nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
"Please ring for assistance when you wish to get out of bed."
"We will have to get a prescription from your provider."
"Yes, you are free to move around as you wish."
"No, you are on strict bedrest and must not be up."
The Correct Answer is A
A. Clients with Ménière's disease may experience dizziness and balance issues, so it is important to ensure safety by asking them to ring for assistance when moving around to prevent falls or injuries.
B. A prescription from the provider is not typically required for ambulation; instead, safety measures should be in place.
C. Allowing free movement without assistance may increase the risk of falls due to balance problems associated with Ménière's disease.
D. Strict bedrest is generally not necessary unless specifically indicated by the provider; assistance and safety measures are more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Urinary output is important but secondary to respiratory concerns in this postoperative context.
B. Arterial blood gases provide valuable information but are less immediate compared to issues directly affecting lung function.
C. Chest tube drainage is critical to monitor for complications such as pneumothorax or hemothorax, which are significant concerns post-thoracotomy and lobectomy.
D. Pain level is important for patient comfort but does not have the immediate impact on recovery compared to chest tube drainage.
Correct Answer is D
Explanation
A. Bradypnea is not a hallmark sign of ARDS; ARDS typically involves tachypnea or rapid breathing.
B. An elevated PaCO2 indicates hypercapnia but is not specific to ARDS.
C. Elevated blood pressure is not a specific indicator of ARDS.
D. A persistently low PaO2 despite receiving high-flow oxygen (such as from a non-rebreather mask) is a hallmark sign of ARDS, indicating severe hypoxemia and impaired gas exchange.
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