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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Elevate the head of the client's bed for 1 hr after the feeding:Elevating the head of the bed helps prevent aspiration and promotes proper digestion by using gravity to keep the feeding solution in the stomach or jejunum.
B. Administer the feeding solution at a cold temperature: Feeding solutions should be administered at room temperature to prevent gastrointestinal discomfort or cramping.
C. Rotate the jejunostomy tube once per day:
Rotation of the jejunostomy tube is not a standard practice. Jejunostomy tubes are typically secured in place, and rotation is not necessary.
D. Flush the tube with 90mL of sterile water before and after the feeding:
Typically, the tube is flushed with about 30 mL of water before and after feedings to ensure patency and prevent clogging, not 90 mL.
Correct Answer is D
Explanation
Choice A Reason:
Leave the television on in the client's room is incorrect. Leaving the television on doesn't directly address the safety concern of falls. While it might provide some distraction or comfort, it doesn't mitigate the risk of the client attempting to leave the bed unsafely.
Choice B Reason:
Raise all four side rails while the client is in bed is incorrect. Using all four side rails can be considered a form of restraint and is generally not recommended due to the risk of entrapment and potential psychological distress for the client. It can also increase the risk of agitation and attempts to climb over the rails, potentially resulting in falls.
Choice C Reason:
Move the overbed table away from the bed is incorrect. Moving the overbed table might reduce clutter around the bed area, but it doesn't directly address the risk of falls for a client with dementia. It's more about optimizing the environment than specifically addressing the safety concern related to the client's condition.
Choice D Reason:
Apply a motion sensor mat to the client's bed is correct. For an older adult with dementia at risk for falls, a motion sensor mat can be an effective safety measure. It alerts the staff when the client attempts to get out of bed, allowing for timely intervention to prevent falls. This helps the nursing staff respond promptly, ensuring the client's safety.
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