What is the priority action of the nurse as the assessment process is started for a patient who came to the hospital with acute shortness of breath?

Reassure the patient that the shortness of breath will be relieved shortly.

Pull the curtain around the bed and ensure patient privacy.

Tell the patient that the physician will be in shortly to start treatment.

Listen to the patient’s lung sounds and check the pulse oximetry level.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an incorrect choice because reassuring the patient that the shortness of breath will be relieved shortly is not the priority action of the nurse as the assessment process is started. Reassurance is a communication technique that involves expressing confidence or support to the patient and alleviating their anxiety or fear. However, it is not the most urgent action for a patient with acute shortness of breath, which is a sign of respiratory distress that can have various causes and complications. The nurse should first assess the patient's condition and provide oxygen therapy if needed.

Choice B reason: This is an incorrect choice because pulling the curtain around the bed and ensuring patient privacy is not the priority action of the nurse as the assessment process is started. Privacy is a patient right that involves protecting the patient's personal information and dignity. However, it is not the most urgent action for a patient with acute shortness of breath, which is a sign of respiratory distress that can have various causes and complications. The nurse should first assess the patient's condition and provide oxygen therapy if needed.

Choice C reason: This is an incorrect choice because telling the patient that the physician will be in shortly to start treatment is not the priority action of the nurse as the assessment process is started. Communication is a nursing skill that involves informing the patient of the plan of care and collaborating with other health care professionals. However, it is not the most urgent action for a patient with acute shortness of breath, which is a sign of respiratory distress that can have various causes and complications. The nurse should first assess the patient's condition and provide oxygen therapy if needed.

Choice D reason: This is the correct choice because listening to the patient’s lung sounds and checking the pulse oximetry level is the priority action of the nurse as the assessment process is started. Assessment is a nursing process that involves collecting and analyzing data about the patient's health status and needs. Listening to the patient’s lung sounds and checking the pulse oximetry level are essential steps to evaluate the patient's respiratory function and oxygenation. These actions can help the nurse to identify the possible cause and severity of the patient's shortness of breath and to initiate appropriate interventions.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. Presbyopia is not a term for age-related hearing loss. Presbyopia is a term for age-related vision loss. Presbyopia is a condition where the lens of the eye becomes less flexible and less able to focus on near objects. It can cause difficulty in reading, writing, or doing other close-up tasks.

Choice B reason: This is correct. Presbycusis is a term for age-related hearing loss. Presbycusis is a condition where the inner ear or the auditory nerve degenerates over time. It can cause difficulty in hearing high-pitched sounds, speech, or background noise. It can also affect the balance and the quality of life.

Choice C reason: This is incorrect. Meniere’s disease is not a term for age-related hearing loss. Meniere’s disease is a term for a disorder of the inner ear that causes episodes of vertigo, hearing loss, tinnitus, and ear fullness. It can affect people of any age, but it is more common in middle-aged adults. It can be triggered by stress, infection, or allergy.

Choice D reason: This is incorrect. Tinnitus is not a term for age-related hearing loss. Tinnitus is a term for a ringing, buzzing, or other sound in the ears or head that is not caused by an external source. It can affect people of any age, but it is more common in older adults. It can be caused by various factors, such as noise exposure, ear infection, medication, or hearing loss.

A. Acute confusion related to delirium and disorientation B. Nausea related to constant sensation of noxious taste C. Autonomic dysreflexia related to distention of bowel or bladder D. Risk for falls related to unsteadiness and loss of balance

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.

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What is the priority action of the nurse as the assessment process is started for a patient who came to the hospital with acute shortness of breath?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which term will the nurse use to document the patient’s age-related hearing loss?

Correct Answer is B

Explanation

Which is the priority nursing diagnosis for a patient who has been diagnosed with Meniere’s disease?

Correct Answer is D

Explanation

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