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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.
Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.
Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.
Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.
Correct Answer is C
Explanation
Choice A reason: Stating that "This type of surgery is very easy and should not cause a major disruption in your activities" minimizes the client's concerns and may not be accurate for every individual. Each person's experience with surgery and recovery is unique, and it is important to acknowledge and address the client's specific concerns and reasons for delaying the surgery.
Choice B reason: Saying "Most women don't have any problems during their recovery" is a generalization that may not apply to every client. It does not address the client's individual fears or concerns and may come across as dismissive of their feelings.
Choice C reason: The correct answer is c because asking, "Can you tell me your reasons for delaying the surgery?" shows empathy and allows the client to express their concerns. This opens a dialogue where the nurse can provide information, support, and address any specific issues the client may have about the surgery and recovery process.
Choice D reason: Telling the client, "If this happened to one of my family members, I would tell them to go ahead and not wait," inserts the nurse's personal opinion and may not be helpful to the client. It is important to focus on the client's feelings and concerns rather than offering personal anecdotes or advice.
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