A nurse is caring for a hospitalized client who is experiencing sensory overload due to the hospital environment. Which of the following actions should the nurse take?
Encourage visitors throughout the day.
Provide the client with earplugs.
Spread client care activities throughout the shift.
Keep the door to the client's room open.
The Correct Answer is B
A. Encourage visitors throughout the day: Increased visitor interactions may worsen sensory overload by adding more stimuli.
B. Provide the client with earplugs. Earplugs help reduce environmental noise and sensory input, addressing the client's sensory overload and promoting rest and comfort.
C. Spread client care activities throughout the shift: Consolidating care activities, rather than spreading them out, minimizes interruptions and helps reduce sensory input.
D. Keep the door to the client's room open: Keeping the door open can increase noise and stimuli, exacerbating sensory overload.
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Related Questions
Correct Answer is C
Explanation
A. Encouraging client feedback about satisfaction with the facility experience: This reflects client-centered care but does not directly demonstrate autonomy.
B. Explaining unit rules and policies regarding unacceptable behaviors: This action involves setting expectations rather than promoting client autonomy.
C. Supporting the client's wish to refuse prescribed medications. Autonomy involves respecting a client's right to make their own decisions about their care, including the decision to refuse treatment, as long as they have the capacity to do so.
D. Making sure the client understands expectations for client participation: This is about ensuring clarity of expectations rather than honoring the client's right to self-determination.
Correct Answer is A
Explanation
A. Determine the location of the pain. The nurse should first assess the client's pain, including its location, intensity, quality, and factors that alleviate or exacerbate it. This assessment is critical to determining the most appropriate intervention and evaluating the effectiveness of the treatment.
B. Reposition the client: Repositioning is a valid nursing intervention for managing pain caused by discomfort or poor positioning. However, it should not be the first action, as the nurse must first assess the pain to determine if repositioning alone is sufficient or if medication is necessary.
C. Review the effects of the pain medication: While reviewing the effects of the prescribed medication is important to ensure its appropriateness and safety, this step is part of preparation for medication administration. It is not the first action; assessment of the client's pain takes priority.
D. Administer the medication: Administering pain medication without assessing the client's pain is not appropriate. Pain management should be individualized, and assessment ensures that the prescribed medication is suitable for the client's current pain and condition.
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