The nurse is caring for a patient who becomes agitated when visitors stay for extended periods or the hospital unit becomes noisy. The nurse identifies this as sensory overload. Which interventions will be of benefit to the patient? (Select all that apply.)
Turn on the television to drown out noise from other patients.
Institute a unit-wide quiet time at 10:00 p.m. each night.
Reduce the number of visitors to the patient’s room.
Provide a dedicated period of rest time each afternoon.
Coordinate therapies and tests with other departments and providers.
Correct Answer : B,C,D,E
Choice A reason: This is incorrect. Turning on the television to drown out noise from other patients can worsen the sensory overload by adding more auditory stimulation. The patient may prefer a quiet and calm environment.
Choice B reason: This is correct. Instituting a unit-wide quiet time at 10:00 p.m. each night can benefit the patient by reducing the noise level and promoting rest and relaxation. The patient may sleep better and feel less agitated.
Choice C reason: This is correct. Reducing the number of visitors to the patient’s room can benefit the patient by minimizing the social and emotional demands and allowing the patient to have some privacy and personal space. The patient may feel less overwhelmed and more comfortable.
Choice D reason: This is correct. Providing a dedicated period of rest time each afternoon can benefit the patient by giving the patient a break from the sensory input and activities of the day. The patient may use this time to meditate, listen to soothing music, or do other calming activities.
Choice E reason: This is correct. Coordinating therapies and tests with other departments and providers can benefit the patient by avoiding unnecessary duplication or interruption of services and ensuring a smooth and consistent care plan. The patient may feel less stressed and more confident.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Emission is the process by which an object emits heat or light. For example, the sun emits heat and light to the earth.
Choice B reason: This is incorrect. Radiation is the process by which heat or light travels through space or air without direct contact. For example, the heat from a fireplace radiates to the room.
Choice C reason: This is incorrect. Convection is the process by which heat is transferred by the movement of a fluid, such as air or water. For example, the warm air from a heater rises and circulates in the room.
Choice D reason: This is correct. Conduction is the process by which heat is transferred by direct contact between two objects. For example, the heat from the warmed blanket is conducted to the patient’s skin.
Correct Answer is A
Explanation
Choice A reason: This is correct. Risk for injury related to smoking near supplemental oxygen is the priority nursing diagnosis for this family. Smoking near supplemental oxygen can cause a fire or an explosion that can injure or kill the patient and the spouse. The nurse should educate the family about the dangers of smoking near oxygen and provide resources to help the spouse quit smoking.
Choice B reason: This is incorrect. Risk-prone health behavior related to inability to quit smoking is a relevant nursing diagnosis for this family, but not the priority. Smoking is a harmful habit that can cause various health problems, such as lung cancer, heart disease, and stroke. The nurse should assess the spouse's readiness to quit smoking and provide support and counseling.
Choice C reason: This is incorrect. Ineffective health maintenance related to continued use of cigarettes is a valid nursing diagnosis for this family, but not the priority. Smoking can impair the health of the patient and the spouse, especially if the patient has a respiratory condition that requires supplemental oxygen. The nurse should monitor the patient's and the spouse's vital signs, oxygen saturation, and respiratory status.
Choice D reason: This is incorrect. Ineffective family therapeutic regimen management related to noncompliance is an appropriate nursing diagnosis for this family, but not the priority. Smoking near supplemental oxygen can indicate that the family is not following the prescribed treatment plan for the patient's condition. The nurse should evaluate the family's understanding of the patient's oxygen therapy and the reasons for noncompliance.
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