Where will the restraints be tied to the patient’s bed when the nurse is applying soft wrist restraints to the patient?

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 a correct choice because autonomy is a key element of decentralized decision making. Autonomy refers to the ability and right of individuals or groups to make their own decisions without interference from others. Decentralized decision making empowers the employees to exercise their autonomy and use their own judgment and expertise to solve problems and improve performance².

Choice B reason: This is a correct choice because authority is a key element of decentralized decision making. Authority refers to the power and legitimacy to make decisions and take actions. Decentralized decision making delegates the authority from the top management to the lower levels of the organization, allowing them to make decisions that affect their work and outcomes².

Choice C reason: This is an incorrect choice because prioritization is not a key element of decentralized decision making. Prioritization refers to the process of ranking tasks or goals according to their importance and urgency. Decentralized decision making does not necessarily involve prioritization, as different individuals or groups may have different criteria and preferences for setting their priorities².

Choice D reason: This is a correct choice because responsibility is a key element of decentralized decision making. Responsibility refers to the obligation and duty to perform the assigned tasks and achieve the desired results. Decentralized decision making assigns the responsibility to the individuals or groups who make the decisions and hold them accountable for their actions and outcomes².

Choice E reason: This is a correct choice because accountability is a key element of decentralized decision making. Accountability refers to the expectation and requirement to report and explain the decisions and actions taken and the results achieved. Decentralized decision making ensures that the individuals or groups who make the decisions are accountable for their performance and quality, and that they receive feedback and recognition for their work².