Deck 39: Sensory Perception

Question 1

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?

A) Vary the volume of voice through sentences.
B) Face the client during conversation.
C) Use short phrases.
D) Overarticulate words.

Answer 1

Face the client during conversation.

Question 2

The client has had a cerebral vascular accident (CVA) and now cannot speak. It is unclear from assessment if the client understands spoken words. What NANDA-I nursing diagnosis problem statement would be used for this client?

Answer 2

Disturbed Sensory Perception: Auditory

Question 3

The client who has the medical diagnosis of Alzheimer's disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis problem statement most accurately describes this client's situation?

A) Disturbed Thought Processes.
B) Altered Role Performance.
C) Disturbed Sensory Perception.
D) Acute Confusion.

Answer 3

Disturbed Thought Processes.

Question 4

The nurse is providing education for the parents of a newborn. What advice should the nurse provide in respect to hearing loss screening?

A) Newborns' hearing is not developed until they are post-neonatal stage, so screening should occur at around 4-6 weeks.
B) Hearing loss is not serious until 1 year of age.
C) Hearing loss can only be detected after 6 months old so screening for hearing loss should occur between 6 and 9 months of age.
D) Expect that your newborn will be screened before you take the baby home from hospital.

Question 5

The middle-aged client reports having diabetes mellitus since childhood. Today's blood glucose reading is 180. Because of this history, the nurse would monitor this client for which sensory disturbance?

A) Loss of ability to taste.
B) Loss of ability to smell.
C) Hearing loss.
D) Vision loss.

Question 6

An older client has become very confused since being hospitalised earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How would the nurse document this mental state?

A) As delirium.
B) As sundown syndrome.
C) As dementia.
D) As reversible confusion.

Question 7

The nurse is assessing a client who was just brought to the emergency department. The client can be aroused only with extreme or repeated stimuli. How should the nurse describe this client in a report to the ED physician?

A) Somnolent.
B) Disoriented.
C) Semicomatose.
D) Comatose.

Question 8

Which assessment findings would the nurse interpret as being possible signs of sensory overload in a hospitalised client?

A) Sleeplessness.
B) Anxiety.
C) Apathy.
D) Racing thoughts.
E) Somatic complaints.

Question 9

The odour from a hospitalised client's draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful?

A) Instil a vinegar solution into the wound.
B) Burn a candle in the room.
C) Spray the room routinely with a floral room spray.
D) Keep the wound dressing dry and clean.

Question 10

A nurse is visiting an elderly client who lives at home alone and has no family supports. The nurse observes that the client is becoming increasingly depressed and focused on her health problems. The nurse encourages the client to:

A) consider having a pet dog that needs daily walks.
B) increase the amount of rest and sleep the client has.
C) undertake stress management therapies.
D) set up a daily schedule of what to expect.

Question 11

The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this intervention?

A) Walk on the left side of the client.
B) Walk about half a metre in front of the client.
C) Walk on the right side of the client.
D) Walk slightly behind the client.

Question 12

Sensoristasis is a term used to describe when a person:

A) has cessation of cognition.
B) has an optimum arousal.
C) can adapt to environmental stimuli.
D) can sleep for long periods.

Question 13

A new client has recently undergone a series of extensive tests for cancer and undergone major surgery. The nurse notices that the client is restless, irritable and having difficulty undertaking activities of daily living. The client is experiencing:

A) sensory deprivation.
B) sensory overload.
C) acute confusion.
D) disorientation.

Question 14

A hospitalised elderly man suddenly does not recognise his daughter and complains that his wife has not visited him, even though she has been dead for five years. The client was clear of mind and thought prior to hospitalisation. What NANDA-I nursing diagnosis problem statement would be used for this client?

Question 15

The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ?

A) Confront the client with the nurse's suspicion.
B) Schedule a Weber and Rinne test.
C) Observe the client's interaction with family.
D) Use an otoscope to visualise the inner ear.

Question 16

The client is being treated in an intensive care unit for a complicated myocardial infarction. The client's family lives 250 kilometres away and is unable to visit. Is this client at greater risk for sensory overload or sensory deprivation?

Question 17

Which of the following clients would be at a higher risk of sensory deprivation?

A) A child in acute pain admitted to the hospital for the first time.
B) An adult in an intensive care unit on continuous monitoring.
C) A resident in a nursing home with impaired hearing.
D) A client living alone with vision and mobility impairment.

Question 18

The client has a long history of congestive heart failure and has been treated with large amounts of intravenous frusemide (Lasix). Based upon this history, for which sensory impairment would the nurse monitor this client?

A) Loss of ability to taste.
B) Vision loss.
C) Hearing loss.
D) Loss of ability to smell.

Question 19

Which recent change, reported by a client's family, would indicate that the client's hearing ability is decreasing?

A) Inability to follow directions.
B) Mood swings.
C) Decreased appetite.
D) Complaints of dizziness.
E) Answering questions incorrectly.

Question 20

During review of admission data, the nurse learns that the new client has impairment of kinaesthetic sensation. Which nursing intervention should be planned for this client?

A) Use only non-irritating soaps for bathing.
B) Use the clock face as a format for describing the position of food on meal trays.
C) Ensure that the client has assistance when ambulating.
D) Provide all teaching materials in very large font.

Question 22

The nurse is planning care for a client who is experiencing dementia. What essential concept should the nurse consider for this planning?

A) Background noise like music will keep this client calm.
B) It is important to talk with the client throughout procedures.
C) Pain mediation will increase dementia.
D) Activities should be scheduled at the same time each day.

Question 23

A nurse working in a nursing home is caring for a client with acute delirium. Which of the following would not be an appropriate strategy to maintain the client's orientation?

A) Eliminate unnecessary noise.
B) Keep room uncluttered.
C) Reduce bright fluorescent lighting during the day.
D) Keep her glasses and hearing aid within reach.

Question 24

Match the following terms with its relevant description.
1. Delirium
2. Dementia
3. Depression
4. Confusion
A. Awakens often during night
B. Visual impairment increases risk
C. Sudden onset
D. Chinese medicine uses ginseng for this