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 ["7.9"]
Explanation
Step 1: Identify the desired dose: 165 mg.
Step 2: Identify the concentration of the medication: 105 mg in 5 mL.
Step 3: Set up a proportion to find the required volume (x mL):
105 mg / 5 mL = 165 mg / x mL
Step 4: Solve for x:
105 × x = 165 × 5
Step 5:
105x = 825
Step 6:
x = 825 ÷ 105
Step 7:
x ≈ 7.857 mL
Final Answer: The nurse should give approximately 7.9 mL.
Correct Answer is A
Explanation
Choice A rationale
Infants are at the highest risk for fluid and electrolyte imbalance due to diarrhea because they have a higher percentage of body water compared to adults, and a larger proportion of this water is extracellular. Their kidneys are also immature and less efficient at regulating fluid and electrolytes. Additionally, their higher metabolic rate and greater body surface area to weight ratio lead to increased insensible fluid losses.
Choice B rationale
Adolescents have a body composition and physiological regulatory mechanisms that are more similar to adults, making them less vulnerable to rapid fluid and electrolyte shifts from diarrhea compared to infants. Their kidneys are fully developed and can manage fluid and electrolyte balance more effectively.
Choice C rationale
Young adults also have well-developed regulatory mechanisms and a lower proportion of extracellular fluid compared to infants. While prolonged diarrhea can still lead to imbalances, they are generally more resilient than infants due to their mature physiology.
Choice D rationale
School-age children have a body composition and physiological maturity that places them at a lower risk for severe fluid and electrolyte imbalance from diarrhea compared to infants. Their regulatory systems are more developed than those of infants, allowing for better compensation for fluid losses. .
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