A nurse is assessing a client who has Meniere’s disease. Which of the following manifestations should the nurse expect?

Severe myopia

Vertigo

Anosmia

Photopsia

Answer and Explanation

The Correct Answer is B

A. Severe myopia: Severe myopia, or nearsightedness, is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to balance and hearing rather than vision.

B. Vertigo: Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, which is a sensation of spinning or dizziness. Vertigo is a hallmark symptom of Meniere's disease and is often accompanied by nausea, vomiting, and a feeling of fullness or pressure in the affected ear.

C. Anosmia: Anosmia refers to a loss of the sense of smell and is not typically associated with Meniere's disease. Meniere's disease primarily affects the vestibular system (balance) and auditory system (hearing) rather than the sense of smell.

D. Photopsia: Photopsia refers to the perception of flashes of light in the visual field and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is not directly related to visual disturbances.

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Correct Answer is A

Explanation

A. "A deregulated cytokine storm causes an inflammatory response": Systemic inflammatory response syndrome (SIRS) is characterized by a dysregulated inflammatory response triggered by various insults such as infection, trauma, burns, or ischemia. In SIRS, the immune system responds excessively, leading to the release of pro-inflammatory cytokines (cytokine storm), including tumor necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), and interleukin-6 (IL-6). This cytokine cascade results in widespread inflammation and systemic manifestations, such as fever, tachycardia, tachypnea, and leukocytosis.

B. "The major organ prone to injury during SIRS is the heart": While SIRS can lead to multi-organ dysfunction, including cardiac dysfunction, it does not primarily target the heart. SIRS affects multiple organs, including the lungs, kidneys, liver, and gastrointestinal tract. Cardiac dysfunction in SIRS may result from the inflammatory response, hypoperfusion, or direct myocardial injury.

C. "Spleen dysfunction causes blood clotting issues": SIRS can lead to coagulation abnormalities, but spleen dysfunction is not the primary cause. Coagulation abnormalities in SIRS are often attributed to endothelial dysfunction, activation of the coagulation cascade, and consumption of clotting factors, rather than spleen dysfunction.

D. "Activation of the inflammatory cascade causes increased perfusion": Activation of the inflammatory cascade in SIRS does not typically lead to increased perfusion. Instead, SIRS can lead to alterations in perfusion, including tissue hypoperfusion and microvascular dysfunction. In severe cases, SIRS can progress to septic shock, characterized by profound hypotension and inadequate tissue perfusion.

A. Isolated B. permanent C. Reversible D. Unique

Correct Answer is C

Explanation

A. Isolated: This term refers to something that is separate or distinct. Confusion and agitation in a client are not typically isolated but can be part of a broader clinical picture.

B. Permanent: These manifestations are not typically permanent and can often be reversed with appropriate interventions.

C. Reversible: Confusion and agitation in a client are often reversible and can be due to various factors such as medications, infections, metabolic disturbances, or other medical conditions. Identifying and addressing the underlying cause can often restore the client to their baseline mental status.

D. Unique: While every individual's presentation may have unique aspects, confusion and agitation are not considered unique manifestations in the context of acute changes in mental status. They are common symptoms that can occur due to a variety of reasons and are not exclusive to any particular condition.

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A nurse is assessing a client who has Meniere’s disease. Which of the following manifestations should the nurse expect?

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