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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Autonomy: Respecting a client’s right to make their own decisions, including the refusal of a protein and calorie supplement, demonstrates the ethical principle of autonomy.

B. Fidelity: Fidelity involves being faithful to commitments and responsibilities, but this scenario focuses on the client’s decision-making rights rather than the nurse’s loyalty.

C. Veracity: Veracity refers to truth-telling, which is not directly related to the client refusing the supplement.

D. Beneficence: Beneficence involves acting in the client’s best interest, but forcing treatment would conflict with respecting autonomy.

A. Use written communication to supplement verbal instructions and ensure the client understands the information. B. Use gestures and non-verbal cues only, without speaking, as the client is able to read lips effectively. C. Avoid standing in front of the client while speaking, D. Speak loudly and slowly to the client to ensure they can hear you clearly.

Correct Answer is A

Explanation

A. "Use written communication to supplement verbal instructions and ensure the client understands the information." Written communication supports understanding, especially when hearing impairment may limit verbal communication.

B. "Use gestures and non-verbal cues only, without speaking, as the client is able to read lips effectively." Lip reading alone is insufficient for most hearing-impaired clients. Combining gestures, speech, and written communication is more effective.

C. "Avoid standing in front of the client while speaking." Standing in front of the client is crucial to ensure visibility for lip-reading or interpreting gestures.

D. "Speak loudly and slowly to the client to ensure they can hear you clearly." Speaking too loudly may distort sounds, and slow speech does not always enhance comprehension. Instead, normal tone and clear enunciation are recommended.

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