The nurse is caring for a patient who becomes agitated when visitors stay for extended periods or the hospital unit becomes noisy. The nurse identifies this as sensory overload. Which interventions will be of benefit to the patient? (Select all that apply.)
Turn on the television to drown out noise from other patients.
Institute a unit-wide quiet time at 10:00 p.m. each night.
Reduce the number of visitors to the patient’s room.
Provide a dedicated period of rest time each afternoon.
Coordinate therapies and tests with other departments and providers.
Correct Answer : B,C,D,E
Choice A reason: This is incorrect. Turning on the television to drown out noise from other patients can worsen the sensory overload by adding more auditory stimulation. The patient may prefer a quiet and calm environment.
Choice B reason: This is correct. Instituting a unit-wide quiet time at 10:00 p.m. each night can benefit the patient by reducing the noise level and promoting rest and relaxation. The patient may sleep better and feel less agitated.
Choice C reason: This is correct. Reducing the number of visitors to the patient’s room can benefit the patient by minimizing the social and emotional demands and allowing the patient to have some privacy and personal space. The patient may feel less overwhelmed and more comfortable.
Choice D reason: This is correct. Providing a dedicated period of rest time each afternoon can benefit the patient by giving the patient a break from the sensory input and activities of the day. The patient may use this time to meditate, listen to soothing music, or do other calming activities.
Choice E reason: This is correct. Coordinating therapies and tests with other departments and providers can benefit the patient by avoiding unnecessary duplication or interruption of services and ensuring a smooth and consistent care plan. The patient may feel less stressed and more confident.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A reason: This is incorrect. Tramadol is not a nonsteroidal anti-inflammatory medication. Tramadol is an opioid analgesic medication that works by binding to opioid receptors in the brain and spinal cord. It can relieve moderate to severe pain, but it does not have any anti-inflammatory effect.
Choice B reason: This is correct. Aspirin is a nonsteroidal anti-inflammatory medication. Aspirin is a salicylate medication that works by inhibiting the enzyme cyclooxygenase, which is involved in the synthesis of prostaglandins. Prostaglandins are chemical messengers that mediate inflammation, pain, and fever. Aspirin can reduce inflammation, pain, and fever, as well as prevent blood clots and protect the heart.
Choice C reason: This is incorrect. Acetaminophen is not a nonsteroidal anti-inflammatory medication. Acetaminophen is a para-aminophenol medication that works by inhibiting the enzyme cyclooxygenase in the central nervous system, but not in the peripheral tissues. It can reduce pain and fever, but it does not have any anti-inflammatory effect.
Choice D reason: This is correct. Ibuprofen is a nonsteroidal anti-inflammatory medication. Ibuprofen is a propionic acid medication that works by inhibiting the enzyme cyclooxygenase, which is involved in the synthesis of prostaglandins. Prostaglandins are chemical messengers that mediate inflammation, pain, and fever. Ibuprofen can reduce inflammation, pain, and fever, as well as treat arthritis and menstrual cramps.
Choice E reason: This is incorrect. Codeine is not a nonsteroidal anti-inflammatory medication. Codeine is an opioid analgesic medication that works by binding to opioid receptors in the brain and spinal cord. It can relieve mild to moderate pain, but it does not have any anti-inflammatory effect.
Correct Answer is ["C"]
Explanation
Choice A reason: This is an incorrect choice because calculating the patient’s fluid intake and output at the end of every shift is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can monitor the patient’s fluid balance and document the results.
Choice B reason: This is an incorrect choice because assessing the patient’s abdomen for distention, bowel sounds, and passage of flatus is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can perform a physical examination of the patient’s abdomen and document the findings.
Choice C reason: This is a correct choice because administering a mild stool softener daily to prevent constipation is an example of a dependent nursing intervention. A dependent nursing intervention is an action that the nurse can perform only with a physician's order. The nurse cannot give any medication to the patient without a prescription.
Choice D reason: This is an incorrect choice because encouraging fluid and fiber intake to prevent constipation from pain medications is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can educate the patient about the importance of hydration and nutrition and document the teaching.
Choice E reason: This is a correct choice because reinserting the patient's urinary catheter for retention of greater than 500 mL of urine is an example of a dependent nursing intervention. A dependent nursing intervention is an action that the nurse can perform only with a physician's order. The nurse cannot insert or remove any invasive device from the patient without a prescription.
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