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 B

Explanation

A. The nurse wears a gown when bathing the client: This is appropriate to prevent contact with the lesions and reduce the risk of spreading the virus.

B. The nurse admits another client who has shingles to the client's double room. Shingles (herpes zoster) is highly contagious, especially for individuals who have never had chickenpox or been vaccinated against it. Cohorting clients with shingles in a shared room is not recommended due to the risk of viral transmission and potential complications.

C. The nurse wears gloves when providing direct care to the client: This is necessary to protect against direct contact with the lesions and prevent the spread of infection.

D. The nurse wears an N95 respirator mask: While not always required, wearing an N95 respirator can be appropriate in certain circumstances to prevent aerosolized transmission, especially in cases of disseminated shingles.

A. 4 hr B. 2 hr C. 8 hr D. 6 hr

Correct Answer is A

Explanation

A. 4 hr - The total infusion time for packed RBCs should not exceed 4 hours. Infusing beyond this period increases the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications.

B. 2 hr - While blood can be infused in 2 hours for some patients, especially in non-emergent situations, the standard maximum time allowed is 4 hours to prevent complications.

C. 8 hr - Infusing blood over 8 hours is too long and increases the risk of bacterial contamination and decreased efficacy of the blood product.

D. 6 hr - Similar to 8 hours, a 6-hour infusion time is too lengthy and poses significant risks for bacterial growth and sepsis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention by the nurse's supervisor?

Correct Answer is B

Explanation

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

Correct Answer is A

Explanation

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