Which assessment finding indicates to the nurse why the patient is having difficulty sleeping at night?

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.

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.