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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "A deregulated cytokine storm causes an inflammatory response": Systemic inflammatory response syndrome (SIRS) is characterized by a dysregulated inflammatory response triggered by various insults such as infection, trauma, burns, or ischemia. In SIRS, the immune system responds excessively, leading to the release of pro-inflammatory cytokines (cytokine storm), including tumor necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), and interleukin-6 (IL-6). This cytokine cascade results in widespread inflammation and systemic manifestations, such as fever, tachycardia, tachypnea, and leukocytosis.

B. "The major organ prone to injury during SIRS is the heart": While SIRS can lead to multi-organ dysfunction, including cardiac dysfunction, it does not primarily target the heart. SIRS affects multiple organs, including the lungs, kidneys, liver, and gastrointestinal tract. Cardiac dysfunction in SIRS may result from the inflammatory response, hypoperfusion, or direct myocardial injury.

C. "Spleen dysfunction causes blood clotting issues": SIRS can lead to coagulation abnormalities, but spleen dysfunction is not the primary cause. Coagulation abnormalities in SIRS are often attributed to endothelial dysfunction, activation of the coagulation cascade, and consumption of clotting factors, rather than spleen dysfunction.

D. "Activation of the inflammatory cascade causes increased perfusion": Activation of the inflammatory cascade in SIRS does not typically lead to increased perfusion. Instead, SIRS can lead to alterations in perfusion, including tissue hypoperfusion and microvascular dysfunction. In severe cases, SIRS can progress to septic shock, characterized by profound hypotension and inadequate tissue perfusion.

A. Comply with compression therapy. B. Monitor wounds on lower extremities. C. Take antiplatelet medications as ordered. D. Monitor for gradual onset of symptoms

Correct Answer is D

Explanation

A. Comply with compression therapy:

Compression therapy typically refers to the use of compression garments or devices to improve circulation and reduce swelling in the extremities, particularly in conditions such as venous insufficiency or deep vein thrombosis.

While compression therapy may be beneficial for certain circulatory disorders, it is not a standard treatment for cardiac tamponade.

Cardiac tamponade is a medical emergency characterized by the accumulation of fluid in the pericardial sac, leading to increased pressure on the heart and impaired cardiac function.

Treatment for cardiac tamponade involves prompt recognition and intervention to relieve the pressure on the heart, such as pericardiocentesis or surgical drainage of the pericardial effusion.

B. Monitor wounds on lower extremities:

Monitoring wounds on the lower extremities is essential for assessing healing, preventing complications such as infection, and promoting overall wound care.

However, monitoring wounds on the lower extremities is not directly related to the management or monitoring of cardiac tamponade.

In cardiac tamponade, the focus of monitoring is on assessing signs and symptoms of cardiac compromise, such as hypotension, tachycardia, dyspnea, and pulsus paradoxus, rather than wound care.

C. Take antiplatelet medications as ordered:

Antiplatelet medications, such as aspirin or clopidogrel, are commonly prescribed to prevent platelet aggregation and reduce the risk of thrombotic events, particularly in patients with cardiovascular disease or a history of myocardial infarction or stroke.

While antiplatelet medications may be part of the long-term management of certain cardiac conditions, they are not specific to the treatment or monitoring of cardiac tamponade.

The primary treatment for cardiac tamponade involves interventions to relieve the pressure on the heart and restore cardiac function, such as pericardiocentesis or surgical drainage of the pericardial effusion.

D. Monitor for gradual onset of symptoms:

Phase II of cardiac tamponade is characterized by a gradual onset of symptoms as the pressure within the pericardial sac increases, leading to impaired cardiac filling and decreased cardiac output.

Symptoms may include dyspnea, fatigue, orthopnea, tachycardia, and chest discomfort, which may develop gradually over time.

Early recognition of symptoms is crucial for prompt diagnosis and intervention to prevent further deterioration and improve outcomes in patients with cardiac tamponade.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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