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
Choice A Reason:
Passing of flatus is correct. Passing flatus (gas) is an encouraging sign that the digestive system is functioning and that gas is moving through the colostomy. This is a positive indicator of colostomy function.
Choice B Reason:
Stoma is pinkish-red. A pinkish-red stoma indicates good blood circulation to the area, which is vital for the health of the stoma tissue. A healthy-colored stoma is a positive sign.
Choice C Reason:
Tolerating a clear liquid diet. Tolerating a clear liquid diet might be an indicator of gastrointestinal function, but it might not specifically confirm the functionality of the colostomy itself.
D. Absent bowel sounds
Absent bowel sounds might be present immediately postoperatively due to the effects of anesthesia and abdominal surgery. However, bowel sounds aren't a direct indicator of colostomy function.
Correct Answer is D
Explanation
Choice A Reason:
"Having a total cholesterol level below 200 mg/dl increases my risk for a stroke." This statement is incorrect. Generally, having a total cholesterol level below 200 mg/dl is considered beneficial for heart health and reducing the risk of stroke.
Choice B Reason:
"My risk for a stroke increases if my HbA1c level is 6 percent or less." This statement is incorrect. An HbA1c level of 6 percent or less is an indicator of good blood sugar control, which usually reduces the risk of stroke. A higher HbA1c level is associated with an increased risk of complications in diabetes, including stroke.
Choice C Reason:
"My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke." - Glucocorticoids are not typically prescribed to reduce the risk of stroke in individuals with diabetes. These medications may have various uses but are not a standard preventive measure for stroke in this context.
Choice D Reason:
"I can decrease my risk for a stroke by losing excess weight." This statement is appropriate. Maintaining a healthy weight is a significant factor in reducing the risk of stroke, especially for individuals with diabetes. Weight management contributes to better control of blood pressure, cholesterol levels, and blood sugar, which collectively reduce the risk of stroke.
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