1. Right Answer: B
Explanation: (A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of the most common manifestations of Menieres disease. (C) Adequate nutrition is important, but the emphasis in Menieres disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem.
2. Right Answer: B
Explanation: (A) Neurovascular checks are a routine part of assessment with clients having this diagnosis. (B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. (C) Arteriogram is a routine diagnostic order. (D) Smoking is highly correlated with this disorder.
3. Right Answer: C
Explanation: (A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. (C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.
4. Right Answer: D
Explanation: (A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
5. Right Answer: B
Explanation: (A) Sitting the client up defeats the goal of re-establishing cerebral blood flow. (B) Elevating the legs anatomically redirects blood flow to the cerebral area. (C) This strategy is a nice general comfort measure after the victim has regained consciousness. (D) This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
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