Question 1

Which of the following measures would promote a therapeutic environment for a person with dementia?

Accepted Answer

Assigning consistent caregivers helps to provide familiarity and stability for a person with dementia, which can reduce their anxiety and confusion. It also allows the caregivers to better understand the person's individual needs and preferences, leading to a more personalized and effective care plan. Keeping explanations to a minimum may actually increase confusion and frustration, while allowing clients to schedule care and keeping activities to a minimum may limit social engagement and stimulation, which are important for maintaining cognitive function in people with dementia.

Question 2

Mr.Clayton,a 60-year-old accountant,has been admitted to the intensive care unit (ICU)with a myocardial infarction.Two days after his admission he states that he is tired and has not slept well since admission.He appears anxious,tense,and seems disoriented at times.Considering Mr.Clayton's symptoms,what nursing measures would be implemented?

Accepted Answer

Explaining sounds in the environment can help reduce anxiety and disorientation by making the ICU setting less intimidating and more understandable for the patient.

Question 3

The nurse is planning care for Mr.Taylor who is experiencing delirium.Which of the following guidelines are important to consider while providing care to Mr.Taylor?

Accepted Answer

Maintaining a consistent schedule can help reduce confusion and anxiety in patients with delirium.

Question 4

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

Accepted Answer

When assisting a visually impaired client with ambulation, the nurse should walk slightly ahead, allowing the client to grasp the nurse's arm. This position helps guide the client safely.

Question 5

Mrs.Gresham's vision is deteriorating.She tells you that she is having difficulty preparing her meals.Which of the following actions might help to support her visual function?

Accepted Answer

Colour-coded dials on her stove can help Mrs.Gresham differentiate between the different burners and their settings, making it easier for her to cook her own meals. It also allows her to maintain her independence in the kitchen. The other options involve relying on someone else to prepare her meals, which may not be the most desirable outcome for Mrs.Gresham.

Question 6

During a review of Mr.Dennis's admission data,the nurse learns that he has impairment of kinesthetic sensation.Which nursing measures should be planned for Mr.Dennis?

Accepted Answer

Impairment of kinesthetic sensation refers to the loss of the ability to perceive the position and movement of body parts. This can increase the risk of falls and injury, so it is important to ensure that the client has assistance when ambulating to prevent accidents. Using a clock face format for tray positioning (A) may be helpful for individuals with visual impairments, but it is not directly related to kinesthetic sensation. Providing teaching materials in large font (B) may be helpful for individuals with visual impairments, but again, it is not directly related to kinesthetic sensation. Using nonirritating soaps (D) may be helpful for individuals with skin sensitivities, but it is not specifically related to impairment of kinesthetic sensation.

Question 7

Which of the following nursing measures would be included in the care of a client experiencing sensory deprivation?

Accepted Answer

Encouraging visits by family and friends helps provide sensory stimulation, which is important for a client experiencing sensory deprivation.

Question 8

Mrs.Avalon,33 years old,is at the health clinic with her 6-month-old daughter for a check-up.What suggestions might the nurse offer Mrs.Avalon about the prevention of sensory impairment?

Accepted Answer

Vaccinations for her daughter can prevent sensory impairments such as hearing loss caused by meningitis or rubella, which can both be prevented with routine childhood vaccinations. Regular screening for diabetes, annual eye exams for her and her husband, and screening for mumps before another pregnancy may be important for overall health but are not specifically related to the prevention of sensory impairment in infants.

Question 9

Which of the following would indicate that a client has met the goal of preventing sensory overload?

Accepted Answer

Reduced feelings of anxiety suggest that the client is not overwhelmed by excessive sensory input, indicating that sensory overload has been prevented.

Question 10

Mr.Gabbard,79 years old,is hospitalized for an exacerbation of congestive heart failure.He does not recognize his daughter and wonders why his wife,who died years ago,has not visited him.What is Mr.Gabbard most likely experiencing?

Accepted Answer

Mr. Gabbard is most likely experiencing delirium, which is a sudden change in mental status characterized by confusion, disorientation, and impaired thinking. It is commonly seen in elderly patients who are hospitalized or are suffering from an acute illness. Delirium can cause perceptual disturbances, such as hallucinations or delusions, which may explain Mr. Gabbard's belief that his wife has not visited him even though she is deceased.

Question 11

Mrs.Ellis's family brought her to her health care provider's office because she was having hallucinations and delusions.These two problems occur with which of the following sensory alterations?

