Which of the following safety measures is most important for the ...

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Which of the following safety measures is most important for the nurse to implement for a hos-pitalized client with a visual impairment?
 
  1. Orient the client to the room.
  2. Open the window blinds to let in light.
  3. Keep the client's door to the room open so that he or she can be visualized.
  4. Keep all four side rails up to remind the client not to get up on his or her own.

Question 2

The 85-year-old female client has moved to an assisted living apartment so that she can remain independent yet have some limited assistance with her ADLs.
 
  Which of the following suggestions should the nurse make that would be most appropriate to reduce sensory deprivation?
  1. Provide pictures of the client's family.
  2. Purchase all-new furnishings.
  3. Suggest that the client take all her meals in her apartment until she gets the chance to know her neighbors better.
  4. Ask family and friends to wait a few days to visit until the client has an oppor-tunity to settle in.

[yifu223]

Answer to Question 1

ANS: 1
Clients with serious visual impairment need to feel comfortable in knowing the boundaries of the immediate environment. Normally we see physical boundaries within a room. The blind or se-verely visually impaired often touch the boundaries or objects to gain a sense of their surround-ings. The client needs to walk through a room and feel the walls to establish a sense of direction. Help clients by explaining objects within the room, such as furniture or equipment. It takes time for the client to absorb a room's arrangement. The client often needs to reorient again, with your explaining the location of key items. Glare from the window may actually cause more visual problems. The client may prefer to have the door to the room closed for privacy. Putting all four side rails up on the bed increases the risk for falls.

Answer to Question 2

ANS: 1
Meaningful stimuli reduce the incidence of sensory deprivation. In the home, meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock Keeping as many of her own furnishings as possible may help make her new environment more like home. The presence of others offers positive stimulation. The ability to discuss concerns with loved ones is an important coping mechanism for most people. Therefore the absence of meaningful conver-sation will result in feelings of isolation, loneliness, anxiety, and depression for the client. Often, this is not apparent until behavioral changes occur.

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