The nurse identifies the client at risk for sensory overload based on several factors, including:(Select all that apply) Standard Text: Select all that apply
1. In-patient hospitalization
2. Extreme shortness of breath
3. Signs of depression
4. Increased anxiety over a new diagnosis
5. Lost hearing aids
1,2,4
Rationale: This client is at risk for sensory overload due to being admitted to a noisy healthcare setting
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Upon admission to the post-anasthetic care unit (PACU), a client's Aldrete score (post-anesthetic recovery score) is 4 . Within 30 minutes, it has become 8 . The nurse recognizes this score means that the client:
a. may be dismissed from the PACU b. must be admitted to a critical care unit c. needs oxygen d. needs to remain in the PACU for further evaluation and care
A patient is seen resting quietly; however, when the nurse enters the room, the patient begins to grimace and asks for more pain medication. Which of the following should the nurse do?
1. Assess the level of pain and provide the requested pain medication. 2. Confront the patient and ask about the sudden demonstration of pain. 3. Tell the patient that medication cannot be provided at this time and leave the room. 4. Refuse the medication and document that the patient appears to be faking the need for pain medication.
Placing a client in restraints before using other methods of intervention violates the client's right to:
A) Receive confidential and respectful care B) Provide informed consent C) Refuse treatment D) Receive treatment in the least restrictive environment
A client who delivered a baby 4 months ago says, "I keep thinking that this boy is some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can't stand it." Which statement by the nurse is most important?
A. "Have you been having any thoughts of hurting your baby?" B. "Do you think that something physically wrong is causing your baby to cry?" C. "Do you think that your baby cries so frequently because he's not getting enough nourishment from breastfeeding?" D. "You say that he doesn't seem to be satisfied. Do you feel that this is significantly different from when your daughter was a baby?"