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: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.

Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.

Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.

Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.

A. Eat plenty of fresh fruits and vegetables. B. Avoid crowded places. C. Participate in gardening for mild exercise. D. Take temperature weekly.

Correct Answer is B

Explanation

Choice A reason: Fresh fruits and vegetables can harbor bacteria and other pathogens that pose a significant infection risk to neutropenic clients. It's advisable to avoid these foods unless they are cooked or properly washed and peeled.

Choice B reason: Avoiding crowded places is essential for neutropenic clients because their immune system is weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to infectious agents.

Choice C reason: Participating in gardening is not recommended as it exposes neutropenic clients to soil bacteria and fungi, which can cause infections. Activities should be chosen carefully to minimize infection risk.

Choice D reason: Taking temperature weekly is not adequate for neutropenic clients. Daily temperature monitoring is important for early detection of infections, which can progress rapidly in immunocompromised individuals.

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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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