A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

Choice B rationale Labyrinthitis is an inflammation of the inner ear that often affects both the cochlear and vestibular nerves. This condition typically causes significant vertigo, nystagmus, and balance disturbances. Monitoring the cardinal fields of vision allows the nurse to assess for nystagmus, which is the involuntary rhythmic oscillation of the eyes. This assessment helps determine the severity of the vestibular involvement and the patient's risk for falls or continued equilibrium issues during recovery. Choice A rationale Encouraging ambulation is contraindicated during the acute phase of labyrinthitis. Because the patient experiences severe vertigo and a loss of balance, they are at an extremely high risk for falls and related injuries. The nursing priority is safety and bed rest in a quiet, darkened environment. Ambulation should only be attempted with significant assistance once the acute vertigo has subsided and the patient has regained some sense of stability. Choice C rationale Limiting fluid intake is not a standard intervention for labyrinthitis. While some inner ear disorders like Meniere's disease may involve fluid volume management, labyrinthitis is usually inflammatory or infectious. Maintaining adequate hydration is important for general health, especially if the patient is experiencing nausea and vomiting due to vertigo. Dehydration could lead to orthostatic hypotension, which would further complicate the patient's balance and increase the risk of injury. Choice D rationale Bright lights can exacerbate the symptoms of vertigo and discomfort in patients with labyrinthitis. A brightly lit room can increase sensory stimulation, making the sensation of spinning or dizziness more intense. The nurse should provide a calm, dimly lit environment to minimize sensory input. This helps the patient remain still and reduces the triggers that lead to nausea and worsening of the vestibular symptoms during the acute inflammatory period.