A nurse is caring for a hospitalized client who is experiencing sensory overload due to the hospital environment. Which of the following actions should the nurse take?

Encourage visitors throughout the day.

Provide the client with earplugs.

Spread client care activities throughout the shift.

Keep the door to the client's room open.

Answer and Explanation

The Correct Answer is B

A. Encourage visitors throughout the day: Increased visitor interactions may worsen sensory overload by adding more stimuli.

B. Provide the client with earplugs. Earplugs help reduce environmental noise and sensory input, addressing the client's sensory overload and promoting rest and comfort.

C. Spread client care activities throughout the shift: Consolidating care activities, rather than spreading them out, minimizes interruptions and helps reduce sensory input.

D. Keep the door to the client's room open: Keeping the door open can increase noise and stimuli, exacerbating sensory overload.

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Correct Answer is A

Explanation

A. Insomnia: Physical manifestations of grief often include insomnia, fatigue, appetite changes, headaches, and muscle tension due to the emotional and psychological stress of loss.

B. Bradycardia: Bradycardia is not a common physical manifestation of grief. Increased stress may more commonly cause tachycardia.

C. Blurred vision: While stress-related symptoms can occur, blurred vision is not typically associated with grief.

D. Increased ability to concentrate: Grief often reduces the ability to concentrate, not increases it.

A. Assess the client's ability to perform activities of daily living (ADLs) and their impact on the client's overall health. B. Review the client's current medication list and check for any missed doses. C. Focus on the client's most recent laboratory results and compare them to past results. D. Conduct a detailed family history to identify any genetic predispositions to the chronic illness.

Correct Answer is A

Explanation

A. Assess the client's ability to perform activities of daily living (ADLs) and their impact on the client's overall health. ADL assessment provides crucial information about how well the client is managing their chronic illness and maintaining functional independence.

B. Review the client's current medication list and check for any missed doses. While this is important, it is a secondary concern compared to assessing functional status, which has a broader impact on health outcomes.

C. Focus on the client's most recent laboratory results and compare them to past results. Lab results are valuable but do not provide a comprehensive view of how the illness affects the client's daily life.

D. Conduct a detailed family history to identify any genetic predispositions to the chronic illness. Genetic predispositions are relevant for diagnosis and prevention but do not evaluate current management of the condition.

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A nurse is caring for a hospitalized client who is experiencing sensory overload due to the hospital environment. Which of the following actions should the nurse take?

Nursing Test Bank

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