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 B
Explanation
Choice A Reason:
Requesting a dosage increase if the apical heart rate is less than 60/min is not necessary. Propranolol is used to lower heart rate in conditions like atrial fibrillation, so a heart rate below 60/min might be the desired effect of the medication.
Choice B Reason:
Withholding the medication if the systolic blood pressure is less than 90 mm Hg is necessary. Propranolol is a beta-blocker that can lower blood pressure. If the systolic blood pressure drops below 90 mm Hg, withholding the medication is necessary to prevent further lowering of blood pressure, which could lead to adverse effects like dizziness, fainting, or inadequate blood perfusion to vital organs.
Choice C Reason:
Administering the medication with an antacid might interfere with the absorption of propranolol, so they shouldn't be taken together unless instructed by the healthcare provider.
Choice D Reason:
Expecting increased hair growth is not an anticipated effect of propranolol. Hair growth is not a usual side effect associated with this medication.
Correct Answer is D
Explanation
Choice A Reason:
"I will apply heat to my affected ankle to decrease swelling." Heat application is generally not recommended for acute injuries like ankle sprains. Heat can increase blood flow and potentially worsen swelling. Cold therapy (like ice) is typically advised in the early stages to reduce inflammation and swelling.
Choice B Reason:
"I can bear full weight on my affected ankle." For a grade 2 ankle sprain, bearing full weight on the affected ankle might not be advisable initially. Grade 2 sprains involve partial tearing of ligaments and usually require some period of rest or limited weight-bearing to allow healing.
Choice C Reason:
"I can dangle my affected ankle from the edge of the bed. “Dangling the affected ankle from the edge of the bed is a common recommendation to help with gentle movement and improve blood flow without putting excessive stress on the injured ankle. This activity can aid in the recovery process and is often recommended.
Choice D Reason:
"I will wrap my affected ankle with an elastic bandage. “Wrapping the affected ankle with an elastic bandage is a supportive measure recommended for managing ankle sprains. It helps provide compression, support, and stabilization to the injured area, assisting in reducing swelling and providing comfort.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today