The nurse is concerned that a hospitalized client is experiencing ...

[skymedlock]

The nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to come to this conclusion?
 
  1. Sleeplessness
  2. Anxiety
  3. Apathy
  4. Racing thoughts
  5. Somatic complaints

Question 2

The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception, Auditory. What would indicate that interventions to address this diagnosis have been successful?
 
  1. Client places hearing aid on beside table when not in use.
  2. Client does not respond appropriately to questions.
  3. Client demonstrates use and care of hearing aid.
  4. Client demonstrates difficulty with problem solving.

[fauacakatahaias]

Answer to Question 1

Correct Answer: 1, 2, 4
Rationale 1: Sleeplessness is an indication of sensory overload.
Rationale 2: Anxiety is an indication of sensory overload.
Rationale 3: Apathy is associated with sensory deprivation.
Rationale 4: Racing thoughts are an indication of sensory overload.
Rationale 5: Somatic complaints are an indication of sensory deprivation.

Answer to Question 2

Correct Answer: 3
Rationale 1: The client's placing the hearing aid on a bedside table when not in use would indicate that interventions were not successful.
Rationale 2: The client's responding inappropriately to questions would indicate that interventions were not successful.
Rationale 3: Outcome criteria that indicate interventions to address Disturbed Sensory Perception, Auditory have been successful would include the client's demonstrating use and care of the hearing aid.
Rationale 4: The client's demonstrating difficulty with problem solving is an indication of sensory overload.

[skymedlock]

Gracias!

[bblaney]

TYSM