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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A reason: Serosanguineous drainage from the puncture site is an expected finding after a thoracentesis and does not typically indicate a complication.
Choice B reason: Discomfort at the puncture site is common following a thoracentesis and does not necessarily indicate a complication.
Choice C reason: The correct answer is c because an increased heart rate can be a sign of respiratory distress or hypovolemia, which are potential complications of a thoracentesis. This finding warrants immediate notification of the provider.
Choice D reason: A decreased temperature is not a common complication of thoracentesis and is less relevant than the other options. It is more important to monitor for signs of respiratory distress or circulatory changes.
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