Question 1

The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority?

Accepted Answer

Some antibiotics (e.g., streptomycin, gentamicin, and tobramycin) are ototoxic and permanently damage the auditory nerve, whereas chloramphenicol sometimes irritates the optic nerve. Smell and taste are not as affected.

Question 2

The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care?

Accepted Answer

Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through means such as pointing and gestures. Goals and outcomes need to be realistic and measurable; recovery in 1 day is not realistic. A patient who has expressive aphasia may not be able to speak or write words with a pen and paper. Thickening drinks prevents aspiration risk and is not included in a plan of care for this patient.

Question 3

A nurse is teaching a patient about vision. In which order will the nurse describe the pathway for vision, beginning with the first structure?
1) Lens
2) Pupil
3) Retina
4) Cornea
5) Optic nerve

Accepted Answer

Light rays enter the convex cornea and begin to converge. An adjustment of light rays occurs as they pass through the pupil and lens. Change in the shape of the lens focuses light on the retina. The sensory retina contains the rods and cones (i.e., photoreceptor cells sensitive to stimulation from light). Photoreceptor cells send electrical potentials by way of the optic nerve to the brain.

Question 4

A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?

Accepted Answer

Comfort measures such as washing the face and hands and providing back rubs improve the quality of stimulation and lessen the chance of sensory deprivation. The patient with sensory deprivation needs meaningful stimuli, and therapeutic massage helps establish a humanistic relationship that the patient is missing. All of the other options do not promote patient-nurse interaction and promote further social isolation.

Question 5

A nurse is establishing a relationship with the patient who is severely visually impaired and is teaching the patient how to contact the nurse for assistance. Which action will the nurse take?

Accepted Answer

The nurse should devise a plan of care that is accommodating of the patient's visual deficit. Placing a sticker on the call light allows the patient to page the nurse for assistance as needed. Using family members is not the best option. Making hourly rounds is not sufficient; the nurse needs to ensure that the patient can get in touch at any time. Color coding the call light will not help a severely visually impaired patient.

Question 6

The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a "Do not disturb" sign on the door. A few hours later, the nurse notices a surgeon who is not involved in the patient's care attempting to enter the room. Which response by the nurse is most appropriate?

Accepted Answer

The nurse acts as an advocate for the patient (who is experiencing sensory overload and would benefit from a quiet environment) by firmly and politely asking the surgeon to leave regardless of position in the hospital. A creative solution to decrease excessive environmental stimuli that prevents restful, healing sleep is to institute "quiet time" in ICUs. Data collected from one hospital that implemented 1 hour of quiet time daily found decreased staff and unit noise and improved patient satisfaction. The nurse should not allow anyone to enter unless the patient approves it. Security is not a necessary measure at this time. The nurse should handle the situation with professionalism when addressing the surgeon; scolding the visitor is not appropriate.

Question 7

The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion?

Accepted Answer

Keeping a calendar in the patient's room helps to orient the patient to the dates. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock. The same stimuli need to be present in health care settings. Assessing the patient's level of consciousness is not an action that will directly affect the patient's confusion. A patient observer is unnecessary unless the patient is in danger from the confusion. The nurse should encourage the patient toward recovery but should be sensitive to the time it takes for progression.

Question 8

A home care nurse is inspecting a patient's house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply.)

Accepted Answer

Assess the patient's home for common hazards, including the following: (1) loose area rugs and runner placed over carpeting, (2) poor lighting in stairways, and (3) absence of smoke alarms. Because of reduced depth perception, patients can trip on throw rugs, runners, or the edge of stairs. A bathtub with grab bars is safe and does not need to be addressed. Teach patients and family members to keep all flooring in good repair, and advise them to use low-pile carpeting. Thresholds between rooms need to be level with the floor.

Question 9

A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action by the nursing assistive personnel (NAP) will cause the nurse to praise the NAP?

Accepted Answer

Dressing the left side first will be praised by the nurse. If a patient has partial paralysis and reduced sensation, the patient dresses the affected side first; in this case, the left. A stroke on the right hemisphere affects the left side of the body. The right side or upper and lower extremities are not as effective.

Question 10

The nurse is caring for a group of patients and is monitoring for sensory deprivation. Which patient will the nurse monitor $\bold{most}$ closely?

Accepted Answer

A group at risk includes patients isolated in a health care setting or at home because of conditions such as active tuberculosis. Sensory deprivation occurs when a person has decreased stimulation and limited sensory input. A patient in isolation (airborne precautions) is at risk for sensory deprivation because of limited exposure to meaningful stimuli. A patient in the ICU would be at risk for sensory overload with all the monitors and visitors. A patient with a stroke may have difficulty with tactile sensation but is not at as high a risk for sensory deprivation as is one in isolation. A patient with lung cancer may have deficits, but hospice is present so the patient is at home with others.

Quiz 49: Sensory Alterations