The nurse is caring for a client at risk for sensory overload. ...

[Yi-Chen]

The nurse is caring for a client at risk for sensory overload. What interventions should the nurse implement? Select all that apply.
 
  A) Remove clutter from the client's room.
  B) Implement measures to reduce the client's pain.
  C) Assist with all ADLs.
  D) Limit interruptions to the client's rest/sleep times.
  E) Limit extraneous noise.

Question 2

The nurse is caring for a client at risk for sensory deprivation. What interventions should the nurse implement to decrease the client's risk? Select all that apply.
 
  A) Encourage the client's family to bring in personal objects.
  B) Keep the television on at all times.
  C) Place a clock and calendar in the client's room.
  D) Brush the client's hair.
  E) Speak slowly and clearly to the client.

[Brummell1998]

Answer to Question 1

Ans: A, B, D, E
Feedback:
If the client is experiencing sensory overload, interventions should focus on reducing stimulation involving information, the environment, and internal factors. Limiting extraneous noise, bright lights, room clutter, interruptions, pain, and stress reduces stimulation. Clients with sensory overload may neglect their ADLs to the point that they need assistance. Such assistance can be problematic because it can add to sensory overload. With this in mind, assist the client only with the immediately essential ADLs (moving, eating, toileting, and resting). Additional tasks may be added as the client is able to cope.

Answer to Question 2

Ans: A, C, D, E
Feedback:
Measures to provide stimulation include playing the television or the radio occasionally, playing music for brief periods, encouraging use of a clock and calendar, encouraging the client to dress for the day's activities, putting up colorful pictures, encouraging visitors, encouraging family to bring in personal items such as photographs, opening the drapes, and turning on lights. Place the bed or chair so the client can see or hear activities in the area and when someone enters the room. Frequent interaction with the client also may help. Discussing scheduling of care and placement of equipment, encouraging self-care activities, providing tactile stimulation through back rubs, combing and brushing the client's hair (or encouraging the client to do so), reading to the client, speaking slowly and clearly, and identifying yourself verbally and with a name tag are meaningful interactions.