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

Choice A Reason:

Experiences nocturia is incorrect. Nocturia (waking up at night to urinate) is a common symptom and, while it's important to address for the client's comfort and potential underlying causes, it doesn't pose an immediate risk to the client's roommate or necessitate urgent intervention in a shared room setting.

Choice B Reason:

History of generalized anxiety disorder is incorrect. A history of generalized anxiety disorder is relevant to the client's mental health and overall care. However, in the context of a shared room, it might not require immediate attention or interventions that directly impact the roommate's health or safety.

Choice C Reason:

Recent exposure to tuberculosis is correct. Tuberculosis (TB) is an infectious disease that spreads through the air when an infected person coughs or sneezes. In a shared room, a history of recent exposure to TB is a significant concern as it poses a potential risk to both the client and the roommate. Immediate measures to prevent transmission and ensure proper isolation protocols are necessary to protect the health of both individuals in the shared space.

Choice D Reason:

Reports periodic migraine headaches is correct.

Periodic migraine headaches are a health concern for the client experiencing them, but they typically do not pose an immediate risk or concern for the client's roommate. While addressing pain management is important, it might not require immediate action in the shared room environment.

Choice A Reason:
Suction equipment is recommended. This is a crucial supply to have at hand. During or after a seizure, the client might have excessive secretions or vomit, which could potentially obstruct their airway. Suction equipment helps clear the airway and maintain breathing, making it an essential item to have bedside.
Choice B Reason:
Padded tongue blades is incorrect. The use of padded tongue blades during a seizure is not recommended. Placing anything inside the mouth during a seizure could cause injury or pose a risk of choking. Keeping the airway clear and ensuring the client's safety is more important than attempting to manipulate the tongue.
Choice C Reason:
Backboard is incorrect.Backboards are typically used for spinal immobilization in cases of suspected spinal injury, not specifically for seizure management. Unless there's a concurrent injury or trauma, a backboard wouldn't be routinely necessary for a client having a seizure.
Choice D Reason:
Wrist restraints is incorrect. Restraints are generally not used for managing seizures. Using restraints during a seizure could potentially cause harm, restrict movement, and increase the risk of injury to the client. Restraints are not considered appropriate or safe for managing seizures.