What environmental changes should the nurse make for a client who is experiencing perceptual alterations?
Provide bright lighting and check on the client's mental status hourly.
Keep the lights dim and keep a radio on continuously.
Have the client sit by the nurse's desk while awake and provide rest periods in a room with the television on.
Provide a well-lit room without glare or shadows and limit noise.
The Correct Answer is D
Choice A Reason:
Bright lighting can be overwhelming for clients experiencing perceptual alterations. While regular checks on the client's mental status are important, excessive brightness can exacerbate sensory overload. The goal is to create an environment that is calming and reduces sensory stimuli to manageable levels.
Choice B Reason:
Keeping the lights dim may help to soothe some clients, but continuous noise from a radio can contribute to sensory overload. It's crucial to tailor the environment to the individual needs of the client, which often means providing a quiet space with minimal auditory distractions.
Choice C Reason:
Having the client sit by the nurse's desk may provide necessary supervision, but it can also expose the client to high levels of activity and noise, which can be disorienting. Rest periods with the television on can be distracting and may not offer the tranquil environment needed for a client with perceptual alterations.
Choice D Reason:
Providing a well-lit room without glare or shadows and limiting noise is the most appropriate environmental change for a client with perceptual alterations. This approach helps to reduce the risk of misperceptions and hallucinations, which can be triggered by shadows and glare. A quiet and well-lit environment supports better sensory processing and helps to maintain orientation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Limiting ambulation is not typically recommended as part of the management for pneumonia. While rest is important, some movement is beneficial for preventing complications such as deep vein thrombosis. Ambulation should be encouraged as tolerated to promote circulation and prevent stasis of secretions.
Choice B reason:
Administering pain medication every two hours may not be necessary and could lead to overmedication. Pain management should be based on the client's reported pain levels and response to medication, with adjustments made as needed for effective relief.
Choice C reason:
Encouraging the client to hold their chest with a pillow or hands, known as splinting, can help reduce the pain experienced during coughing by providing support and stabilizing the chest wall. This technique is a non-pharmacological intervention that can effectively manage pain associated with coughing in pneumonia patients.
Choice D reason:
Teaching pursed-lip breathing and deep breathing techniques is beneficial for clients with respiratory conditions, including pneumonia. These techniques can help improve ventilation and oxygenation, but they are not specifically aimed at managing pain during coughing. However, they can be included as part of the overall respiratory care plan.
Correct Answer is D
Explanation
Choice A Reason:
A blood pressure of 98/60, while on the lower side, is not necessarily alarming post-surgery unless the patient shows symptoms of hypotension or if there is a significant drop from the patient's baseline blood pressure. It is important to monitor trends in blood pressure readings rather than a single isolated measurement.
Choice B Reason:
A urine output of 40 mL/hour can be considered within normal limits post-surgery, as the expected urine output is at least 0.5 mL/kg/hr. However, it should be monitored closely to ensure that it does not decrease further, which could indicate renal complications.
Choice C Reason:
Pain rated as 5 on a 0-10 scale indicates moderate pain, which is expected post-surgery. Pain management should be continued as prescribed, and the patient should be reassessed regularly to ensure that the pain does not escalate.
Choice D Reason:
The absence of a popliteal pulse is a critical finding that must be reported immediately. The popliteal artery provides blood flow to the lower leg, and its absence could indicate graft occlusion or other serious circulatory issues, which could lead to limb-threatening complications if not addressed promptly.
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