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 A
Explanation
Choice A rationale
Kussmaul respirations are deep, labored breathing patterns associated with metabolic acidosis, commonly seen in severe hyperglycemia and diabetic ketoacidosis.
Choice B rationale
Diaphoresis, or sweating, is typically associated with hypoglycemia rather than hyperglycemia. Hyperglycemia often leads to dehydration and dry skin.
Choice C rationale
Urinary ketones are typically present in cases of severe hyperglycemia and diabetic ketoacidosis. Absence of urinary ketones does not indicate hyperglycemia.
Choice D rationale
Chvostek's sign, a twitching of facial muscles, is indicative of hypocalcemia rather than hyperglycemia. It is not a reliable indicator of high blood sugar levels.
Correct Answer is D
Explanation
Choice D rationale
Easily bruised is a common sign of Cushing's syndrome due to increased cortisol levels, which weaken blood vessel walls, leading to capillary fragility and easy bruising.
Choice A rationale
Jaundice is not a typical finding in Cushing's syndrome. It is usually associated with liver conditions where bilirubin levels increase.
Choice B rationale
Muscle rigidity is not a common symptom of Cushing's syndrome. It is more associated with neurological or muscular disorders.
Choice C rationale
Weight loss is contrary to what is seen in Cushing's syndrome, where weight gain, particularly in the abdomen and face (moon face), is more typical.
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