69. What physical assessment data should a nurse consider typical for a client during an acute attack of Ménière's disease?
69. What physical assessment data should a nurse consider typical for a client during an acute attack of Ménière's disease?
. Jerking eye movements, high BP, tachycardia.
. Difficulty ambulating, normal BP, tachycardia.
. Jerking eye movements, normal vital signs.
. Difficulty ambulating, high BP, tachycardia.
Test-Taking Tip
Know the expected effect of an inner ear problem. Choose the option that is different from the others. Only one option has normal vital signs; the other options have either pulse or BP that is not normal.
Content Area: Adult Health, Sensory; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is incorrect because vital signs are normal in Ménière's disease. Answer 2 is incorrect because, although ambulating would be difficult with nystagmus, the pulse would be normal. Answer 3 is correct because the most objective sign of Ménière's disease is nystagmus, or jerking eye movements. The vital signs are normal in clients with this disease. Ménière's disease affects the inner ear, which would cause the eye movements. Answer 4 is incorrect because the vital signs are normal in Ménière's disease.