A nurse is assessing a client who has Meniere’s disease. Which of the following manifestations should the nurse expect?

Severe myopia

Vertigo

Anosmia

Photopsia

Answer and Explanation

The Correct Answer is B

A. Severe myopia: Severe myopia, or nearsightedness, is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is characterized by symptoms related to balance and hearing rather than vision.

B. Vertigo: Meniere's disease is a disorder of the inner ear that causes episodes of vertigo, which is a sensation of spinning or dizziness. Vertigo is a hallmark symptom of Meniere's disease and is often accompanied by nausea, vomiting, and a feeling of fullness or pressure in the affected ear.

C. Anosmia: Anosmia refers to a loss of the sense of smell and is not typically associated with Meniere's disease. Meniere's disease primarily affects the vestibular system (balance) and auditory system (hearing) rather than the sense of smell.

D. Photopsia: Photopsia refers to the perception of flashes of light in the visual field and is not a typical manifestation of Meniere's disease. Meniere's disease primarily affects the inner ear and is not directly related to visual disturbances.

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Correct Answer is A

Explanation

Answer: A. Ensuring that the client and their family are kept informed about the client's care

Rationale:

A. Ensuring that the client and their family are kept informed about the client's care:
This action is the priority because communication is vital in managing a client with multiple organ dysfunction syndrome (MODS). Keeping the client and their family informed can help them understand the seriousness of the condition, the plan of care, and potential outcomes. It also fosters trust and ensures that the family can make informed decisions regarding the client's care.

B. Being aware of the client's wishes regarding care:
While being aware of the client’s wishes is important, especially in critical conditions like MODS, the priority lies in ensuring ongoing communication about the client's current status and treatment. Understanding the client's wishes can guide care but should follow the immediate need for clear communication about the evolving situation.

C. Scheduling periods of rest for the client:
Rest is essential for recovery, particularly in clients with MODS, but scheduling rest periods is a part of implementing care rather than a primary action. It can be planned based on the client’s needs and condition but does not take precedence over ensuring that the family is informed.

D. Discussing the client's resting times with the family:
While involving the family in discussions about the client's care is beneficial, the immediate priority is to ensure they are fully informed about the overall condition and care plan. This discussion can occur after establishing a solid communication foundation regarding the client's status and care approach.

A. Lie on your back when sleeping. B. Lie on your front when sleeping. C. Resume your exercise routine. D. Wash your hair 24 hr after surgery.

Correct Answer is D

Explanation

A. Lie on your back when sleeping: Lying on the back when sleeping may be recommended initially after cochlear implant surgery to avoid putting pressure on the surgical site. However, this instruction should not be included in the plan of care indefinitely. Once the client is comfortable and the surgical site is healing well, they should be allowed to sleep in any position that is comfortable for them.

B. Lie on your front when sleeping: Lying on the front when sleeping is not typically recommended after cochlear implant surgery, as it may put pressure on the surgical site and disrupt healing. This position could potentially cause discomfort and increase the risk of complications. Therefore, this instruction should not be included in the plan of care.

C. Resume your exercise routine: Resuming the exercise routine immediately after cochlear implant surgery may not be advisable. The client should be instructed to avoid strenuous activities and heavy lifting for a certain period as advised by the healthcare provider. Engaging in vigorous exercise too soon after surgery could potentially disrupt the healing process and increase the risk of complications. Therefore, this instruction should not be included in the plan of care immediately after surgery.

D. Wash your hair 24 hr after surgery: After cochlear implant insertion, it is important to keep the surgical site clean to prevent infection. Washing the hair 24 hours after surgery helps to maintain cleanliness and hygiene without disrupting the surgical site. It is typically safe to wash the hair after this period as long as gentle care is taken to avoid excessive manipulation of the implant site.

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A nurse is assessing a client who has Meniere’s disease. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who has multiple organ dysfunction syndrome (MODS). Which of the following actions is the priority when planning care for this client?

Correct Answer is A

Explanation

Rationale:

A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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