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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Additional laboratory tests: While monitoring is essential, at this stage, the priority is comfort, not disease progression.
B. Pain and discomfort: Mrs. Thompson is nearing the end of life and likely experiencing pain due to her advanced metastatic cancer. Pain management should always be a priority in palliative care.
C. Physical therapy: Physical therapy is not typically a priority in the end-of-life stage where the focus is on comfort rather than mobility.
D. Elevated blood pressure: This is unlikely to be the primary concern at this stage. Blood pressure is usually low, and interventions should be focused on comfort and symptom relief.
Correct Answer is C
Explanation
A. Instruct the family about anticipatory grieving: While anticipatory grieving is important, it is better addressed after the family has had time to express initial feelings.
B. Explore effective ways of family coping: This is important but should come after encouraging the family to process their immediate feelings.
C. Encourage the family’s expression of their feelings. The first priority is to allow the family to express their emotions and begin the grieving process. Encouraging emotional expression helps the family cope with the overwhelming news and facilitates their emotional support needs.
D. Discuss the disease and its manifestations with family members: While understanding the disease is essential, focusing on the family's emotional response is more critical at this initial stage of shock and grief.
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