The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse?

Question

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease.  Which action by the UAP will require follow-up by the nurse?

Quizplus · Accepted Answer

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks). Fall precautions that should be instituted include assisting the client when arising and ambulating (Option A), placing the bed in low position, and raising side rails. However, raising all side rails is considered a restraint and would be inappropriate. The nurse would need to intervene and instruct the UAP that 2 or 3 side rails lifted up would be sufficient (Option C). (Options B and D) Vertigo may be minimized by staying in a quiet, dark roomand avoiding sudden head movements. The client should reduce stimulation by not watching television and not looking at flickering lights. Educational objective: Safety is a priority for the client experiencing an acute attack of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimized by staying in a quiet, dark room without a television or flickering lights.

The Nurse Has Unlicensed Assistive Personnel (UAP) Caring for a Client