You are taking care of a client who suffers from Meniere's disease. On assessment, you note what common symptoms of this disorder? Select all that apply.

Hearing loss.

Nystagmus.

Vertigo.

Tinnitus.

Loss of vision.

Answer and Explanation

Correct Answer : A,C,D

Meniere's disease is a disorder of the inner ear characterized by episodes of vertigo, hearing loss, tinnitus, and a feeling of fullness or pressure in the ear. Nystagmus is not a common symptom of Meniere's disease. Nystagmus is a rhythmic oscillation of the eyes and may be present in other conditions such as vestibular disorders, drug toxicity, or brainstem lesions.

Choice B, nystagmus, is incorrect because although nystagmus can occur in other vestibular disorders, it is not a common symptom of Meniere's disease.

Choice E, loss of vision, is incorrect because Meniere's disease affects the inner ear and does not typically cause vision loss.

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Correct Answer is A

Explanation

The client's vital signs are temperature, 101.9 F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute, and blood pressure, 138/80 mm Hg. An elevated temperature is a significant finding that may indicate the presence of an infection, which can cause further neurological damage in a client with an intracranial injury. The physician should be notified promptly, as the client may require antibiotic therapy to prevent the spread of infection.

B. Periorbital edema and ecchymosis are normal findings following head injury and should be monitored but do not require immediate intervention.

C. Resting in semi-Fowler's position is an appropriate position to maintain after intracranial pressure-reducing surgery.

D. Improved level of consciousness is a positive finding and indicates that the client is responding well to treatment.

A. Place end of tube in water and observe for bubbling. B. Using auscultation technique. C. Measure pH of aspirates. D. Radiographic confirmation.

Correct Answer is D

Explanation

Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.

Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.

Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.

Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.

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You are taking care of a client who suffers from Meniere's disease. On assessment, you note what common symptoms of this disorder? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

Correct Answer is A

Explanation

The client had a nasogastric tube placed two days ago. Which nursing action provides the most reliable means to assess placement of a client's nasogastric tube, prior to each medication administration?

Correct Answer is D

Explanation

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