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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While assessing perianal skin integrity is important for managing ulcerative colitis, it is not the immediate priority. Addressing electrolyte imbalances is crucial for stabilizing the client's condition first.
B. Emotional concerns are important but are secondary to addressing immediate physical health needs, such as electrolyte imbalances, which can be life-threatening if not managed promptly.
C. Reviewing electrolyte values is critical in an acute exacerbation of ulcerative colitis because diarrhea and fluid loss can lead to significant electrolyte imbalances, which need to be corrected to prevent complications.
D. Obtaining a dietary history is relevant for overall management but is not the immediate priority. Addressing electrolyte imbalances and hydration status is more urgent in acute exacerbations.
Correct Answer is D
Explanation
A. Decreased specific gravity is not typical of right-sided heart failure. Increased specific gravity is often associated with fluid retention.
B. PAWP is more relevant for left-sided heart failure; right-sided heart failure would typically not show an increase in PAWP.
C. BNP levels usually increase in heart failure, including right-sided heart failure, not decrease.
D. Elevated CVP and jugular vein distention are classic signs of right-sided heart failure due to increased venous pressure and fluid overload.
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