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 D
Explanation
Choice A reason: Emptying the collection chamber every 4 hours is unnecessary and can increase the risk of introducing infection. The chamber should be emptied as needed based on the volume of drainage.
Choice B reason: Stripping the chest tube, which involves squeezing and releasing sections of the tube to move clots, is not recommended as it can create high negative pressure and cause damage to the lung tissue.
Choice C reason: Pinning the chest tube to the client’s gown can lead to accidental dislodgement. The chest tube should be secured appropriately without tension.
Choice D reason: The correct answer is d because taping the connections on the client’s chest tube ensures that the system remains airtight and prevents air leaks, which is essential for effective functioning of the chest tube and prevention of pneumothorax recurrence.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: The correct answer is a because orange juice is high in potassium and should be avoided by clients with chronic kidney disease to prevent hyperkalemia, which can lead to serious cardiac complications.
Choice B reason: The correct answer is b because watermelon, although refreshing, is high in potassium and should be limited or avoided by clients with chronic kidney disease to maintain safe potassium levels.
Choice C reason: The correct answer is c because bananas are well-known for their high potassium content and should be avoided by clients with chronic kidney disease to prevent elevated potassium levels in the blood.
Choice D reason: Corn flakes cereal is generally low in potassium and is not a food that needs to be avoided in clients with chronic kidney disease. It can be included in their diet in moderation.
Choice E reason: White rice is also low in potassium and can be safely consumed by clients with chronic kidney disease. It does not pose a significant risk of increasing potassium levels.
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