A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?

Myopia

Vertigo

Photophobia

Presbycusis

Answer and Explanation

The Correct Answer is B

Correct answer: B

A. Myopia - Myopia (near-sightedness) is a vision condition related to the shape of the eye and is not related to Meniere's disease or endolymph fluid accumulation.

B. Vertigo - Vertigo is a primary symptom of Meniere's disease and is caused by the excessive accumulation of endolymph fluid in the inner ear, which affects balance and spatial orientation.

C. Photophobia - Sensitivity to light is not a symptom of Meniere's disease; it is more commonly associated with migraines or eye conditions.

D. Presbycusis - Presbycusis is age-related hearing loss and is unrelated to the fluid balance issues seen in Meniere's disease.

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Correct Answer is A

Explanation

A. Stop the infusion of blood. The client’s symptoms suggest a possible acute hemolytic transfusion reaction, which is a life-threatening emergency. The first and most critical action is to stop the blood transfusion immediately to prevent further reaction and additional hemolysis.

B. Inform the provider: This is an important action but should be done after stopping the transfusion to prevent further complications.

C. Obtain a urine specimen: This is done to check for hemoglobinuria, but it is not the immediate priority.

D. Notify the laboratory: This is part of the follow-up procedure but should be done after stopping the transfusion and stabilizing the patient.

A. To place my leg under a heat lamp every 3 hours B. Keep a heating pad on the calf of my right leg when I am lying down." C. wrap a warm, wet towel around my right calf every 4 hours." D. "will sit on the side of the tub and soak my right leg two times every day."

Correct Answer is C

Explanation

A. "To place my leg under a heat lamp every 3 hours." Using a heat lamp can cause burns and uneven heating, which is not recommended for cellulitis.

B. "I will keep a heating pad on the calf of my right leg when I am lying down." Continuous heat application can cause burns and damage tissues, especially in clients with impaired sensation or circulation.

C. "I will wrap a warm, wet towel around my right calf every 4 hours." Using a warm, wet towel ensures that heat is evenly distributed and provides moist heat, which can help increase blood flow and promote healing in cellulitis.

D. "I will sit on the side of the tub and soak my right leg two times every day." Soaking the leg may not maintain consistent warmth and could also introduce the risk of infection if the water is not clean.

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A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?

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A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?