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

Ensure the blinds in the client's room remain open.

Place the client in a room near the nurses' station.

Play quiet music in the client's room.

Break up nursing care into small, frequent sessions.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Ensure the blinds in the client's room remain open is not appropriate. Bright light can contribute to sensory overload. It's better to create a subdued and calming environment, so keeping the blinds closed or partially closed might help reduce excess stimuli.

Choice B Reason:

Place the client in a room near the nurses' station is not appropriate. Being near the nurses' station could increase the noise and activity around the client, potentially worsening sensory overload. It's advisable to place the client in a quieter area away from high-traffic zones to minimize auditory and visual stimulation.

Choice C Reason:

Play quiet music in the client's room is incorrect. While soothing music might help some individuals relax, for someone experiencing sensory overload, even low-volume music could add to the stimuli. Silence or minimal ambient noise might be more beneficial.

Choice D Reason:

Break up nursing care into small, frequent sessions is correct. This action is beneficial for managing sensory overload. Breaking up care into smaller sessions allows for adequate rest periods between activities, reducing the overall sensory input at any given time.

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Correct Answer is D

Explanation

Choice A Reason:
"I will perform breast exams the day my period begins." This statement is incorrect because performing breast exams just before or during your period might not be ideal. Breasts can be more tender or swollen during this time, which could make it harder to detect any abnormalities.
Choice B Reason:
"I will perform breast exams every other month." This statement is incorrect. Regular breast self-exams are important, but doing them every other month might not be frequent enough. It's generally recommended to perform breast self-exams once a month, ideally around the same time each month, to detect any changes or abnormalities early.
Choice C Reason:
"It is common for the skin on my breasts to dimple." This statement is incorrect. Dimpling or puckering of the skin on the breasts can sometimes be a sign of an underlying issue, such as breast cancer. It's not considered a normal or common occurrence, so this statement doesn't indicate an understanding of what to look for during a breast self-exam. If a person notices skin changes like dimpling, it's recommended to seek medical advice.
Choice D Reason:
"It is common for one breast to be larger than the other." This statement reflects an understanding that breast asymmetry, where one breast is slightly larger than the other, is a common and normal occurrence.

Correct Answer is ["1000"]

Explanation

To lose 0.9 kg (2 lb) of body fat per week, the client needs to create a weekly caloric deficit of 7000 calories (3500 x 2).

This means that he needs to reduce his daily caloric intake by 1000 calories (7000 / 7).

The nurse should instruct the client to calculate his current daily caloric intake and then subtract 1000 calories from that amount. The nurse should also advise the client to eat a balanced diet and exercise regularly to achieve his weight loss goal.

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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 reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who wants to lose 0.9kg (2lb) of body fat per week. The nurse knows that 0.45 kg (1lb) of body fat is equal to 3500 calories. The nurse should instruct the client to reduce his daily caloric intake by how many calories?

Correct Answer is ["1000"]

Explanation

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