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: Brudzinski's sign is an indicator of meningitis, where flexion of the neck causes involuntary flexion of the hips and knees. This sign is not related to hypocalcemia and is more specific to central nervous system infections.
Choice B reason: Chvostek's sign is a clinical sign of hypocalcemia. It is elicited by tapping on the facial nerve in front of the ear, which causes twitching of the facial muscles. This sign indicates neuromuscular irritability due to low calcium levels and is a key indicator for diagnosing hypocalcemia.
Choice C reason: Cullen's sign is a superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is associated with acute pancreatitis and intra-abdominal bleeding, not hypocalcemia. Therefore, it is not an appropriate sign to monitor for in clients with hypocalcemia.
Choice D reason: Kernig's sign is another indicator of meningitis. It involves pain and resistance to knee extension when the hip is flexed. Like Brudzinski's sign, it is specific to meningitis and is not related to hypocalcemia. Monitoring for this sign would not be relevant for a client with low calcium levels.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: The correct answer is a because orange juice is high in potassium and should be avoided by clients with chronic kidney disease to prevent hyperkalemia, which can lead to serious cardiac complications.
Choice B reason: The correct answer is b because watermelon, although refreshing, is high in potassium and should be limited or avoided by clients with chronic kidney disease to maintain safe potassium levels.
Choice C reason: The correct answer is c because bananas are well-known for their high potassium content and should be avoided by clients with chronic kidney disease to prevent elevated potassium levels in the blood.
Choice D reason: Corn flakes cereal is generally low in potassium and is not a food that needs to be avoided in clients with chronic kidney disease. It can be included in their diet in moderation.
Choice E reason: White rice is also low in potassium and can be safely consumed by clients with chronic kidney disease. It does not pose a significant risk of increasing potassium levels.
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