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 A
Explanation
Choice A reason: A low-sodium diet is essential for clients with acute glomerulonephritis to prevent fluid retention and reduce the workload on the kidneys. This dietary modification helps manage edema and hypertension, common complications of the condition. By limiting sodium intake, the body retains less water, which helps control swelling and blood pressure, making it a crucial intervention in the plan of care.
Choice B reason: Encouraging increased fluid intake is not recommended for clients with acute glomerulonephritis. Excessive fluid intake can lead to fluid overload, worsening edema and hypertension. The kidneys are already compromised in their ability to excrete fluid efficiently, so increasing fluid intake would exacerbate these issues. Instead, fluid intake should be carefully monitored and potentially restricted to prevent further strain on the kidneys.
Choice C reason: Obtaining weekly weight is not specific enough to monitor the acute phase of glomerulonephritis. Daily weights are more appropriate to closely monitor fluid balance and detect changes in edema. Daily weight measurements can help in assessing the effectiveness of interventions such as a low-sodium diet or diuretics and provide timely information for adjusting the plan of care.
Choice D reason: Encouraging frequent ambulation, while generally beneficial for overall health, is not a specific intervention for managing acute glomerulonephritis. The primary focus should be on dietary modifications and monitoring fluid balance to manage symptoms and prevent complications. Ambulation should be encouraged based on the client's overall condition and ability but is not a direct intervention for glomerulonephritis.
Correct Answer is B
Explanation
Choice A reason: While gowns may be part of the precautions, they are not sufficient alone for preventing the spread of TB, which is transmitted via airborne particles.
Choice B reason: Placing the client in a private room with a special ventilation system is crucial for preventing the spread of TB. The special ventilation system, typically a negative pressure room, ensures that airborne particles do not escape into other areas, thereby protecting staff and other patients.
Choice C reason: A semi-private room with another patient requiring droplet precautions is inappropriate for a TB patient, as TB requires strict airborne precautions to prevent transmission.
Choice D reason: Removing personal protective equipment in the hallway increases the risk of contaminating the hallway and spreading TB. PPE should be removed inside the room or anteroom to contain potential contaminants.
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