Author Question: A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness ... (Read 112 times)

Mr.Thesaxman · **on:** Jul 23, 2018

A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety, and the nurse believes the client is experiencing sensory overload.

Which of the following interventions will be most therapeutic in assisting the client?
1. Limiting interaction with the client to the safe minimum
2. Moving the client to a space furthest from the nursing station
3. Keeping the client's lights dimmed and curtains partially drawn
4. Asking the client's health care provider to consider early discharge to the unit

Question 2

The wife of a 70-year-old client who is recuperating at home from hip replacement surgery ex-presses a concern to the nurse that He must be getting depressed. He just doesn't interact with people like he used to.

Which of the following is the nurse's most therapeutic response?
1. Are there any other signs of depressions?
2. Does he usually enjoy interacting with visitors?
3. Do you think he may be having difficulty hearing what people are saying to him?
4. Well he could be. Do you want me to see if his health care provider will order an antidepressant?

vboyd24 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 3
Constant reorientation and control of excessive stimuli becomes an important part of the client's care. Although the remaining options may have value, they are not the most therapeutic because external stimulation is the most likely cause of the problem.

Answer to Question 2

ANS: 3
A concern with normal age-related sensory changes is that older adults with a deficit are some-times inappropriately diagnosed with dementia or depression. The remaining options assume that depression may be the cause of his personality change.