Question 1

The nurse is delegating care to an unlicensed assistive personnel (UAP) to a patient who has sensory overload. Which statement by the UAP indicates a need for further orientation?

Accepted Answer

To prevent or alleviate overload, the nurse reduces sensory stimuli, dimming unnecessary lights and turning down the sound on alarms if possible. Nursing care is planned so that the patient is not constantly disturbed. Visitation by family provides reality orientation and a soothing, recognizable presence for some patients experiencing overload.

Question 2

The nurse is assessing the patient's ability to hear. Which is the correct procedure for the doing this?

Accepted Answer

Hearing ability can be determined by observing the patient's conversation and responses and by talking with the patient in a normal conversational tone while standing slightly behind the patient. If the patient does not respond appropriately, a hearing impairment may exist. Standing in front of the patient allows the patient to read your lips and will not detect a hearing loss. A whispered voice will also give a false reading.

Question 3

The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need for further education?

Accepted Answer

Bright lighting in hallways and stairways prevents falls by the patient who has limited vision. Furniture is placed to allow wide passageways. Throw rugs, which are a tripping hazard, are removed. If vision is severely limited, use of a cane or walking stick held slightly in front helps the patient feel objects in his/her path.

Question 4

An appropriate goal for a patient with the diagnosis of acute confusion is:

Accepted Answer

The patient has acute confusion and therefore an appropriate early goal as the confusion resolves is to remember where they are. Remembering to use a call light would be appropriate for Risk for falls. Using a calendar is appropriate for Impaired memory, and remaining in the unit is appropriate for Chronic confusion.

Question 5

The nurse notices her 50-year-old patient is holding his lunch menu at arm's length while trying to read his choices. This is an indication of:

Accepted Answer

The patient demonstrates presbyopia by holding reading materials at a distance or by being unable to read normal-sized or small print. Retinopathy is damage to the retina and occurs in diabetics. Cataracts are a clouding of the lens. Macular degeneration is a chronic condition that causes loss of vision in the center of your field of vision.

Question 6

An appropriate goal for a patient with a diagnosis of social isolation is:

Accepted Answer

Interacting with others during activities is an appropriate goal to help the patient not feel so alone. Cognitive exercise is a goal for a patient with disturbed thought processes. Communication of basic needs through the use of photos is a goal for a patient with a diagnosis of Impaired verbal communication, and remaining in the unit is appropriate for Chronic confusion.

Question 7

A nurse is caring for a patient with a stroke that has impacted her ability to see. Which area of the brain was likely impacted by the stroke that is responsible for visual function?

Accepted Answer

The occipital lobes process visual information. The frontal lobes of the cerebrum are the areas of the brain responsible for voluntary motor function, concentration, communication, decision making, and personality. The parietal lobes are responsible for the sense of touch, distinguishing the shape and texture of objects. The temporal lobes are concerned with the senses of hearing and smell.

Question 8

You are providing education to the family of a patient being discharged with dementia. Which statement by the family indicates a good level of understanding of dementia? (Select all that apply.)

Accepted Answer

Dementia, which is a permanent decline in mental function, has a subtle onset. The most common type of dementia is Alzheimer's disease. Dementia is not reversible and worsens over time. Behavioral problems that arise in dementia patients include wandering, agitation, repetitive behaviors, and sundowning, or worsening of agitation and confusion in the evening.

Question 9

The nurse is caring for a patient who is complaining of tingling in her hands and fingers. The nurse knows this is a sign of what electrolyte imbalance?

Accepted Answer

Tactile disturbances, such as tingling and numbness around the mouth and in the fingers, are signs of hypocalcemia. Mental changes are associated with both hypercalcemia and hypocalcemia. Both hypernatremia and hyponatremia have symptoms of central nervous system disorder.

Question 10

The nurse is caring for a patient with depression. Which statement by the patient indicates a need for further education?

Accepted Answer

Depression is usually reversible with treatment either by eliminating the underlying cause, providing counseling, or prescribing antidepressive agents. Depression is a mood disorder and is believed to be caused by chemical changes in the brain. Depression usually has a rapid onset, and the patient's mood is constant.

