Which is the priority nursing diagnosis for a patient who has been diagnosed with Meniere’s disease?
Acute confusion related to delirium and disorientation
Nausea related to constant sensation of noxious taste
Autonomic dysreflexia related to distention of bowel or bladder
Risk for falls related to unsteadiness and loss of balance
The Correct Answer is D
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because utilizing a no-rinse shampoo cap is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A no-rinse shampoo cap is a disposable cap that contains a pre-moistened shampoo and conditioner. It can be heated in a microwave and applied to the patient's head without the need for water or rinsing. It can clean and condition the patient's hair without causing any discomfort or movement of the affected shoulder.
Choice B reason: This is an incorrect choice because using a handheld shower sprayer is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A handheld shower sprayer is a device that attaches to a faucet and allows the user to direct the water flow. It can be difficult and painful for the patient to use or hold the sprayer with the affected shoulder, and it can also wet the surgical dressing or incision site.
Choice C reason: This is an incorrect choice because having the patient lean over the wash basin is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A wash basin is a bowl or sink that contains water and soap for washing. It can be uncomfortable and risky for the patient to lean over the basin with the affected shoulder, and it can also wet the surgical dressing or incision site.
Choice D reason: This is an incorrect choice because having the patient lean back into the sink is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A sink is a basin with a faucet that provides water for washing. It can be uncomfortable and risky for the patient to lean back into the sink with the affected shoulder, and it can also wet the surgical dressing or incision site.
Correct Answer is ["B","D"]
Explanation
Choice A reason: This is incorrect. Tramadol is not a nonsteroidal anti-inflammatory medication. Tramadol is an opioid analgesic medication that works by binding to opioid receptors in the brain and spinal cord. It can relieve moderate to severe pain, but it does not have any anti-inflammatory effect.
Choice B reason: This is correct. Aspirin is a nonsteroidal anti-inflammatory medication. Aspirin is a salicylate medication that works by inhibiting the enzyme cyclooxygenase, which is involved in the synthesis of prostaglandins. Prostaglandins are chemical messengers that mediate inflammation, pain, and fever. Aspirin can reduce inflammation, pain, and fever, as well as prevent blood clots and protect the heart.
Choice C reason: This is incorrect. Acetaminophen is not a nonsteroidal anti-inflammatory medication. Acetaminophen is a para-aminophenol medication that works by inhibiting the enzyme cyclooxygenase in the central nervous system, but not in the peripheral tissues. It can reduce pain and fever, but it does not have any anti-inflammatory effect.
Choice D reason: This is correct. Ibuprofen is a nonsteroidal anti-inflammatory medication. Ibuprofen is a propionic acid medication that works by inhibiting the enzyme cyclooxygenase, which is involved in the synthesis of prostaglandins. Prostaglandins are chemical messengers that mediate inflammation, pain, and fever. Ibuprofen can reduce inflammation, pain, and fever, as well as treat arthritis and menstrual cramps.
Choice E reason: This is incorrect. Codeine is not a nonsteroidal anti-inflammatory medication. Codeine is an opioid analgesic medication that works by binding to opioid receptors in the brain and spinal cord. It can relieve mild to moderate pain, but it does not have any anti-inflammatory effect.
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