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?

"Please ring for assistance when you wish to get out of bed."

"We will have to get a prescription from your provider."

"Yes, you are free to move around as you wish."

"No, you are on strict bedrest and must not be up."

Answer and Explanation

The Correct Answer is A

A. Clients with Ménière's disease may experience dizziness and balance issues, so it is important to ensure safety by asking them to ring for assistance when moving around to prevent falls or injuries.
B. A prescription from the provider is not typically required for ambulation; instead, safety measures should be in place.
C. Allowing free movement without assistance may increase the risk of falls due to balance problems associated with Ménière's disease.
D. Strict bedrest is generally not necessary unless specifically indicated by the provider; assistance and safety measures are more appropriate.

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Correct Answer is D

Explanation

A. Applying petroleum jelly to the client's lips can lead to aspiration if the client is unable to swallow properly. It is not recommended as a routine practice for oral care.

B. A stiff toothbrush can cause gum damage or discomfort. A soft toothbrush is preferred for oral care, especially for clients who may have sensitive or fragile gums.

C. Using the thumb and index finger to keep the client's mouth open is not safe or effective. It can cause discomfort or injury. Using appropriate tools, like a mouth prop or suction if necessary, is recommended.

D. Turning the client on their side before starting oral care is the correct action. This position helps prevent aspiration of secretions or water during oral care, reducing the risk of choking or aspiration pneumonia.

A. Learn to control impulsive behavior. B. Establish the ability to communicate effectively. C. Compensate for loss of depth perception. D. Improve left-side motor function.

Correct Answer is B

Explanation

A. Controlling impulsive behavior is more relevant to right hemispheric strokes, which often affect impulse control and behavior.
B. A left hemispheric CVA often affects language and communication skills, making it crucial to focus on improving these abilities.
C. Loss of depth perception is more associated with right hemispheric strokes.
D. Motor function improvement for the affected side (right side for left hemispheric stroke) is important, but communication deficits are a primary focus for left hemispheric strokes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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