Question 11

The nurse is caring for a patient who suffered a stroke on the right side of the brain. The nurse is careful to implement what safety measures? (Select all that apply.)

Accepted Answer

If the damage is on the right side of the brain, there is loss of sensation and motor function in the extremities on the left side of the body and visual-spatial problems occur. Therefore placing the call light on the side where the patient is likely to be strong is important. The patient will not necessarily have communication problems but might have visual problems, so the bathroom light is helpful. If the damage is on the left side of the brain, there is loss of sensation and motor function in the extremities on the right side of the body and problems with speech occur.

Question 12

The nurse is performing a health history to determine the patient's cognitive status. Which questions will be best suited to elicit the information needed? (Select all that apply.)

Accepted Answer

Smell is a sensory function. Driving and adding numbers relates to cognitive ability. Asking about being sad helps understand mood, and asking if they live with anyone helps understand social status.

Question 13

The nurse is completing her assessment of an older adult and notices some cognitive impairment not normally associated with aging. Which of these alterations would prompt further follow-up? (Select all that apply.)

Accepted Answer

Symptoms of cognitive impairment include disorientation, loss of language skills, loss of the ability to calculate, poor judgment, and memory loss. If a patient exhibits these symptoms, further investigation is needed. Some decline in cognitive function occurs with aging, such as the ability to navigate easily in new areas.

Question 14

The nurse is performing a health history to determine the patient's sensory status. Which questions will be best suited to elicit the information needed? (Select all that apply.)

Accepted Answer

Balance, eyesight, hearing and sensation are all sensory function. Asking the patient if he/she reads the newspaper is a question to determine if he/she can read or understand what is read and is aimed at cognition.

Question 15

The nurse is providing discharge education to her patient with diabetes regarding foot care. Which of the following statements by the patient indicates a need for further education?

Accepted Answer

Diabetic patients should not go barefoot outside even in the summer as they often have neuropathy, which decreases the patient's ability to discern touch, especially in the lower extremities. This can lead to foot injuries that can become infected and are slow to heal. The patient should wear good fitting shoes, should avoid extreme temperatures, and can use lotion to keep their skin moist to avoid overly dry skin.

Question 16

The nurse is providing discharge instructions to an older adult who is being discharged with orthostatic hypotension. Which of the following responses by the patient indicates a need for further education?

Accepted Answer

In orthostatic hypotension, dizziness and loss of consciousness may occur if a patient changes position too quickly. Instead they should change positions slowly. A patient can take their blood pressure at home to monitor it, and drinking water will keep them hydrated.

Question 17

The family of a patient who was in a motor vehicle accident tells you he "just isn't the same person before the crash." You know this is likely because of the injury to what area of his brain?

Accepted Answer

The frontal lobes of the cerebrum are the areas of the brain responsible for voluntary motor function, concentration, communication, decision making, and personality. The parietal lobes are responsible for the sense of touch, distinguishing the shape and texture of objects. The temporal lobes are concerned with the senses of hearing and smell. The occipital lobes process visual information.

Question 18

The nurse is educating the family to care for a patient at home with cognitive alterations. Which statement by the family indicates a need for further education?

Accepted Answer

Use of door locks that require a key may be necessary if the patient wanders. Keep the environment free of hazards such as sharp objects, and minimize distractions. If the patient is not safe to be left alone, 24-hour supervision may be necessary.

Question 19

The nurse is caring for a diabetic patient who has had a long history of poor glucose control. For what complications is the patient at risk? (Select all that apply.)

Accepted Answer

Long-term complications of hyperglycemia may contribute to cognitive and sensory deficits such as memory loss. They also can lead to diabetic retinopathy, peripheral neuropathy, and stroke. Loss of consciousness is usually seen with hypoglycemia.

Question 20

The nurse is educating the family of a patient in the intensive care unit about the patient's cognitive status, including her current problem of delirium. Which statement by the family indicates a need for further education?

Accepted Answer

Delirium is a reversible state of acute confusion. It is characterized by a disturbance in consciousness or a change in cognition that develops over 1 to 2 days and is caused by a medical condition. Delirium may occur in intensive care patients as a result of sensory overload. It is not a mood disorder.

Quiz 31: Cognitive and Sensory Alterations