# A nurse is caring for a 60-year-old client diagnosed with acute labyrinthitis who presents to the emergency department with severe vertigo, nausea, vomiting, and hearing loss that started suddenly this morning. The client reports feeling like the room is spinning and has difficulty maintaining balance. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541706 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a 60-year-old client diagnosed with acute labyrinthitis who presents to the emergency department with severe vertigo, nausea, vomiting, and hearing loss that started suddenly this morning. The client reports feeling like the room is spinning and has difficulty maintaining balance. Which nursing intervention should be the priority? A 45-year-old client presents to the emergency department with severe vertigo, nausea, vomiting, and hearing loss that started suddenly this morning. The client reports feeling like the room is spinning and has difficulty maintaining balance. The physician diagnoses acute labyrinthitis and admits the client for observation and treatment. ## 보기 1. Implement fall prevention measures and assist with ambulation **✔ 정답** 2. Administer prescribed antiemetics for nausea and vomiting 3. Provide emotional support and reassurance to reduce anxiety 4. Encourage fluid intake to prevent dehydration **정답: 1** ## 해설 The priority nursing intervention for labyrinthitis is fall prevention and ambulation assistance due to severe vertigo and balance impairment. Other interventions like antiemetics, emotional support, and hydration are important but secondary to safety. ## 심화 해설 Understanding the Priority: Safety in Acute Labyrinthitis For a client presenting with acute labyrinthitis, the sudden onset of severe vertigo creates an immediate and significant safety risk. The sensation that "the room is spinning" is not merely discomforting; it represents a profound disruption of the vestibular system, which is responsible for balance and spatial orientation. This directly impairs the client's ability to maintain posture and walk safely, making a fall the most imminent physical danger. While nausea, vomiting, and hearing loss are distressing and require intervention, they do not pose the same immediate threat to physical safety as a fall does. Therefore, the nursing process dictates that ensuring a safe environment is the foundational first step. Deep Dive into the Rationale The priority intervention is to implement fall prevention measures and assist with ambulation. This is grounded in the understanding that vestibular dysfunction is a direct contributor to postural instability. Research on patients with dizziness has established a clear link between vestibular disorders and an increased risk of falls. A large-scale study analyzing claims data found that among older adults with dizziness, the use of vestibular suppressant medications was associated with subsequent falls, highlighting the inherent fall risk in this population even before medication is introduced [1]. This evidence underscores that the disease process itself—the labyrinthine inflammation causing vertigo—makes the client a high fall risk from the moment of symptom onset. Your immediate action must be to mitigate this by keeping the bed in the lowest position, ensuring the call light is within reach, and providing physical assistance if the client needs to get up. The other options, while important components of care, address secondary concerns. Administering an antiemetic will help control nausea and vomiting, but it does not immediately stabilize the client’s balance or prevent a fall that could occur right now. Similarly, providing emotional support is essential for a frightening experience, but it is not the physiological priority over physical safety. Encouraging fluid intake addresses dehydration from vomiting, a concern that develops over time, whereas a fall can happen in an instant. The clinical reasoning path is clear: first, ensure the client is physically safe from the most acute threat—a fall due to severe vertigo [1,4].References (research sources) - [1]Vestibular Suppressant Utilization and Subsequent Falls Among Patients 65 Years and Older With Dizziness in the United States.Research articleMarmor S, Karaca-Mandic P, Adams ME. (2025) · DOI: 10.1111/jgs.19377 ## 임상 시나리오 Clinical Safety Guide: Acute Vertigo Management **Priority Nursing Action:** Implement immediate fall precautions before any other intervention for a patient presenting with acute, severe vertigo. Immediate Bedside Actions - **Keep Bed Low & Locked:** Position the bed in the lowest position with wheels locked and top side rails up as a reminder, not a restraint. - **Call Light Within Reach:** Ensure the call light and personal items are easily accessible, instructing the patient to call for any need to get up. - **Assist with All Ambulation:** Do not allow independent walking. Use a two-person assist or gait belt for any transfers to a commode or bathroom. - **Environmental Safety:** Clear clutter, ensure a clear path to the bathroom, and use night lights to reduce disorientation in the dark. Ongoing Monitoring & Education - **Orthostatic Vital Signs:** Monitor for postural hypotension, which can compound the fall risk from vertigo. - **Medication Caution:** Be aware that prescribed vestibular suppressants (e.g., meclizine, diazepam) and antiemetics can cause drowsiness and further increase fall risk. - **Patient Teaching:** Educate the patient to move the head slowly, avoid sudden position changes, and fixate the gaze on a stationary object during vertigo episodes. - **Reassess Frequently:** Fall risk is dynamic; reassess with each shift and as the acute vertigo begins to subside. Clinical reasoning based on safety-first nursing principles for vestibular disorders. Reference: Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology–Head and Neck Surgery. 2017;156(3_suppl):S1-S47. ## 핵심 개념 - **Labyrinthitis** — An inflammation of the inner ear or labyrinth, typically caused by a viral infection, leading to acute vertigo, hearing loss, and nystagmus. - **Vertigo** — A false sensation of rotational movement, often described as the room spinning, resulting from dysfunction of the vestibular system. - **Vestibular System** — The sensory system located in the inner ear that provides the brain with information about motion, head position, and spatial orientation, essential for balance. - **Fall Prevention** — A set of safety interventions designed to reduce the risk of a patient falling, including environmental modifications, assistance with mobility, and use of assistive devices. - **Priority Setting** — The nursing process of ranking patient problems and interventions using frameworks like Maslow's hierarchy or the ABCs (Airway, Breathing, Circulation) to address the most life-threatening or immediate safety needs first. ## 같은 주제 문제 - [A nurse is assessing a client diagnosed with labyrinthitis. 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