Accepted Answer

The answer of Mrs.Ellis's family brought her to her health...

Question 12

Kevin,who has had a traumatic brain injury,is physiologically stable but remains in a coma a week after being admitted to hospital.His family stays with him around the clock.Which of the following should the nurse encourage the family to do?

Accepted Answer

Talking to Kevin as if he was conscious can provide auditory stimulation, which may be beneficial in coma recovery. It helps maintain a connection and can be comforting for both the patient and the family.

Question 13

The nurse suspects that Mr.Clayton has a hearing deficit; however,Mr.Clayton denies not being able to hear.Which intervention can the nurse use to improve communication with Mr.Clayton?

Accepted Answer

Ensuring that Mr.Clayton can see the nurse's face easily and that the room is well lit would help him to better understand the nurse's nonverbal cues, such as facial expressions and gestures, and also help him to read lips if needed. The other options (A, B, C) do not address the issue of possible hearing deficit and may further complicate communication.

Question 14

Mr.Clayton,a 60-year-old accountant,has been admitted to the intensive care unit (ICU)with a myocardial infarction.The nurse suspects that Mr.Clayton has a hearing deficit; however,Mr.Clayton denies not being able to hear.What initial assessment technique should the nurse employ?

Accepted Answer

Observing Mr. Clayton's interactions with his family is a non-invasive and subtle way to assess his hearing capabilities without directly confronting him or requiring specialized tests. This approach can provide initial insights into potential hearing difficulties based on how he responds to conversations and interacts with his family members.

Question 15

Mr.Clayton,a 60-year-old accountant,has been admitted to the intensive care unit (ICU)with a myocardial infarction.Two days after his admission he states that he is tired and has not slept well since admission.He appears anxious,tense,and seems disoriented at times.What type of sensory alteration is Mr.Clayton experiencing?

Accepted Answer

Mr. Clayton is experiencing sensory overload, which occurs when one is exposed to too many stimuli, a common situation in the ICU due to constant noise, lights, and activity. This can lead to symptoms such as anxiety, tension, and disorientation, as described.

Question 16

Mrs.Barnes,a 45-year-old client,reports having diabetes mellitus since childhood.This morning's blood glucose reading is 20.Because of this history,the nurse would monitor Mrs.Barnes for which sensory deficit?

Accepted Answer

High blood glucose levels can lead to diabetic retinopathy, a complication that affects the eyes and can cause vision loss or blindness. Therefore, the nurse would monitor Mrs. Barnes for any changes in vision. Sensory deficits in taste, hearing, or olfactory function are not typically associated with diabetes.

Question 17

The nurse is assessing 16-year-old Kevin,who was brought into the emergency room from a motor vehicle accident.Kevin can be aroused only with repeated or intense stimulation.How should the nurse describe this client in a report?

Accepted Answer

Kevin's condition, where he can be aroused only with repeated or intense stimulation, is best described as semicomatose. This term is used for patients who are in a state between consciousness and coma and require significant stimuli to show any signs of awareness.

Question 18

Mr.Wilkins is a 34-year-old paraplegic hospitalized for pneumonia.He has a history of recent surgery for appendicitis,and an incisional wound infection.He lives at home with his wife and 7-year-old twin sons.What factors place Mr.Wilkins at higher risk for sensory deprivation?

Accepted Answer

Paraplegia places Mr. Wilkins at a higher risk for sensory deprivation. Sensory deprivation is the absence or reduction of stimuli or input to the senses, and paraplegia can limit or eliminate sensations from the lower body. The recent surgery, wound infection, and home care environment may contribute to other risks, but they are not directly related to sensory deprivation.

Question 19

Mrs.Carson has a long history of congestive heart failure and has been treated with large amounts of furosemide (Lasix).During this hospitalization,Mrs.Carson is receiving intravenous furosemide.Given her history,for which sensory impairment would the nurse monitor Mrs.Carson?

Accepted Answer

Furosemide, especially when used in large doses or over a long period, can cause ototoxicity, leading to hearing loss. This is a known side effect of loop diuretics like furosemide.

Question 20

Mr.Laberge,a 70-year-old man,was hospitalized earlier in the week.Prior to this illness,Mr.Laberge exhibited clear thought processing and was able to maintain an independent lifestyle.On assessment today,the nurse observes that he is quite confused.How would the nurse document this mental state?

Accepted Answer

The answer of Mr.Laberge,a 70-year-old man,was hospitalized earlier in the...

Quiz 37: Sensory Perception