The client is in the intensive care unit following a stroke.
The nurse is intervening in the plan of care to promote relaxation for the client and to prevent sensory overload.
What independent nursing intervention would the nurse choose to do?

Play music the client chooses.

Encourage visitors frequently throughout the day.

Sit in a chair next to the client and talk.

Turn on the television to the Super Bowl.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Playing music chosen by the client can promote relaxation by providing a familiar and comforting auditory stimulus. Music can help to reduce anxiety and create a calming environment, thus minimizing sensory overload in a client recovering from a stroke in the intensive care unit. This personalized approach respects the client's preferences and can positively influence their emotional state, fostering a more restful atmosphere conducive to healing.

Choice B rationale

Encouraging frequent visitors throughout the day can contribute to sensory overload for a client recovering from a stroke. While social support is important, excessive stimulation from multiple visitors can be overwhelming and disrupt the client's rest and recovery process in the intensive care unit, potentially increasing agitation and hindering relaxation.

Choice C rationale

Sitting in a chair next to the client and talking can be stimulating and may not promote relaxation, especially for a client who has recently experienced a stroke. Depending on the content and tone of the conversation, this interaction could increase sensory input and potentially cause agitation or fatigue rather than fostering a calm and restful environment needed for recovery in the intensive care unit.

Choice D rationale

Turning on the television to the Super Bowl would likely exacerbate sensory overload due to the bright lights, loud noises, and fast-paced visual stimulation. This type of environment is counterproductive to promoting relaxation and can be particularly overwhelming for a client recovering from a stroke in the intensive care unit, potentially increasing anxiety and hindering rest.

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Correct Answer is D

Explanation

Choice A rationale

While reporting communicable diseases is a public health responsibility, it is typically mandated by law and health regulations, not specifically a requirement that nurses *always* report to the Board of Nursing in Texas. Reporting protocols usually involve health departments.

Choice B rationale

Parents declining treatment for a child can raise ethical and legal concerns, potentially involving child protective services or the legal system, but it is not always a direct reporting requirement to the Texas Board of Nursing unless it involves professional misconduct by a nurse.

Choice C rationale

A patient's decision to leave against medical advice is a matter of patient autonomy. While nurses document this and ensure the patient understands the risks, it is not typically a mandatory reporting situation to the Texas Board of Nursing unless there are specific concerns about the nurse's conduct related to the discharge.

Choice D rationale

Abuse of older adults by another nurse directly involves the professional conduct and potential harm caused by a licensed nurse. The Texas Board of Nursing is responsible for regulating nursing practice and ensuring patient safety, making it mandatory for nurses to report such instances of misconduct by a colleague.

A. adrenal glands. B. renin-angiotensin-aldosterone system. C. cranial nerves. D. reticular activating system.

Correct Answer is D

Explanation

Choice A rationale

The adrenal glands primarily produce hormones that regulate metabolism, immune system, blood pressure, stress response, and other essential functions. While these hormones are crucial for overall bodily function and indirectly influence alertness and arousal, they are not the primary neurological structures responsible for maintaining a conscious and aroused state.

Choice B rationale

The renin-angiotensin-aldosterone system (RAAS) is a hormonal system that regulates blood pressure and fluid balance. While changes in blood pressure and fluid balance can affect overall well-being and indirectly influence alertness, the RAAS is not the neurological center responsible for a person's state of arousal.

Choice C rationale

Cranial nerves are a set of twelve paired nerves that emerge directly from the brain. They are responsible for a wide range of sensory and motor functions, including vision, hearing, taste, smell, facial movements, and swallowing. While some cranial nerves contribute to sensory input that can influence alertness, they are not the central structure responsible for maintaining arousal itself.

Choice D rationale

The reticular activating system (RAS) is a network of neurons located in the brainstem that plays a crucial role in regulating wakefulness, alertness, and the sleep-wake cycle. It filters incoming sensory information and relays important signals to the cerebral cortex, maintaining a state of arousal and consciousness. Damage to the RAS, such as that which can occur following a stroke, can lead to altered levels of consciousness. .

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The client is in the intensive care unit following a stroke.The nurse is intervening in the plan of care to promote relaxation for the client and to prevent sensory overload.What independent nursing intervention would the nurse choose to do?

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The client is in the intensive care unit following a stroke.
The nurse is intervening in the plan of care to promote relaxation for the client and to prevent sensory overload.
What independent nursing intervention would the nurse choose to do?