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 B

Explanation

Choice A reason: Taking a laxative the day before an IVP is a common preparation to clear the intestines for better imaging. This statement does not require additional data collection.

Choice B reason: The correct answer is b because taking metformin before an IVP can increase the risk of lactic acidosis, a serious complication. Metformin should be temporarily discontinued before and after the procedure, and the nurse should gather more information to manage the client’s diabetes safely.

Choice C reason: Fasting before an IVP is standard procedure to ensure clear imaging. This statement does not require additional data collection.

Choice D reason: Painful voiding may be related to kidney stones but is not a contraindication for an IVP. This statement does not require additional data collection.

A. Review relaxation techniques with the client. B. Provide immediate rest for the client. C. Remind the client not to try to talk. D. Administer a short-acting beta-adrenergic medication.

Correct Answer is D

Explanation

Choice A reason: Reviewing relaxation techniques can be beneficial for managing anxiety during an asthma attack, but it is not the highest priority in an acute situation.

Choice B reason: Providing immediate rest can help the client conserve energy and reduce the work of breathing, but it does not address the underlying cause of the asthma exacerbation.

Choice C reason: Reminding the client not to try to talk helps reduce the work of breathing, but it is not the most urgent intervention.

Choice D reason: The correct answer is d because administering a short-acting beta-adrenergic medication, such as albuterol, is the highest priority. These medications act quickly to relax the bronchial muscles, reduce bronchospasm, and improve airflow, which is critical in an acute asthma exacerbation.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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