A nurse is caring for a client who has cardiomyopathy and is experiencing sensory overload.Which of the following actions should the nurse take?
Place the client in a room near the nurses' station.
Break up nursing care into small, frequent sessions.
Ensure the blinds in the client's room remain open.
Play quiet music in the client's room.
The Correct Answer is B
Choice A rationale
Placing the client near the nurses' station may increase sensory overload due to increased noise and activity.
Choice B rationale
Breaking up nursing care into small, frequent sessions helps prevent overwhelming the client and reduces sensory overload.
Choice C rationale
Keeping the blinds open can add to sensory overload from excessive light and external stimuli.
Choice D rationale
Playing quiet music may be calming, but it does not directly address the need to reduce sensory input from various sources. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Step 1: (25 mg ÷ 12.5 mg) × 5 mL = 2 × 5 mL = 10 mL.
Answer: 10 mL.
Correct Answer is C
Explanation
Choice A rationale
Rotating the jejunostomy tube daily is not necessary and may cause unnecessary discomfort or complications.
Choice B rationale
Administering the feeding solution at a cold temperature can cause abdominal cramping and discomfort. It should be given at room temperature.
Choice C rationale
Elevating the head of the client's bed for 1 hour after feeding helps prevent aspiration, a serious complication of enteral feedings.
Choice D rationale
Flushing the tube with 90 mL of sterile water is excessive; the standard practice is to use 30-60 mL to clear the tube before and after feedings. .
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