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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice a reason:
Placing the client on 2L via nasal cannula is a common intervention for hypoxemia, but with the client's pulse oximetry at 88%, which is below the normal range of 95-100%, and the presence of tachypnea, a more immediate assessment of the client's respiratory status is warranted. Oxygen therapy should be guided by the results of arterial blood gas (ABG) analysis to tailor the treatment to the client's specific needs.
Choice b reason:
Obtaining a blood glucose level is not the most immediate concern in the context of altered mental status and respiratory distress. While it is important to rule out hypoglycemia as a cause of altered mental status, the primary concern indicated by the vital signs is the client's respiratory condition.
Choice c reason:
Calling the physician for an order for a stat arterial blood gas is the most appropriate action. The ABG will provide detailed information about the client's oxygenation, carbon dioxide levels, and acid-base balance. This is crucial for a client with a new onset change in mental status and tachypnea, as it can indicate respiratory failure or other serious complications of pneumonia.
Choice d reason:
Requesting an order for lorazepam is not appropriate given the client's current respiratory status. Lorazepam, a benzodiazepine, can depress the central nervous system and respiratory drive, potentially worsening the client's hypoxemia and respiratory effort.
Correct Answer is A
Explanation
Choice a reason:
A history of allergy to iodine is a critical finding to report before a coronary angiography because the contrast dye used in the procedure typically contains iodine. Patients with an iodine allergy may experience severe reactions, including anaphylaxis, which can be life-threatening. Precautions such as premedication with steroids and antihistamines or the use of alternative contrast agents may be necessary.
Choice b reason:
A serum potassium level of 4.0 mEq/L is within the normal range, which is approximately 3.5 to 5.2 mEq/L for adults. Therefore, this finding is not significant and does not need to be reported to the healthcare provider prior to the procedure.
Choice c reason:
A blood pressure reading of 138/90 mmHg is slightly elevated but does not reach the threshold for stage 1 hypertension, which starts at 140/90 mmHg for individuals under 60 years of age. While it should be monitored, it is not an urgent concern that needs to be reported immediately before a coronary angiography unless the patient shows symptoms of hypertensive crisis.
Choice d reason:
An EKG showing atrial fibrillation is an important finding; however, it is not typically a contraindication for coronary angiography unless the patient is hemodynamically unstable or symptomatic. Atrial fibrillation can increase the risk of stroke, but anticoagulation management is usually the focus rather than postponing necessary diagnostic procedures.
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