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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 4 hr - The total infusion time for packed RBCs should not exceed 4 hours. Infusing beyond this period increases the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications.
B. 2 hr - While blood can be infused in 2 hours for some patients, especially in non-emergent situations, the standard maximum time allowed is 4 hours to prevent complications.
C. 8 hr - Infusing blood over 8 hours is too long and increases the risk of bacterial contamination and decreased efficacy of the blood product.
D. 6 hr - Similar to 8 hours, a 6-hour infusion time is too lengthy and poses significant risks for bacterial growth and sepsis.
Correct Answer is ["B","E"]
Explanation
A. Massage over erythematous bony prominences: Incorrect. Massaging over areas of erythema (redness) can cause further damage to the underlying tissues and should be avoided. It may exacerbate tissue injury and increase the risk of skin breakdown.
B. Use pillows to keep heels off the bed surface: Correct. Elevating the heels with pillows helps to reduce pressure and prevent pressure ulcers by keeping them off hard surfaces. This is a recommended practice to reduce the risk of heel pressure ulcers.
C. Implement turning schedule every 4 hr: Incorrect. A turning schedule of every 2 hours is generally recommended to prevent pressure ulcers. Four hours is too long and increases the risk of skin breakdown in immobile patients.
D. Keep the client's skin dry with powder: Incorrect. Powders can dry out the skin and increase friction, potentially leading to skin breakdown. It's more important to maintain moisture balance and avoid the use of powders on skin at risk.
E. Minimize skin exposure to moisture: Correct. Moisture can contribute to skin breakdown, especially in incontinent patients. It is crucial to keep the skin clean and dry to prevent moisture-associated skin damage.
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