Nokea
Which nursing problem has the highest priority when planning care for a client with Meniere's disease?
- A. Potential for injury related to vertigo.
- B. Alteration in comfort due to ear pain.
- C. Impaired skin integrity due to immobility.
- D. Anxiety due to fear of falling.
Correct Answer: A
Rationale: The correct answer is A. When caring for a client with Meniere's disease, the highest priority nursing problem is the potential for injury related to vertigo. Meniere's disease is characterized by symptoms like vertigo, which can increase the risk of falls and injuries. Ensuring the client's safety and preventing falls take precedence over other concerns. Choices B, C, and D are not the highest priority because they do not directly address the immediate risk of harm associated with vertigo and falls.
You may also like to solve these questions
A male client tells the nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
- A. Observe the perineal area for a chancroid-like lesion.
- B. Obtain a specimen of urethral drainage for culture.
- C. Assess for perineal itching, erythema, and excoriation.
- D. Identify all sexual partners in the last four days.
Correct Answer: B
Rationale: In this scenario, the most appropriate action for the nurse to take is to obtain a specimen of urethral drainage for culture. This procedure can help diagnose the cause of burning on urination, which could be indicative of a sexually transmitted infection. Option A, observing for a chancroid-like lesion, may not be the most immediate or relevant action in this case. Option C, assessing for perineal itching, erythema, and excoriation, is important but obtaining a culture specimen would provide more specific diagnostic information. Option D, identifying all sexual partners, is relevant for contact tracing but obtaining a culture specimen is the priority to determine the current infection status.
A client with COPD is receiving home oxygen therapy. Which instruction is most important for the nurse to include in the discharge teaching?
- A. Increase oxygen flow rate during physical activity
- B. Smoke at least 10 feet away from the oxygen source
- C. Use petroleum jelly to prevent nasal dryness
- D. Ensure the oxygen tank is stored in a secure upright position
Correct Answer: D
Rationale: The most important instruction for the nurse to include in the discharge teaching for a client with COPD receiving home oxygen therapy is to ensure the oxygen tank is stored in a secure upright position. This is crucial to prevent accidents such as leaks or falls that can lead to serious injury or damage. Choice A is incorrect as increasing the oxygen flow rate during physical activity without a healthcare provider's guidance can be harmful. Choice B is incorrect as smoking near an oxygen source can cause a fire hazard. Choice C is incorrect as petroleum jelly is flammable and should not be used around oxygen due to the risk of combustion.
In a disaster area, a nurse assesses an adult male with partial-thickness burns on his lower legs, approximately 10% of his lower body. Which color of triage tag should the nurse place on this client?
- A. Yellow.
- B. Black.
- C. Red.
- D. Green.
Correct Answer: A
Rationale: A yellow triage tag should be placed on the client with partial-thickness burns covering 10% of his lower body. Yellow tags indicate delayed treatment, suitable for serious injuries that are not immediately life-threatening. Black tags are used for deceased individuals, red tags for immediate treatment of life-threatening injuries, and green tags for minor injuries.
What should be included in the therapeutic management of iron deficiency anemia?
- A. Multivitamins
- B. Calcium
- C. Ferrous sulfate
- D. Iodine
Correct Answer: C
Rationale: The correct answer is C: Ferrous sulfate. The therapeutic management of iron deficiency anemia should include iron supplementation, specifically with ferrous sulfate. This helps to replenish the body's iron stores. Multivitamins (choice A) may contain iron, but iron supplementation is more direct and effective. Calcium (choice B) and iodine (choice D) are not typically part of the primary treatment for iron deficiency anemia.
A client with partial-thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Apply a sterile dressing to the wound.
- B. Administer an analgesic.
- C. Encourage the client to drink fluids.
- D. Ensure the client's nutritional needs are met.
Correct Answer: B
Rationale: Administering an analgesic before whirlpool therapy is the priority intervention in this scenario. Whirlpool therapy for debridement can be painful for the client with partial-thickness burns. Administering an analgesic before the procedure helps manage pain during the debridement process, ensuring the client's comfort. Applying a sterile dressing (Choice A) may be necessary after the whirlpool therapy but is not the immediate pre-transport intervention. Encouraging the client to drink fluids (Choice C) and ensuring nutritional needs are met (Choice D) are important aspects of care but are not specifically related to preparing the client for whirlpool therapy.