A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?
Limit fluid intake.
Monitor client’s cardinal fields of vision.
Encourage ambulation.
Ensure the room is brightly lit.
The Correct Answer is B
Choice A reason: Limiting fluid intake is not an appropriate intervention for labyrinthitis. Adequate hydration is important for overall health and should be maintained.
Choice B reason: The correct answer is b because labyrinthitis can affect the vestibular system, leading to dizziness and vertigo. Monitoring the client’s cardinal fields of vision helps assess for nystagmus, which is a common symptom of vestibular disorders.
Choice C reason: Encouraging ambulation is not advisable for clients with labyrinthitis, as it can increase the risk of falls and injury due to dizziness and imbalance.
Choice D reason: Ensuring the room is brightly lit is not necessary for the management of labyrinthitis and may not provide any therapeutic benefit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A reason: Phenazopyridine is a urinary tract analgesic used to relieve symptoms such as burning, pain, and urgency during urination. It should reduce burning during urination, not cause it.
Choice B reason: The correct answer is b because reddish-orange urine is a common and expected side effect of phenazopyridine. The medication can cause discoloration of urine, which is harmless but important for clients to be aware of to avoid unnecessary concern.
Choice C reason: Visual disturbances are not a known side effect of phenazopyridine. Clients should be informed to report any unusual symptoms, but this is not typically associated with the medication.
Choice D reason: Lethargy is also not a common side effect of phenazopyridine. The medication primarily acts on the urinary tract and does not generally cause significant systemic effects.
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