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 A
Explanation
A. Respiratory rate 8/min: Morphine sulfate is an opioid that can depress respiratory function. A respiratory rate of 8/min is dangerously low and indicates opioid-induced respiratory depression, a serious adverse effect that requires immediate intervention.
B. SaO2 94%: A SaO2 of 94% is within the normal range for many clients and does not indicate an immediate issue.
C. Pain level of 6 on a scale from 0 to 10: This is an expected finding after morphine administration, as it typically reduces pain but may not eliminate it entirely.
D. Sleepy, but arousing when her name is called: Sedation is a common side effect of morphine, but the client being arousable when their name is called is not an alarming sign.
Correct Answer is D
Explanation
A. "Cultural competence means that healthcare providers must follow a standardized approach to care that applies to all clients, regardless of their cultural background." Cultural competence requires an individualized approach tailored to the client's cultural values, beliefs, and practices, not a standardized method.
B. "Cultural competence requires that nurses adopt the cultural practices of their clients to provide the best care." Nurses should respect and incorporate cultural practices into care when possible, but they are not required to adopt these practices themselves.
C. "Cultural competence is only necessary when caring for clients from cultures that are significantly different from one's own." Cultural competence is essential for all clients, as cultural beliefs can influence health perceptions, even in those with similar backgrounds.
D. "Cultural competence involves understanding and respecting diverse cultural backgrounds and incorporating this understanding into client care to improve outcomes and client satisfaction." This accurately reflects the essence of cultural competence in nursing practice.
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