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 B

Explanation

Choice A reason: Positioning the client supine may increase intracranial pressure. The client should be positioned with the head of the bed elevated to promote drainage and reduce pressure.

Choice B reason: The correct answer is b because changing the nasal drip pad as needed helps monitor for excessive drainage, cerebrospinal fluid leaks, and infection following pituitary gland removal.

Choice C reason: Frequent brushing of teeth should be avoided initially to prevent disruption of the surgical site and decrease the risk of infection. Gentle oral hygiene can be encouraged instead.

Choice D reason: Encouraging the client to cough every 2 hours can increase intracranial pressure and is not recommended following pituitary gland surgery. Deep breathing exercises without coughing are more appropriate.

A. A dry raised rash B. Excessive salivation C. Periorbital edema D. Hardened skin

Correct Answer is D

Explanation

Choice A reason: A dry raised rash is not a typical finding in scleroderma. Scleroderma primarily affects the skin and connective tissues, leading to hardening and tightening of the skin.

Choice B reason: Excessive salivation is not associated with scleroderma. Clients with scleroderma may experience dry mouth (xerostomia) instead.

Choice C reason: Periorbital edema is not a characteristic feature of scleroderma. Scleroderma involves systemic sclerosis that affects the skin, blood vessels, and internal organs.

Choice D reason: The correct answer is d because hardened skin is a hallmark of scleroderma. This autoimmune disease causes the skin to become thickened, tight, and stiff due to excessive collagen deposition.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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