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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Serosanguineous drainage from the puncture site is an expected finding after a thoracentesis and does not typically indicate a complication.

Choice B reason: Discomfort at the puncture site is common following a thoracentesis and does not necessarily indicate a complication.

Choice C reason: The correct answer is c because an increased heart rate can be a sign of respiratory distress or hypovolemia, which are potential complications of a thoracentesis. This finding warrants immediate notification of the provider.

Choice D reason: A decreased temperature is not a common complication of thoracentesis and is less relevant than the other options. It is more important to monitor for signs of respiratory distress or circulatory changes.

A. Excessive thrombosis and bleeding. B. Progressive increase in platelet production. C. Immediate sodium and fluid retention. D. Increased clotting factors.

Correct Answer is A

Explanation

Choice A reason: Disseminated intravascular coagulation (DIC) is a condition characterized by both excessive clotting and excessive bleeding. The clotting cascade is inappropriately activated throughout the body, leading to the formation of numerous small blood clots in the blood vessels. These clots consume clotting factors and platelets, which can then lead to excessive bleeding. This paradoxical combination of thrombosis and bleeding is a hallmark of DIC.

Choice B reason: In DIC, platelet consumption exceeds production. The formation of numerous clots uses up platelets faster than they can be produced, which can result in thrombocytopenia and bleeding. Therefore, a progressive increase in platelet production is not an expected finding in DIC.

Choice C reason: Immediate sodium and fluid retention is not a feature of DIC. This condition primarily involves the clotting and bleeding mechanisms, not fluid balance or sodium levels.

Choice D reason: In DIC, clotting factors are consumed in the formation of numerous clots. This leads to a deficiency of clotting factors, contributing to the bleeding tendency seen in this condition. Increased clotting factors would not be expected in a patient with DIC.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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