While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively.
Which action should the nurse implement?

Demonstrate the skill speaking slowly and using simple terms.

Reassure the client that the skill is not difficult to learn.

Reduce the stimuli in the area before continuing the teaching.

Provide the client with step-by-step written instruction.

Answer and Explanation

The Correct Answer is C

Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process 1.

Therefore, reducing the stimuli in the area can help the client’s brain to better process the information being taught.

Choice A is not the answer because demonstrating the skill speaking slowly and using simple terms does not address the issue of sensory overload 1.

Choice B is not the answer because reassuring the client that the skill is not difficult to learn does not address the issue of sensory overload 1.

Choice D is not the answer because providing step-by-step written instruction does not address the issue of sensory overload 1.

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Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

A. Ask the client to describe the pain. B. Provide a numeric pain scale. C. Identify effective pain relief measures. D. Observe body language and movement.

Correct Answer is A

Explanation

To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.

This will help the nurse to understand the characteristics of the pain and how it is affecting the client.

Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.

Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.

Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.

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While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively.
Which action should the nurse implement?