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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A rationale
While nurses are generally expected to follow physician's orders, they also have a professional and ethical responsibility to advocate for their patients. In situations where an order conflicts with the patient's wishes and ethical principles, blindly following the order can lead to moral distress.
Choice B rationale
The physician's order, which contradicts the patient's explicit request, can indeed create a barrier to establishing an effective nurse-client relationship built on trust and respect for the patient's autonomy. The nurse may feel conflicted in carrying out an unwanted intervention.
Choice C rationale
The situation creates an ethical dilemma for the nurse because there are conflicting courses of action with moral implications. The nurse faces a conflict between the duty to follow the physician's order and the ethical principle of respecting the patient's autonomy and right to refuse treatment, even life-sustaining measures at the end of life.
Choice D rationale
The nurse is not unable to provide care but faces a complex ethical challenge in determining the most appropriate and ethical course of action that respects the patient's wishes while navigating the physician's order.
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