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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.

Answer and Explanation

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. .

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Correct Answer is A

Explanation

Choice A rationale

Weighing the client before and after peritoneal dialysis helps assess fluid balance and ensure that the correct amount of fluid is removed during treatment. Monitoring weight changes is critical for evaluating the effectiveness of the dialysis.

Choice B rationale

Clean gloves are not sufficient for handling dialysate bags; sterile technique is required to prevent infection. Peritoneal dialysis involves a sterile procedure to reduce the risk of peritonitis.

Choice C rationale

The dialysate should be warmed to body temperature before infusion to prevent discomfort and vasoconstriction. Chilling the dialysate can cause abdominal cramping and reduce the effectiveness of the treatment.

Choice D rationale

Monitoring for diarrhea is not a standard part of peritoneal dialysis care. Peritonitis, not diarrhea, is a common complication of peritoneal dialysis, so monitoring for signs of infection is crucial.

A. The client has ecchymosis around the eyes. B. The client reports ringing in the ears. C. The client has a delayed response to verbal commands. D. The client is unable to remember details of the motor-vehicle crash.

Correct Answer is C

Explanation

Choice C rationale

A delayed response to verbal commands is a sign of increased intracranial pressure, indicating possible brain function impairment due to the pressure.

Choice A rationale

Ecchymosis around the eyes, known as "raccoon eyes," can indicate a basal skull fracture but does not directly indicate increased intracranial pressure.

Choice B rationale

Ringing in the ears, or tinnitus, is not a specific sign of increased intracranial pressure. It is usually related to auditory or vestibular issues.

Choice D rationale

Inability to remember details of the motor-vehicle crash can indicate a concussion or other brain injury but is not solely indicative of increased intracranial pressure. .

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A nurse is caring for a client who has cardiomyopathy and is experiencing sensory overload.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is receiving peritoneal dialysis.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash.For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?

Correct Answer is C

Explanation

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