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: Squamous cell carcinoma commonly occurs on sun-exposed areas such as the face, ears, neck, and hands, but not necessarily the trunk. It is important to emphasize the role of sun exposure in the development of this type of skin cancer.

Choice B reason: Radiation therapy is used in the treatment of certain types of skin cancer, but it is not typically the first choice for metastatic skin cancer. Other treatments, such as surgery, immunotherapy, or targeted therapy, are often preferred depending on the type and stage of skin cancer.

Choice C reason: The correct answer is c because sun exposure, especially during childhood, significantly increases the risk of developing skin cancer later in life. This highlights the importance of sun protection measures from an early age to prevent skin cancer.

Choice D reason: Basal cell carcinoma is the most common and least aggressive type of skin cancer. It rarely metastasizes and is usually slow-growing, making early detection and treatment highly effective.

A. Complete two cycles of compression/rescue breathing before attaching the automated external defibrillator (AED). B. Check for a brachial pulse. C. Provide chest compressions at a rate of 100/min. D. After a set of 50 compressions, give the client 2 rescue breaths.

Correct Answer is C

Explanation

Choice A reason: While early CPR is crucial, the AED should be attached as soon as it is available to analyze the heart rhythm and provide a shock if needed. Delaying the use of the AED can reduce the chances of successful resuscitation.

Choice B reason: In adults, the carotid pulse is typically checked, not the brachial pulse. The brachial pulse is more commonly assessed in infants.

Choice C reason: The correct answer is c because providing chest compressions at a rate of 100-120 compressions per minute is the recommended rate for effective CPR. High-quality chest compressions are essential for maintaining circulation during cardiac arrest.

Choice D reason: The recommended ratio of chest compressions to rescue breaths is 30:2, not 50:2. Performing 50 compressions before providing rescue breaths is not aligned with current CPR guidelines.

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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?

Nursing Test Bank

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