A client experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective?
Blood pressure of 120/80 mm Hg.
Oxygen saturation level of 99%
Headache rated at 0 on 0 to 10 scale.
Ambulates easily without vertigo
The Correct Answer is D
A. This assessment finding may be within the normal range for blood pressure, but it does not directly indicate the effectiveness of the antihistamine medication for Ménière's disease. Antihistamines are not typically prescribed to directly affect blood pressure.
B. While maintaining adequate oxygen saturation is important for overall health, this finding is not specific to the management of Ménière's disease with antihistamine medication. Antihistamines are not typically prescribed to directly affect oxygen saturation levels. Therefore, this finding may not directly indicate the effectiveness of the medication for Ménière's disease.
C. Headache rated at 0 on a 0 to 10 scale is not specific to vertigo.
D. Ambulating easily without vertigo is relevant for assessing the effectiveness of the antihistamine medication for Ménière's disease. Vertigo, characterized by a sensation of spinning or dizziness, is a hallmark symptom of Ménière's disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Breakthrough pain is a transient exacerbation of pain that occurs despite the use of around- the-clock analgesics for persistent pain. Breakthrough pain episodes require rapid intervention with additional analgesics or adjustments to the current pain management regimen to provide adequate pain relief and improve the client's quality of life.
A. Replacing transdermal analgesic patches every 72 hours is important for ensuring consistent delivery of medication, but it is not directly related to addressing breakthrough pain.
B. Administering analgesics on a fixed and continuous schedule is important for maintaining baseline pain control, but it may not address breakthrough pain adequately.
D. Frequently evaluating the client's pain is essential, but monitoring specifically for breakthrough pain ensures timely intervention when pain exacerbations occur.
Correct Answer is A
Explanation
A. Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse's priority is to closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.
B. While activity intolerance is a common nursing diagnosis for clients following an acute myocardial infarction due to myocardial ischemia, it is not the priority in this case where the client is actively receiving thrombolytic therapy.
C. While respiratory complications can occur following thrombolytic therapy, such as pulmonary embolism or bleeding into the lungs, the risk of bleeding complications takes precedence as the priority nursing problem for this client.
D. Education about the new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period.
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