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 C

Explanation

Choice A Reason:

A client whose injection site is scabbed is incorrect. Scabbing at the injection site does not provide information about the presence or absence of induration. It doesn't contribute to interpreting the test result directly.

Choice B Reason:

A client whose injection site is firm and measures 3 mm (0.1 in) is incorrect. A measurement of 3 mm of induration is generally considered a negative result for most individuals, including those without any risk factors for tuberculosis (TB).

Choice C Reason:

A client whose injection site has an elevated area measuring 15 mm (0.6 is correct. An area of induration measuring 15 mm or more is considered positive in individuals with no known risk factors for TB.

Choice D Reason:

A client whose injection site is ecchymotic is incorrect. Ecchymosis (bruising) at the injection site is not relevant to the interpretation of the tuberculin skin test. It does not contribute to determining a positive or negative result.

A. Experiences nocturia B. History of generalized anxiety disorder C. Recent exposure to tuberculosis D. Reports periodic migraine headaches

Correct Answer is C

Explanation

Choice A Reason:

Experiences nocturia is incorrect. Nocturia (waking up at night to urinate) is a common symptom and, while it's important to address for the client's comfort and potential underlying causes, it doesn't pose an immediate risk to the client's roommate or necessitate urgent intervention in a shared room setting.

Choice B Reason:

History of generalized anxiety disorder is incorrect. A history of generalized anxiety disorder is relevant to the client's mental health and overall care. However, in the context of a shared room, it might not require immediate attention or interventions that directly impact the roommate's health or safety.

Choice C Reason:

Recent exposure to tuberculosis is correct. Tuberculosis (TB) is an infectious disease that spreads through the air when an infected person coughs or sneezes. In a shared room, a history of recent exposure to TB is a significant concern as it poses a potential risk to both the client and the roommate. Immediate measures to prevent transmission and ensure proper isolation protocols are necessary to protect the health of both individuals in the shared space.

Choice D Reason:

Reports periodic migraine headaches is correct.

Periodic migraine headaches are a health concern for the client experiencing them, but they typically do not pose an immediate risk or concern for the client's roommate. While addressing pain management is important, it might not require immediate action in the shared room environment.

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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

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