A nurse is caring for a client who has cardiomyopathy and is experiencing sensory overload. Which of the following actions should the nurse take?

Ensure the blinds in the client's room remain open.

Place the client in a room near the nurses' station.

Play quiet music in the client's room.

Break up nursing care into small, frequent sessions.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Ensure the blinds in the client's room remain open is not appropriate. Bright light can contribute to sensory overload. It's better to create a subdued and calming environment, so keeping the blinds closed or partially closed might help reduce excess stimuli.

Choice B Reason:

Place the client in a room near the nurses' station is not appropriate. Being near the nurses' station could increase the noise and activity around the client, potentially worsening sensory overload. It's advisable to place the client in a quieter area away from high-traffic zones to minimize auditory and visual stimulation.

Choice C Reason:

Play quiet music in the client's room is incorrect. While soothing music might help some individuals relax, for someone experiencing sensory overload, even low-volume music could add to the stimuli. Silence or minimal ambient noise might be more beneficial.

Choice D Reason:

Break up nursing care into small, frequent sessions is correct. This action is beneficial for managing sensory overload. Breaking up care into smaller sessions allows for adequate rest periods between activities, reducing the overall sensory input at any given time.

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Correct Answer is A

Explanation

Choice A Reason:
Checking the client for ecchymosis is appropriate. Thrombocytopenia increases the risk of bleeding and bruising, so monitoring for ecchymosis (bruising) is essential to detect any signs of bleeding. Ecchymosis can occur more easily in individuals with low platelet counts.
Choice B Reason:
Initiating protective isolation for the client is typically unnecessary solely due to thrombocytopenia. Protective isolation is generally for clients with conditions that compromise their immune system or make them more susceptible to infections.
Choice C Reason:
Administering ibuprofen for a mild headache might not be advisable in someone with thrombocytopenia because ibuprofen can affect platelet function and potentially increase the risk of bleeding.
Choice D Reason:
Instructing the client to shave with a disposable razor isn't recommended because using a sharp blade can increase the risk of cuts and bleeding in someone with a low platelet count. Using an electric razor or avoiding shaving might be safer options to prevent injury and bleeding.

A. "Having a total cholesterol level below 200 mg/dl increases my risk for a stroke." B. "My risk for a stroke increases if my HbA1c level is 6 percent or less." C. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke." D. "I can decrease my risk for a stroke by losing excess weight."

Correct Answer is D

Explanation

Choice A Reason:

"Having a total cholesterol level below 200 mg/dl increases my risk for a stroke." This statement is incorrect. Generally, having a total cholesterol level below 200 mg/dl is considered beneficial for heart health and reducing the risk of stroke.

Choice B Reason:

"My risk for a stroke increases if my HbA1c level is 6 percent or less." This statement is incorrect. An HbA1c level of 6 percent or less is an indicator of good blood sugar control, which usually reduces the risk of stroke. A higher HbA1c level is associated with an increased risk of complications in diabetes, including stroke.

Choice C Reason:

"My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke." - Glucocorticoids are not typically prescribed to reduce the risk of stroke in individuals with diabetes. These medications may have various uses but are not a standard preventive measure for stroke in this context.

Choice D Reason:

"I can decrease my risk for a stroke by losing excess weight." This statement is appropriate. Maintaining a healthy weight is a significant factor in reducing the risk of stroke, especially for individuals with diabetes. Weight management contributes to better control of blood pressure, cholesterol levels, and blood sugar, which collectively reduce the risk of stroke.

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A nurse is caring for a client who has cardiomyopathy and is experiencing sensory overload. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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