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: Providing a diet high in protein is not appropriate during the oliguric phase of acute kidney injury, as it can increase the workload on the kidneys and worsen kidney function. Protein intake should be carefully managed based on the client's condition.
Choice B reason: Ibuprofen is contraindicated in clients with acute kidney injury because it can further impair kidney function. Pain management should be approached with alternative medications that do not have nephrotoxic effects.
Choice C reason: The correct answer is c because monitoring intake and output hourly is crucial in managing acute kidney injury. Accurate measurement of fluid balance helps guide treatment decisions and prevent complications such as fluid overload or dehydration.
Choice D reason: Encouraging the client to consume at least 2 L of fluid daily is not appropriate in the oliguric phase, as the kidneys' ability to excrete fluids is impaired. Fluid intake should be carefully restricted and monitored to avoid fluid overload.
Correct Answer is B
Explanation
Choice A reason: Rubbing the client's feet briskly can increase circulation temporarily, but it may also cause discomfort or irritation, especially if the client has compromised vascular health.
Choice B reason: The correct answer is b because obtaining a pair of slipper socks for the client can help keep the feet warm and improve comfort. Warm socks are a non-invasive and safe way to address the client's complaint of cold feet.
Choice C reason: Increasing the client's oral fluid intake is important for overall health, but it is not a direct solution for addressing cold feet due to vascular occlusion.
Choice D reason: Placing a moist heating pad under the client's feet can be risky, especially for clients with vascular issues, as it can lead to burns or skin damage. Dry heat, if used, should be carefully monitored to avoid injury.
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