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 B

Explanation

A. Differences in upper and lower lung sounds are not indicative of atrial fibrillation but may suggest other conditions such as fluid accumulation or pneumonia.
B. A difference between apical and radial pulses, known as pulse deficit, can indicate atrial fibrillation due to the irregular and often rapid heartbeat that may not always produce a palpable radial pulse.
C. Differences between oral and axillary temperatures are not relevant to the assessment of atrial fibrillation but could indicate issues with measurement accuracy.
D. Different blood pressures in the upper limbs might suggest vascular issues but are not specific indicators of atrial fibrillation.

A. Chvostek's sign B. Kernig's sign C. Babinski's sign D. Brudzinski's sign

Correct Answer is A

Explanation

A. Chvostek's sign is a test for tetany, which is associated with hypocalcemia. The tingling sensation reported by the client is indicative of low calcium levels, and Chvostek's sign involves tapping the facial nerve to see if it triggers facial twitching, which is a sign of hypocalcemia.

B. Kernig's sign is used to assess for meningitis and is not related to hypocalcemia. It involves checking for resistance or pain when extending the leg while the hip is flexed.

C. Babinski's sign is used to assess for neurological conditions and is not related to hypocalcemia. It involves stroking the sole of the foot to check for abnormal reflex responses.

D. Brudzinski's sign is used to assess for meningitis and involves checking for involuntary flexion of the knees and hips when the neck is flexed. It is not related to the symptoms of hypocalcemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

Correct Answer is A

Explanation

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