The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident?
The patient is grouchy and inappropriate, always causing trouble for the nurses.
The patient’s nurse assistant always took her time to answer his call lights.
The patient probably urinated on the floor and slipped on the wet floor.
The patient was found on the floor and his urinal was on the floor next to him.
The Correct Answer is D
Choice A reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is subjective, biased, and disrespectful. The nurse should not make judgments or assumptions about the patient's personality or behavior, but rather report the facts and observations of the situation.
Choice B reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is irrelevant, speculative, and accusatory. The nurse should not blame or criticize the nurse assistant's performance, but rather focus on the patient's condition and the actions taken to prevent or manage the fall.
Choice C reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is uncertain, hypothetical, and unprofessional. The nurse should not use words like "probably" or "maybe" that indicate a lack of clarity or certainty, but rather state the facts and evidence of the situation.
Choice D reason: This is an appropriate statement for the nurse to include in the description of the incident because it is objective, factual, and concise. The nurse should report the patient's location, status, and environment at the time of the fall, and the possible cause or contributing factors of the fall.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Neuropathy due to uncontrolled diabetes is not an example of nociceptive pain. Neuropathy is a type of neuropathic pain, which is pain that is caused by damage or dysfunction of the nervous system. It can cause sensations of numbness, tingling, burning, or shooting pain in the affected area. It is not related to tissue injury or inflammation.
Choice B reason: This is incorrect. Phantom pain after amputation of a limb is not an example of nociceptive pain. Phantom pain is a type of neuropathic pain, which is pain that is felt in a body part that is no longer present. It can be triggered by memories, emotions, or stimuli. It is not related to tissue injury or inflammation.
Choice C reason: This is correct. Pain from rheumatoid arthritis joint damage is an example of nociceptive pain. Nociceptive pain is pain that is caused by tissue injury or inflammation. It can be triggered by mechanical, thermal, or chemical stimuli. It can cause sensations of aching, throbbing, or stabbing pain in the affected area.
Choice D reason: This is incorrect. Chronic nerve pain after shingles infection is not an example of nociceptive pain. Chronic nerve pain is a type of neuropathic pain, which is pain that is caused by damage or dysfunction of the nervous system. It can be caused by a viral infection, such as shingles, that affects the nerve fibers. It can cause sensations of burning, itching, or electric pain in the affected area. It is not related to tissue injury or inflammation.
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