The nurse is caring for a client diagnosed with bilateral middle ear i

The nurse is caring for a client diagnosed with bilateral middle ear infections. Which of the fol-lowing statements made by the nurse best reflects an understanding of the effects of this condi-tion on the client’s ability to move appropriately?

1. “He hasn’t reported any nausea or vomiting.”
2. “His ability to hear doesn’t seem to be affected.”
3. “I’ll identify the client as a high falls’ risk by noting it on his Kardex.”
4. “I believe he is capable of using his call bell when he needs assistance.”

ANSWER

ANS: 3
Within the inner ear are the semicircular canals, three fluid-filled structures that assist in main-taining balance. An inner ear infection would interfere with the proper functioning of the semi-circular canals and place the client at risk for falling. The remaining options do not deal as direct-ly with mobility.