What environmental changes should the nurse make for a client who is experiencing perceptual alterations?

Provide bright lighting and check on the client's mental status hourly.

Keep the lights dim and keep a radio on continuously.

Have the client sit by the nurse's desk while awake and provide rest periods in a room with the television on.

Provide a well-lit room without glare or shadows and limit noise.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Bright lighting can be overwhelming for clients experiencing perceptual alterations. While regular checks on the client's mental status are important, excessive brightness can exacerbate sensory overload. The goal is to create an environment that is calming and reduces sensory stimuli to manageable levels.

Choice B Reason:
Keeping the lights dim may help to soothe some clients, but continuous noise from a radio can contribute to sensory overload. It's crucial to tailor the environment to the individual needs of the client, which often means providing a quiet space with minimal auditory distractions.

Choice C Reason:
Having the client sit by the nurse's desk may provide necessary supervision, but it can also expose the client to high levels of activity and noise, which can be disorienting. Rest periods with the television on can be distracting and may not offer the tranquil environment needed for a client with perceptual alterations.

Choice D Reason:
Providing a well-lit room without glare or shadows and limiting noise is the most appropriate environmental change for a client with perceptual alterations. This approach helps to reduce the risk of misperceptions and hallucinations, which can be triggered by shadows and glare. A quiet and well-lit environment supports better sensory processing and helps to maintain orientation.

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Correct Answer is B

Explanation

Choice A Reason:
The statement "Forget him. There are other fish in the sea." minimizes the client's feelings and does not acknowledge the emotional pain they are experiencing. It is a cliché that can come across as dismissive rather than empathetic.

Choice B Reason:
"You must have been very upset to do what you did." This statement acknowledges the client's distress and does not judge their actions. It reflects an understanding of the depth of their emotional pain, which is a key component of empathy.

Choice C Reason:
"Don't worry, you'll get over him in time." While this statement may be intended to provide reassurance, it does not address the immediate emotional state of the client. It could be perceived as brushing aside their current feelings.

Choice D Reason:
"Why do you think your boyfriend broke up with you?" This question could be seen as probing for information rather than offering support. It might imply that the client is at fault for the breakup, which is not an empathetic approach.

A. Prevent Wernicke's encephalopathy. B. Prevent alcoholic hepatitis. C. Rehydrate the client. D. Prevent pancreatitis.

Correct Answer is A

Explanation

Choice A Reason
Thiamine, or vitamin B1, is essential for brain function and the metabolism of carbohydrates. In the context of high blood alcohol levels, thiamine is administered to prevent Wernicke's encephalopathy, a serious neurological disorder. This condition is often precipitated by a thiamine deficiency, which can be exacerbated by alcohol abuse. Alcohol consumption can impair thiamine absorption and utilization, leading to depleted stores. Wernicke's encephalopathy is characterized by symptoms such as confusion, ataxia, and ophthalmoplegia, and if left untreated, it can progress to Korsakoff syndrome, a chronic and debilitating condition.

Choice B Reason
While alcoholic hepatitis is a concern in individuals with excessive alcohol intake, thiamine is not specifically used to prevent this condition. Alcoholic hepatitis is inflammation of the liver due to alcohol abuse, and its prevention primarily involves abstinence from alcohol, nutritional support, and medical management of liver inflammation. Thiamine does not play a direct role in preventing liver inflammation but is crucial for overall nutritional replenishment in individuals with alcohol use disorder.

Choice C Reason
Rehydration is indeed important for clients with high blood alcohol levels; however, thiamine does not serve this purpose. Rehydration typically involves the administration of intravenous fluids to restore fluid balance and electrolytes. Thiamine is not a rehydrating agent but is given to prevent neurological complications associated with thiamine deficiency, which can be seen in individuals with chronic alcoholism.

Choice D Reason
Preventing pancreatitis is not the primary reason for administering thiamine in this scenario. Pancreatitis, an inflammation of the pancreas, can be associated with chronic alcohol abuse, but thiamine is not used as a preventative treatment for this condition. The management of pancreatitis involves addressing the underlying causes, supportive care, and sometimes hospitalization for more severe cases.

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What environmental changes should the nurse make for a client who is experiencing perceptual alterations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement shows that the nurse has empathy for a client who has recently made a suicide attempt after breaking up with a significant other?

Correct Answer is B

Explanation

A client was admitted to the emergency department with slurred speech and impaired motor coordination. The blood alcohol level is over 300 mg/dL. The physician orders thiamine for the client. The nurse understands that the physician ordered thiamine to:

Correct Answer is A

Explanation

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