A nurse is caring for a client who has Ménière’s disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?

"You are free to move around your room as you wish, but you should avoid the hallways."

"You are on strict bed rest and must not be up."

"Please call for assistance when you wish to get out of bed."

"Why would we not allow you to walk if you wanted?"

Answer and Explanation

The Correct Answer is C

Choice A reason: Allowing the client to move around the room unsupervised can lead to falls, as Ménière’s disease can cause sudden episodes of vertigo and imbalance.

Choice B reason: Strict bed rest is usually not required for clients with Ménière’s disease. Encouraging mobility with assistance is typically more appropriate.

Choice C reason: Asking the client to call for assistance helps prevent falls and ensures the client's safety. Ménière’s disease often causes vertigo, and assistance is necessary to prevent injuries.

Choice D reason: This response does not address the client's safety concerns and may lead to misunderstanding the risks associated with ambulation in Ménière’s disease.

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Correct Answer is C

Explanation

Choice A reason: Lactulose is a laxative used to treat constipation and hepatic encephalopathy by reducing blood ammonia levels, but it is not effective in lowering serum potassium levels. Therefore, it would not be the appropriate medication for treating hyperkalemia.

Choice B reason: Triamterene is a potassium-sparing diuretic, which means it helps the body retain potassium. Administering Triamterene in a client with high potassium levels (hyperkalemia) would exacerbate the condition rather than improve it. Hence, it is not a suitable choice for this scenario.

Choice C reason: Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by binding to potassium in the intestines and facilitating its removal from the body through feces. It effectively reduces serum potassium levels, making it the appropriate medication for a client with hyperkalemia.

Choice D reason: Acetylcysteine is used primarily as a mucolytic agent to break down mucus in the airways or as an antidote for acetaminophen (paracetamol) overdose. It does not have any effect on serum potassium levels and is not suitable for treating hyperkalemia.

A. Auscultate lung fields. B. Provide mouth care. C. Cup hands and tap on the client’s chest repeatedly. D. Position the client so that the lung area to be drained is above the client’s trachea.

Correct Answer is A

Explanation

Choice A reason: The correct answer is a because auscultating the lung fields allows the nurse to determine the areas of congestion and plan the most effective positioning and techniques for chest percussion, vibration, and postural drainage.

Choice B reason: Providing mouth care is important for client comfort but is not the first step in preparing for chest physiotherapy.

Choice C reason: Cupping hands and tapping on the client’s chest repeatedly is part of the chest percussion technique but should be done after assessing the lung fields to target the appropriate areas.

Choice D reason: Positioning the client so that the lung area to be drained is above the trachea is part of postural drainage but should be planned based on the findings from auscultation.

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A nurse is caring for a client who has Ménière’s disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?

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