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
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Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because gently trimming the patient’s toenails after soaking the feet in warm soapy water is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. Trimming the toenails can be risky for the diabetic patient, as it can cause bleeding, infection, or injury to the nail bed or surrounding skin. The nurse should avoid cutting the toenails of the diabetic patient, unless instructed by a podiatrist.
Choice B reason: This is an incorrect choice because using a pumice stone to smooth roughened areas of skin on the patient’s feet is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. A pumice stone is a porous rock that can be used to exfoliate the skin and remove dead cells. However, it can also damage the skin and cause abrasions, irritation, or infection. The nurse should be careful when using a pumice stone on the diabetic patient, and avoid rubbing too hard or too often.
Choice C reason: This is an incorrect choice because liberally applying lotion to the patient's feet especially between the toes is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. Applying lotion to the feet can help to moisturize and soften the skin, but it can also create a moist environment that can promote fungal growth and infection. The nurse should apply lotion sparingly to the feet of the diabetic patient, and avoid applying it between the toes.
Choice D reason: This is the correct choice because obtaining a consultation for a podiatrist to assess the feet and provide nail care is the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. A podiatrist is a specialist who can diagnose and treat foot problems, such as nail disorders, skin conditions, or infections. The podiatrist can safely and effectively trim the toenails of the diabetic patient, and provide education and advice on foot care and prevention of complications. The nurse should refer the diabetic patient to a podiatrist at least once a year, or more often if needed.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect choice because the hospital is affiliated with a nationally recognized medical school is not a characteristic that qualifies the hospital for Magnet Recognition status. Magnet Recognition status is a credential that recognizes excellence in nursing practice and quality of care. The hospital's affiliation with a medical school is not related to its nursing performance or outcomes.
Choice B reason: This is the correct choice because the hospital participates in nursing research and implements the findings is a characteristic that qualifies the hospital for Magnet Recognition status. Magnet Recognition status is a credential that recognizes excellence in nursing practice and quality of care. The hospital's participation in nursing research and implementation of the findings demonstrates its commitment to evidence-based practice and innovation in nursing.
Choice C reason: This is an incorrect choice because the hospital is owned by a religious order that offers daily prayer services is not a characteristic that qualifies the hospital for Magnet Recognition status. Magnet Recognition status is a credential that recognizes excellence in nursing practice and quality of care. The hospital's ownership and religious affiliation are not related to its nursing performance or outcomes.
Choice D reason: This is an incorrect choice because the hospital receives federal grant funding for advanced medical research is not a characteristic that qualifies the hospital for Magnet Recognition status. Magnet Recognition status is a credential that recognizes excellence in nursing practice and quality of care. The hospital's funding and research activities are not related to its nursing performance or outcomes.
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