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Author Question: Which client is at greatest risk of sensory overload? A) a 17-year-old on bed rest after a ... (Read 88 times)

sheilaspns

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on: Jul 22, 2018
Which client is at greatest risk of sensory overload?
 
  A) a 17-year-old on bed rest after a surgical procedure
  B) a 55-year-old, newly diagnosed with diabetes in a private room in a hospital
  C) an 88-year-old on a ventilator in an intensive care unit
  D) an 8-year-old in isolation in a private room in a hospital

Question 2

A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, Get the bugs off my bed, I can feel them crawling on me
 Which nursing diagnosis is appropriate for this client?

A) Disturbed Sensory Perception: Kinesthetic related to side effects of medication as evidenced by client statement of Get the bugs off my bed, I can feel them crawling on me.
 B) Disturbed Sensory Perception: Tactile as evidenced by client statement of Get the bugs off my bed, I can feel them crawling on me.
 C) Disturbed Sensory Perception related to client statement of Get the bugs off my bed, I can feel them crawling on me.
 D) Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of Get the bugs off my bed, I can feel them crawling on me.



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kswal303

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Reply #1 on: Jul 22, 2018
Answer to Question 1

Ans: C
Feedback:
Intensive care units, mechanical ventilators, lengthy verbal explanations prior to procedures, and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload. Private rooms, mobility restraints (such as traction or bed rest), isolation, and few visitors are all risk factors for sensory deprivation.

Answer to Question 2

Ans: D
Feedback:
The correctly written nursing diagnosis is Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of Get the bugs off my bed, I can feel them crawling on me. Since the nursing diagnosis is not a risk for diagnosis, it must have a related to and as evidenced by statement.


sheilaspns

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Reply #2 on: Jul 22, 2018
Both answers were spot on, thank you once again


kswal303

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Reply #3 on: Jul 22, 2018
Great! Please up vote :D


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