A nurse is caring for a client who has Ménière’s disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?
"You are free to move around your room as you wish, but you should avoid the hallways."
"You are on strict bed rest and must not be up."
"Please call for assistance when you wish to get out of bed."
"Why would we not allow you to walk if you wanted?"
The Correct Answer is C
Choice A reason: Allowing the client to move around the room unsupervised can lead to falls, as Ménière’s disease can cause sudden episodes of vertigo and imbalance.
Choice B reason: Strict bed rest is usually not required for clients with Ménière’s disease. Encouraging mobility with assistance is typically more appropriate.
Choice C reason: Asking the client to call for assistance helps prevent falls and ensures the client's safety. Ménière’s disease often causes vertigo, and assistance is necessary to prevent injuries.
Choice D reason: This response does not address the client's safety concerns and may lead to misunderstanding the risks associated with ambulation in Ménière’s disease.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Asking "Why have you changed your mind about the surgery?" may come across as confrontational or judgmental. It does not address the client's emotions and may make the client feel defensive.
Choice B reason: The correct answer is b because acknowledging the client's feelings by saying, "Bypass surgery must be very frightening for you," shows empathy and understanding. It opens up a supportive conversation where the client can express concerns and emotions related to the surgery.
Choice C reason: Telling the client, "Your provider would not have scheduled the surgery unless you needed it," may dismiss the client's concerns and make them feel that their feelings are not important. It is important to address the client's emotional state and provide support.
Choice D reason: While it is appropriate to involve the healthcare provider in discussing the surgery, simply stating, "I will call your doctor and have him discuss your surgery with you," without first addressing the client's emotions and concerns, may seem dismissive. Providing emotional support should be the first step.
Correct Answer is C
Explanation
Choice A reason: Applying lotion to the skin around the edges of the splint may increase moisture and friction, which can contribute to skin breakdown. It is better to use protective dressings to reduce friction.
Choice B reason: Turning the client every 4 hours is not frequent enough. Clients in skeletal traction should be repositioned frequently, typically every 2 hours, to prevent pressure ulcers and maintain skin integrity.
Choice C reason: The correct answer is c because padding the top of the splint with protective dressings helps reduce friction and pressure on the skin, preventing skin breakdown and ensuring the client's comfort.
Choice D reason: Applying a footplate to the bed is not directly related to preventing skin breakdown. The primary focus should be on reducing friction and pressure around the splint.
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