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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I can take my partner outside of the room as long as they wear a mask."MRSA contact precautions typically involve limiting the spread of the bacteria. Taking the partner outside the room while wearing a mask might not be sufficient for infection control, as MRSA can spread through direct contact with surfaces. This statement might not indicate a full understanding of MRSA precautions.
Choice B Reason:
"I will wash my hands as soon as I leave the room. “Hand hygiene is a crucial component of infection control for MRSA. Washing hands with soap and water or using alcohol-based hand sanitizer after leaving the room helps prevent the spread of MRSA to oneself or others.
Choice C Reason:
"I will wear a gown when I help my partner take a bath." Wearing a gown during tasks that might involve contact with the patient's bodily fluids or surfaces that might be contaminated is recommended for MRSA precautions. This statement aligns with infection control practices.
Choice D Reason:
"I can reuse unsoiled gloves when I re-enter the room. “Reusing gloves, even if they appear unsoiled, is generally not recommended as it can contribute to the spread of MRSA. Gloves should be disposed of after each use and hands washed thoroughly.
Correct Answer is C
Explanation
Choice A Reason:
“I'm going to take your heart rate”. This statement is incorrect. Monitoring vital signs like heart rate is essential in assessing a client's condition. However, in this scenario, the client's report of hives, itching, and a potential allergic reaction is more indicative of an immediate concern for anaphylaxis. While monitoring heart rate is relevant, assessing for signs of anaphylaxis, especially difficulty breathing, takes precedence due to the urgency of potential respiratory distress.
Choice B Reason:
"I need to give you diphenhydramine". This statement is incorrect, administering an antihistamine like diphenhydramine can help alleviate allergic symptoms, including itching and hives. However, confirming the severity of the reaction and ensuring there are no life-threatening symptoms such as breathing difficulties is the immediate priority before administering any medication.
Choice C Reason:
"Are you having difficulty breathing?" This statement is correct. This question directly assesses the client's respiratory status, a crucial indicator of anaphylaxis. If the client is experiencing difficulty breathing, it indicates a severe allergic reaction that requires immediate intervention and emergency medical attention. Recognizing and addressing potential respiratory distress is of utmost importance in managing an allergic reaction to medication.
Choice D Reason:
"Do you have any allergies to medications? This statement is incorrect. Understanding the client's medical history, including allergies, is crucial. However, in this acute situation where the client is already experiencing symptoms of a potential allergic reaction shortly after receiving penicillin, addressing the current symptoms and assessing for signs of anaphylaxis is the most immediate concern.
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