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Question

Difficulty: MediumSensory and Perceptual Alterations

The practical nurse (PN) is observing a client in a long-term care facility's busy dining room. The client, who was recently fitted with new bilateral hearing aids, suddenly becomes visibly agitated, covers their ears with their hands, and attempts to leave the room quickly. In which order should the PN perform the following nursing actions? Arrange the actions from first to last.

  1. 1Approach the client calmly from the front to establish a safe presence.
  2. 2Guide the client to a quiet, low-stimulus environment away from the dining area.
  3. 3Assist the client in lowering the volume settings on the hearing aids.
  4. 4Document the client's reaction to the environmental stimuli and new hearing aids in the medical record.

Answer

The PN must first approach the client calmly, then remove the client from the overstimulating environment, adjust the hearing aids in a quiet space, and finally document the event.
For a client experiencing acute sensory overload, the nursing priority is safety and stimulus reduction. The PN must first approach the client safely, remove them from the overwhelming environment, correct the direct cause of the overload, and conclude with proper documentation.

Step-by-Step Solution

1
Approach the client calmly from the front.
The client sees the nurse and is not startled.
Establishes a non-threatening, therapeutic presence during a moment of acute distress.
2
Guide the client to a quiet, low-stimulus environment.
The client is removed from the excessive noise.
Sensory overload requires immediate reduction of environmental stimuli to prevent escalation of agitation.
3
Assist the client with adjusting the hearing aid volume.
The direct source of auditory amplification is controlled.
Addressing the physical equipment is easier and more effective once the client is in a calmer setting.
4
Document the incident in the client's chart.
The healthcare team is informed of the client's intolerance to the current hearing aid settings in loud environments.
Evaluation and documentation must occur after the client is physically and emotionally stabilized.

Key Concept

Management of Sensory Overload
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Topics

Sensory and Perceptual Alterations

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