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."

Answer and Explanation

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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Correct Answer is D

Explanation

A. Notifying the provider is important if initial interventions do not resolve the issue, but it is not the first action to take.
B. Adjusting the rate of the bladder irrigant may help, but first, it is essential to ensure that there is no mechanical obstruction in the tubing.
C. Irrigating the catheter can help clear any blockages, but the first step is to check for any kinks or obvious obstructions in the tubing.
D. Checking the tubing for kinks is the first action as it is a common and easily rectifiable cause of urinary catheter drainage issues. This should be done before other interventions.

A. Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis B. Suction the tube every 2 hr and as needed to maintain patency C. Maintain constant observation while the balloons are inflated D. Keep the head of the bed flat at all times to prevent the development of shock

Correct Answer is C

Explanation

A. Deflating the balloons regularly is not a standard practice and could potentially lead to rebleeding; balloon inflation should be managed carefully as per protocol.
B. Suctioning the tube should be done based on the need for patency, but every 2 hours might not be necessary unless indicated.
C. Maintaining constant observation while the balloons are inflated is crucial to monitor for complications such as esophageal tissue necrosis and to ensure effective hemostasis.
D. The head of the bed should typically be elevated to reduce the risk of aspiration and facilitate breathing, rather than kept flat.

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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?

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