A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
"Yes, you are free to move around as you wish."
"We will have to get a prescription from your provider.
"No, you are on strict bedrest and must not be up."
"Please ring for assistance when you wish to get out of bed."
The Correct Answer is D
A. Allowing free movement could increase the risk of falls due to dizziness.
B. While involving the provider is important, immediate safety measures should be communicated directly.
C. Strict bedrest is not typically necessary, and movement can help prevent complications like blood clots.
D. Assisting the client when they wish to get out of bed ensures safety by preventing falls, which are a significant risk for those with Ménière's disease due to vertigo.
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Related Questions
Correct Answer is C
Explanation
A. Checking the client's motor strength is important after the seizure has ended to assess for any postictal weakness.
B. Loosening clothing can be done after ensuring the client's safety during the seizure.
C. Turning the client's head to the side helps prevent aspiration and ensures a clear airway during the seizure.
D. Documenting the time the seizure began is important for accurate medical record-keeping but is not the first action during an active seizure.
Correct Answer is A
Explanation
A. Checking the patency of the client's airway is the priority action because maintaining a clear airway is crucial during a seizure to ensure adequate oxygenation and prevent aspiration.
B. Determining the poison is important but not the immediate priority during a seizure.
C. Positioning the client side-lying is important to prevent aspiration, but the first action should be to ensure the airway is clear.
D. Identifying the amount of poison ingested is important for treatment but not the immediate priority during a seizure.
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