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 B

Explanation

Choice A Reason:

Temperature 37.3°C (99.1°F) is incorrect . While a slightly elevated temperature can sometimes accompany an infection, it's not specific to a bladder infection and might not be present in all cases.

Choice B Reason:

Changed mental status is incorrect. Bladder infections or urinary tract infections (UTIs) in older adults can often present with atypical symptoms, and changes in mental status or acute confusion are common indicators in this population. UTIs can cause subtle but significant alterations in mental function, particularly in the elderly, leading to confusion, agitation, or cognitive impairment.

Choice C Reason:

WBC count 9,000/mm3 (5000 to 10,000/mm3) is incorrect .A WBC count within the normal range doesn't necessarily rule out or confirm a bladder infection. In some cases, UTIs might not significantly elevate the white blood cell count, especially in localized infections.

Choice D Reason:

Diminished reflexes is incorrect . Diminished reflexes are not typically associated with a bladder infection. They might indicate other neurological or muscular issues but are not a common sign of a UTI.

A. Administer enemas 2 days before the procedure B. Do not eat or drink anything except water for 12 hr. before the procedure. C. Restrict the diet to clear liquids for 1 to 3 days before the procedure. D. Expect the provider to schedule another procedure to remove any polyps

Correct Answer is B

Explanation

Choice A Reason:

Administering enemas 2 days before the procedure. Enemas are not typically the primary method of bowel preparation for a colonoscopy. Healthcare providers often recommend specific bowel preparation solutions or laxatives that are more effective in thoroughly cleansing the colon.

Choice B Reason:

This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.

Choice C Reason:

This is not necessary for a colonoscopy. A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.

Choice D Reason:

Expect the provider to schedule another procedure to remove any polyps. While identifying and removing polyps is part of the objective of a colonoscopy, scheduling another procedure specifically for polyp removal isn't usually discussed beforehand. Polyp removal is often performed during the colonoscopy procedure if any are found.

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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?

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