Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. "Please ring for assistance when you wish to get out of bed."
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. "We will have to get a prescription from your provider."
A prescription from the provider is not typically required for ambulation; instead, safety measures should be in place.
C. "Yes, you are free to move around as you wish."
Allowing free movement without assistance may increase the risk of falls due to balance problems associated with Ménière's disease.
D. "No, you are on strict bedrest and must not be up."
Strict bedrest is generally not necessary unless specifically indicated by the provider; assistance and safety measures are more appropriate.
This question is an excerpt from Nurse Dive's nursing test bank - Ati critical care midterm proctored exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
A. Mantoux test
The Mantoux test (TB skin test) is used for screening and indicates exposure to TB but cannot confirm active disease.
B. Chest x-ray
A chest x-ray can show signs suggestive of TB, such as lung lesions, but it does not confirm the presence of the bacteria.
C. Sputum culture for acid-fast bacillus
A sputum culture for acid-fast bacillus is the most reliable test for confirming active pulmonary TB as it identifies the presence of Mycobacterium tuberculosis in the sputum.
D. Sputum smear
A sputum smear can detect acid-fast bacilli but is less definitive than a culture, which confirms the diagnosis.
Full Explanation
A. The Mantoux test (TB skin test) is used for screening and indicates exposure to TB but cannot confirm active disease.
B. A chest x-ray can show signs suggestive of TB, such as lung lesions, but it does not confirm the presence of the bacteria.
C. A sputum culture for acid-fast bacillus is the most reliable test for confirming active pulmonary TB as it identifies the presence of Mycobacterium tuberculosis in the sputum.
D. A sputum smear can detect acid-fast bacilli but is less definitive than a culture, which confirms the diagnosis.
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?
A. Hyperactive bowel sounds
Hyperactive bowel sounds are not specific to peritonitis and may occur in other conditions affecting the gastrointestinal tract.
B. Nausea and vomiting
Nausea and vomiting are common symptoms of peritonitis, which is an infection of the peritoneal cavity, and should be closely monitored in clients undergoing peritoneal dialysis.
C. Increased urinary output
Increased urinary output is not related to peritonitis; clients undergoing peritoneal dialysis may have decreased urinary output.
D. Bradycardia
Bradycardia is not a typical manifestation of peritonitis; the focus should be on signs of infection and gastrointestinal symptoms.
Full Explanation
A. Hyperactive bowel sounds are not specific to peritonitis and may occur in other conditions affecting the gastrointestinal tract.
B. Nausea and vomiting are common symptoms of peritonitis, which is an infection of the peritoneal cavity, and should be closely monitored in clients undergoing peritoneal dialysis.
C. Increased urinary output is not related to peritonitis; clients undergoing peritoneal dialysis may have decreased urinary output.
D. Bradycardia is not a typical manifestation of peritonitis; the focus should be on signs of infection and gastrointestinal symptoms.
A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?
A. "Your pain will gradually become less severe."
Pain management is crucial after amputation, and the client should be informed that postoperative pain may gradually decrease, though some level of discomfort can persist.
B. "It's likely that you will have only a tingling sensation."
A tingling sensation is not always expected, and the client should be prepared for a range of sensations postoperatively, including phantom pain.
C. "Phantom pain is mostly psychological."
Phantom pain is a real phenomenon experienced by many individuals following an amputation; it is not purely psychological.
D. "The pain will disappear soon."
Pain management strategies should be discussed, and the client should be aware that pain may not disappear immediately and may require ongoing management.
Full Explanation
A. Pain management is crucial after amputation, and the client should be informed that postoperative pain may gradually decrease, though some level of discomfort can persist.
B. A tingling sensation is not always expected, and the client should be prepared for a range of sensations postoperatively, including phantom pain.
C. Phantom pain is a real phenomenon experienced by many individuals following an amputation; it is not purely psychological.
D. Pain management strategies should be discussed, and the client should be aware that pain may not disappear immediately and may require ongoing management.