A nurse is completing an admission assessment on a client who has hearing loss. Which of the following client statements should indicate to the nurse that the client is experiencing manifestations of Meniere’s disease?

"l can't get out of bed because the room is spinning."

"l did feel some fluid dripping from my ear when I laid down."

"Sometimes I feel slightly dizzy when I am in a loud restaurant."

"l often feel like I have cotton balls in my ears."

Answer and Explanation

The Correct Answer is A

A. "I can't get out of bed because the room is spinning": The sensation of vertigo, or the perception of spinning or movement when there is none, is a hallmark symptom of Meniere's disease. This sensation is often severe and can be debilitating, leading to difficulty with balance and mobility. Therefore, the client's statement indicating that they cannot get out of bed due to the room spinning is consistent with manifestations of Meniere's disease.

B. "I did feel some fluid dripping from my ear when I laid down": While fluid leakage from the ear can be a symptom of various ear conditions, such as otitis externa or otitis media, it is not typically associated with Meniere's disease. Meniere's disease is characterized by recurrent episodes of vertigo, hearing loss, tinnitus, and a feeling of fullness or pressure in the ear, rather than fluid leakage.

C. "Sometimes I feel slightly dizzy when I am in a loud restaurant": Feeling slightly dizzy in a loud environment may suggest sensitivity to noise (phonophobia) or a mild form of dizziness such as disequilibrium, but it is not specific to Meniere's disease. Meniere's disease typically presents with severe episodes of vertigo rather than mild dizziness.

D. "I often feel like I have cotton balls in my ears": The sensation of having cotton balls in the ears may indicate a feeling of fullness or pressure in the ears, which is a common symptom of Meniere's disease. However, this symptom alone is not sufficient to diagnose Meniere's disease, as it can also occur in other conditions affecting the middle ear, such as eustachian tube dysfunction or otitis media. Additionally, Meniere's disease is primarily characterized by vertigo, not just ear fullness or pressure.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Administer pain medication as needed. Rationale: Pain management is essential for clients with traumatic brain injury (TBI) to ensure their comfort and to prevent agitation or increased intracranial pressure (ICP) due to pain. Administering pain medication as needed helps alleviate discomfort and promotes rest, which supports the client's recovery.

B. Maintain ventriculostomy at the correct position. Rationale: Ventriculostomy, also known as an external ventricular drain (EVD), is a critical component of managing intracranial pressure (ICP) in clients with traumatic brain injury. Maintaining the ventriculostomy at the correct position ensures accurate monitoring and drainage of cerebrospinal fluid (CSF), which helps control ICP levels and prevents complications such as cerebral edema.

C. Maintain the neck in the midline position. Rationale: Keeping the neck in a midline position is essential for clients with traumatic brain injury to prevent further injury to the cervical spine. Proper alignment of the neck helps maintain spinal stability and reduces the risk of exacerbating any existing spinal cord injury, which may coexist with the traumatic brain injury.

D. Elevate the head of the bed to 30 degrees. Rationale: Elevating the head of the bed to 30 degrees is recommended for clients with traumatic brain injury to promote cerebral venous drainage and reduce intracranial pressure (ICP). This position helps optimize cerebral perfusion and minimizes the risk of cerebral edema, which can occur with increased ICP.

E. Maintain enteral feedings. Rationale: Nutritional support is crucial for clients with traumatic brain injury to support healing and recovery. Enteral feedings, such as tube feedings, may be necessary if the client is unable to consume adequate nutrition orally due to impaired swallowing or altered consciousness. Providing enteral feedings ensures the client receives essential nutrients to support tissue repair and prevent malnutrition-related complications during the recovery process.

A. Completing hourly endotracheal suctioning B. Ensuring proper ventriculostomy transducer levels C. Monitoring volume status D. Elevating the head of the bed 15°

Correct Answer is D

Explanation

A. Completing hourly endotracheal suctioning: Hourly endotracheal suctioning is not typically indicated for a client with increased intracranial pressure (ICP). Frequent suctioning can lead to increased intrathoracic pressure and potentially compromise venous return, which may further elevate ICP. Suctioning should be performed as needed to maintain airway patency while minimizing the risk of increasing ICP.

B. Ensuring proper ventriculostomy transducer levels: Ensuring proper ventriculostomy transducer levels is important for accurate measurement of intracranial pressure (ICP) but may not directly alleviate elevated ICP. Monitoring ICP through ventriculostomy allows for timely detection of changes in ICP, which can guide interventions to manage elevated pressure levels. However, it is not a direct intervention to reduce ICP.

C. Monitoring volume status: Monitoring volume status is important in managing a client with increased intracranial pressure (ICP) as both hypovolemia and hypervolemia can impact ICP. However, monitoring volume status alone does not directly address elevated ICP. Interventions to optimize volume status, such as fluid administration or diuresis, may be implemented based on assessment findings, but they should be done cautiously to avoid exacerbating cerebral edema or altering cerebral perfusion.

D. Elevating the head of the bed 15°: Elevating the head of the bed 15° (or higher) is a crucial intervention for managing a client with increased intracranial pressure (ICP). This position helps promote venous drainage from the brain, reducing venous congestion and intracranial pressure. Elevating the head of the bed also helps prevent cerebrospinal fluid (CSF) from pooling in the brain, which can further increase ICP. Placing the client in a semi-upright position is a standard practice in managing ICP and is recommended in various clinical guidelines.

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A nurse is completing an admission assessment on a client who has hearing loss. Which of the following client statements should indicate to the nurse that the client is experiencing manifestations of Meniere’s disease?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

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Correct Answer is D

Explanation

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