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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Relying solely on written communication can be time-consuming and may not be suitable for all situations or for clients with low literacy. While it can be a useful adjunct, it shouldn't replace verbal communication entirely.
Choice B rationale
Reducing time spent with the client can hinder effective communication and relationship building. It doesn't address the communication barrier and may leave the client feeling unheard and uncared for.
Choice C rationale
Speaking loudly can distort sounds and make it harder for someone with a hearing deficit to understand. It can also be perceived as disrespectful or condescending. The approach should focus on clarity, not volume.
Choice D rationale
Background noise, such as a television, can significantly interfere with a hearing-impaired person's ability to understand speech. Reducing or eliminating such distractions creates a clearer auditory environment, facilitating better comprehension of verbal communication.
Correct Answer is D
Explanation
Choice A rationale
Dividing time evenly among patients reflects the professional value of justice, ensuring fair allocation of nursing resources based on patient needs rather than strict equality of time. Justice in nursing involves impartiality and equitable treatment.
Choice B rationale
Demonstrating care and concern for a patient's culture and beliefs aligns with the professional value of respect for autonomy and human dignity. It involves acknowledging and valuing the patient's individuality and their right to self-determination in healthcare decisions.
Choice C rationale
Encouraging the patient to make decisions about food selection promotes patient autonomy, allowing them to exercise their right to make choices about their care. This respects their preferences and empowers them in their healthcare journey.
Choice D rationale
Performing patient assessment and recording findings accurately exemplifies integrity, which involves honesty, truthfulness, and adherence to ethical principles. Accurate documentation provides an honest representation of the patient's condition and the care provided, crucial for safe and effective nursing practice.
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