Answer to Question 1
Correct Answer: 1, 3, 5
Rationale 1: Pain can contribute to sensory overload.
Rationale 2: Nocturnal confusion is a manifestation of sensory deprivation.
Rationale 3: Sleeplessness can contribute to sensory overload.
Rationale 4: Being easily annoyed is a manifestation of sensory deprivation.
Rationale 5: Worry can contribute to sensory overload.
Answer to Question 2
Correct Answer: 2
Rationale 1: The lack of telephone calls or visitors will not be assessed through assessing the client's risk for sensory overload.
Rationale 2: The degree of isolation a person feels is significantly influenced by the quality and quantity of support from family members and friends. The nurse should assess the client's living arrangements, visitors, and any signs indicating social deprivation, such as withdrawal from contact with others to avoid embarrassment or dependence on others, negative self-image, reports of lack of meaningful communication with others, and absence of opportunities to discuss fears or concerns that facilitate coping mechanisms.
Rationale 3: The lack of telephone calls or visitors will not be assessed through a mental status assessment.
Rationale 4: The lack of telephone calls or visitors will not be assessed through an environmental assessment.