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 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. .
Correct Answer is D
Explanation
Choice A rationale
A negative airflow room is typically used for airborne pathogens such as tuberculosis, not influenza, which is droplet-borne.
Choice B rationale
An N95 mask is not necessary for influenza care. Standard precautions, including wearing a surgical mask and practicing hand hygiene, are usually sufficient.
Choice C rationale
Administering an influenza immunization is not appropriate for a client who is already infected with influenza. The vaccine is used for prevention, not treatment.
Choice D rationale
Wearing a surgical mask during transport is an effective way to prevent the spread of influenza to others.
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