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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A reason: Asking "Why have you changed your mind about the surgery?" may come across as confrontational or judgmental. It does not address the client's emotions and may make the client feel defensive.
Choice B reason: The correct answer is b because acknowledging the client's feelings by saying, "Bypass surgery must be very frightening for you," shows empathy and understanding. It opens up a supportive conversation where the client can express concerns and emotions related to the surgery.
Choice C reason: Telling the client, "Your provider would not have scheduled the surgery unless you needed it," may dismiss the client's concerns and make them feel that their feelings are not important. It is important to address the client's emotional state and provide support.
Choice D reason: While it is appropriate to involve the healthcare provider in discussing the surgery, simply stating, "I will call your doctor and have him discuss your surgery with you," without first addressing the client's emotions and concerns, may seem dismissive. Providing emotional support should be the first step.
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