, and can cause orthostatic hypotension, cardiac arrhythmias, priapism, or serotonin syndrome. Trazodone can also impair cognitive and motor functions, and increase the risk of falls, fractures, and delirium.

Choice D reason: This is an incorrect choice because triazolam is not the safest sleep aid for the elderly patient with insomnia. Triazolam is a benzodiazepine that enhances the activity of GABA, a neurotransmitter that inhibits brain activity. It has many side effects and interactions, and can cause dependence, tolerance, or withdrawal. Triazolam can also impair cognitive and motor functions, and increase the risk of falls, fractures, and delirium.