Nokea
A client with Ménière'sdisease continues to have disabling attacks of vertigo and elects to have a labyrinthectomy. A priority nursing diagnosis for the client before surgery is:
- A. Deficient diversional activity related to inability to participate secondary to vertigo.
- B. Risk for injury related to vertigo.
- C. Powerlessness related to inability to influence effects of disease process.
- D. Social isolation related to hearing loss.
Correct Answer: B
Rationale: Risk for injury related to vertigo is the priority due to the high risk of falls and accidents during vertigo attacks, which is a significant concern pre-surgery.
You may also like to solve these questions
A nurse is caring for a client who is prescribed a medication with a narrow therapeutic index (NTI). Which action should the nurse take when administering this medication?
- A. Administer the medication as prescribed, ensuring strict adherence to the dosing schedule.
- B. Administer the medication concurrently with herbal supplements to augment its efficacy.
- C. Combine the medication with other medications to enhance its therapeutic effects.
- D. Administer the medication at a higher dose than prescribed to achieve faster results.
Correct Answer: A
Rationale: NTI medications require strict adherence to dosing to maintain therapeutic levels and avoid toxicity.
The nurse should instruct the client to avoid which of the following drugs while taking metoclopramide hydrochloride (Reglan)?
- A. Antihypertensives.
- B. Anticoagulants.
- C. Alcohol.
- D. Cimetidine.
Correct Answer: C
Rationale: Alcohol can enhance the sedative effects of metoclopramide and worsen gastrointestinal symptoms, so it should be avoided.
A client who has undergone a mastectomy is worried about her body image and its impact on her sexual relationship. The nurse should suggest:
- A. Wearing a prosthesis during intimate moments.
- B. Avoiding discussions about her surgery with her partner.
- C. Focusing only on non-physical aspects of intimacy.
- D. Ignoring her concerns as they are temporary.
Correct Answer: A
Rationale: Wearing a prosthesis can help the client feel more confident about her body image during intimate moments, supporting her sexual relationship.
Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)?
- A. Limit caffeine intake to two cups of coffee per day.
- B. Do not lie down for 2 hours after eating.
- C. Follow a low-protein diet.
- D. Take medications with milk to decrease irritation.
Correct Answer: B
Rationale: Avoiding lying down for 2 hours after eating prevents reflux of stomach contents into the esophagus, a key strategy for managing GERD. The other options are incorrect or exacerbate symptoms.
On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following?
- A. Encourage the client to apply full weightbearing.
- B. Order a walker for the client.
- C. Place a straight-backed chair at the foot of the bed.
- D. Apply a knee immobilizer.
Correct Answer: D
Rationale: A knee immobilizer ensures stability and safety during initial transfers post-surgery.