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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Correct Answer is C
Explanation
A. Prednisone is a corticosteroid commonly used to reduce inflammation and manage asthma exacerbations. Its use is appropriate for controlling severe symptoms.
B. Montelukast is a leukotriene receptor antagonist used for long-term control of asthma. It helps to prevent asthma symptoms and is appropriate for ongoing management.
C. Propranolol is a non-selective beta-blocker that can exacerbate asthma by blocking beta-2 receptors in the lungs, leading to bronchoconstriction. It is contraindicated in asthma patients and requires clarification.
D. Theophylline is a bronchodilator used for asthma management. It is appropriate for helping to relax and open the airways.
Correct Answer is D
Explanation
A. Applying restraints should be a last resort and only if less restrictive measures have failed. It is also essential to follow legal and ethical guidelines regarding the use of restraints.
B. Calling the family to stay with the client may provide temporary comfort but does not directly address safety concerns or the underlying cause of restlessness and confusion.
C. Sedating the client might not be appropriate without first assessing the cause of the restlessness and confusion. Medications should be used cautiously and based on a thorough evaluation.
D. Moving the client closer to the nurses' station allows for more frequent monitoring and quick intervention if needed, addressing the immediate safety concern of restlessness and confusion. This measure helps ensure the client’s safety while further assessment and intervention are being planned.
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