A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?
Myopia
Vertigo
Photophobia
Presbycusis
The Correct Answer is B
Correct answer: B
A. Myopia - Myopia (near-sightedness) is a vision condition related to the shape of the eye and is not related to Meniere's disease or endolymph fluid accumulation.
B. Vertigo - Vertigo is a primary symptom of Meniere's disease and is caused by the excessive accumulation of endolymph fluid in the inner ear, which affects balance and spatial orientation.
C. Photophobia - Sensitivity to light is not a symptom of Meniere's disease; it is more commonly associated with migraines or eye conditions.
D. Presbycusis - Presbycusis is age-related hearing loss and is unrelated to the fluid balance issues seen in Meniere's disease.
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Related Questions
Correct Answer is C
Explanation
A. Elevate the limb and apply ice. Elevating the limb and applying ice can help reduce blood flow to the area and minimize swelling. However, it is not the immediate priority in managing active, profuse bleeding.
B. Apply a tourniquet just below the elbow. A tourniquet should be a last resort due to the risk of cutting off blood flow and potential limb damage. It's typically used in life-threatening situations where other methods fail to control bleeding.
C. Apply direct pressure over the wound. The immediate priority for controlling profuse bleeding is to apply direct pressure to the wound to stop or reduce the bleeding. This is a standard first-line intervention in hemorrhage management.
D. Clean the wound. Cleaning the wound is important to prevent infection, but it is not the first priority when dealing with active, profuse bleeding.
Correct Answer is C
Explanation
A. Impaired skin integrity - While the patient does have skin issues due to ulcerations, the root cause is impaired perfusion. Addressing the impaired tissue perfusion will help improve skin integrity.
B. Alteration in activity tolerance - Although the patient might experience reduced activity tolerance due to the heaviness and discomfort, it is not as critical as ensuring adequate tissue perfusion.
C. Impaired tissue perfusion - This diagnosis is the priority because varicose veins and ulcerations with lower extremity edema suggest that there is poor blood flow to the tissues, which can lead to further complications such as worsening ulcerations and potential infection. Effective tissue perfusion is critical to healing and preventing further deterioration.
D. Alteration in body image - This is a valid concern for the patient but is not as immediate or life-threatening as impaired tissue perfusion and the potential for complications from poor circulation.
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