A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

Limit fluid intake.

Monitor client’s cardinal fields of vision.

Encourage ambulation.

Ensure the room is brightly lit.

Answer and Explanation

The Correct Answer is B

Choice A reason: Limiting fluid intake is not an appropriate intervention for labyrinthitis. Adequate hydration is important for overall health and should be maintained.

Choice B reason: The correct answer is b because labyrinthitis can affect the vestibular system, leading to dizziness and vertigo. Monitoring the client’s cardinal fields of vision helps assess for nystagmus, which is a common symptom of vestibular disorders.

Choice C reason: Encouraging ambulation is not advisable for clients with labyrinthitis, as it can increase the risk of falls and injury due to dizziness and imbalance.

Choice D reason: Ensuring the room is brightly lit is not necessary for the management of labyrinthitis and may not provide any therapeutic benefit.

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Correct Answer is C

Explanation

Choice A reason: Squamous cell carcinoma commonly occurs on sun-exposed areas such as the face, ears, neck, and hands, but not necessarily the trunk. It is important to emphasize the role of sun exposure in the development of this type of skin cancer.

Choice B reason: Radiation therapy is used in the treatment of certain types of skin cancer, but it is not typically the first choice for metastatic skin cancer. Other treatments, such as surgery, immunotherapy, or targeted therapy, are often preferred depending on the type and stage of skin cancer.

Choice C reason: The correct answer is c because sun exposure, especially during childhood, significantly increases the risk of developing skin cancer later in life. This highlights the importance of sun protection measures from an early age to prevent skin cancer.

Choice D reason: Basal cell carcinoma is the most common and least aggressive type of skin cancer. It rarely metastasizes and is usually slow-growing, making early detection and treatment highly effective.

A. Have staff and visitors wear gowns while in the client’s room. B. Place the client in a private room with a special ventilation system. C. Move the client to a semi-private room with a client who requires droplet precautions. D. Remove personal protective equipment in the hallway outside of the client’s room.

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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A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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