The nurse is caring for a client in the intensive care unit. The nurse recognizes that to prevent sensory alteration in a client, the nurse needs to do which of the following interventions? Select all that apply.
orient the client to person, place, and time during every contact
limit visitors to one 15-minute visit per 8-hour shift
explain all nursing care
keep the lighting level consistent throughout the day
Numbers 1 and 3 are correct.
Manage the therapeutic environment to provide an appropriate level of stimuli to the client. Orienting the client and explaining interventions actively engages the client in normal cognitive activities. Limiting visitors to one 15-minute visit per 8-hour shift will produce a nonstimulating environment. The level of lighting should be varied throughout the day to provide the client with a sense of normalcy.
