Deck 38: Sensory Alterations

Question 1

An older adult patient residing at an adult assisted living facility complains of hearing and visual disturbances.A nurse must be alert to the effects of sensory deprivation that are associated with which of the following?

A) Stable affect
B) Altered perception
C) Improved task completion
D) Decreased need for social interaction

Answer 1

Altered perception

Question 2

A middle-age patient was admitted to the trauma intensive care unit after a motor vehicle accident.The nurse notes that the patient becomes increasingly agitated when visitors stay for an extended period or after nursing interventions.The nurse identifies this as sensory overload.Which of the following would most likely help the patient? (Select all that apply.)

A) Reducing the number of visitors to her room
B) Performing dressing changes with the bath
C) Providing a dedicated period of rest time each afternoon
D) Requesting that health care providers do rounds when the family is available
E) Coordination with other departments for tests and examinations

Answer 2

Reducing the number of visitors to her room
Performing dressing changes with the bath
Providing a dedicated period of rest time each afternoon
Coordination with other departments for tests and examinations

Question 3

A 63-year-old welder who has gone to the clinic for an annual checkup.The patient shares a concern regarding difficulty hearing conversations at the coffee shop in the mornings.After looking in his ears to determine if there is a build-up of cerumen,the nurse tells the patient that the hearing loss may be associated with his occupation or it may be associated with aging.The nurse is aware that hearing loss associated with the aging process is known as which of the following?

A) Tinnitus
B) Ménière's disease
C) Presbycusis
D) Presbyopia

Answer 3

Presbycusis

Question 4

The patient has a methicillin-resistant Staphylococcus aureus (MRSA)infection in an abdominal surgical wound.The patient is in a private room,is receiving vancomycin (Vancocin)for the MRSA,and pain is well controlled with a morphine sulfate patient-controlled analgesia (PCA)pump,and is receiving docusate sodium (Colace)to prevent constipation.During the nurse's rounds,the patient begins complaining of ringing in the ears.Which is the most likely cause for the patient's tinnitus?

A) Surgical anesthesia
B) Morphine sulfate
C) Vancomycin
D) Docusate sodium

Question 5

A nurse is caring for a patient who signs and lip reads.When communicating,the most appropriate nursing action is to do which of the following?

A) Rely on family members to interpret.
B) Speak louder and more distinctly than normal.
C) Sit facing the patient when speaking.
D) Repeat the entire conversation if it is not understood the first time.

Question 6

An older adult patient has been admitted to a busy medical unit.To control environmental stimuli a nurse should do which of the following?

A) Leave the hospital room lights on at all times.
B) Turn off bedside equipment not in use.
C) Leave the window curtains closed at all times.
D) Leave the door open so the patient can hear the staff and feel secure.

Question 7

A school nurse performs a routine screening on a newly transferred school-age child.This nurse is especially interested in discovering the child's medical history regarding middle ear infections.The nurse knows that chronic ear infections are a major contributing factor to which of the following?

A) Respiratory diseases
B) Strep throat
C) High fevers
D) Hearing impairment

Question 8

A family member is accompanying the elderly patient to their follow-up appointment after a recent hospitalization for gastrointestinal problems.The nurse interrupts a discussion between the family member and the patient regarding rancid food in the patient's refrigerator.The family member looks at the nurse and states,"She was trying to eat spoiled food for lunch,it spelled terrible,and she still wanted to eat it." What is the most likely physiological reason that the patient not realizes that the food is spoiled?

A) She has xerostomia.
B) She has a diminished sense of smell.
C) She has a diminished sense of taste.
D) She has a limited vision.

Question 9

A patient has been hospitalized for 5 days and has had no visitors.The nurse observes the patient to be bored,restless,and anxious.The nurse identifies this behavior as which of the following?

A) Sensory deficits
B) Sensory overload
C) Sensory deprivation
D) Changes in attitudes

Question 10

A nursing student is concerned with sensory deprivation among the patients in the nursing home during the clinical rotation.Which of the following could be caused by sensory deprivation? (Select all that apply.)

A) Confusion
B) Anxiety
C) Disorientation
D) Panic
E) Aggressiveness

Question 11

The spouse of a homebound elderly patient voices a concern to the visiting nurse,"I'm having a hard time getting the patient to eat a balanced diet.All the patient wants to eat are sweets." What is the best explanation the nurse can give to the spouse?

A) "Maybe she has a 'sweet tooth.'"
B) "Older adults seem to be able to taste sweet foods best."
C) "I wouldn't worry about it as long as she is eating something."
D) "She is probably getting all the nutrients that she needs."

Question 12

A 16-year-old mother and her newborn come into the clinic for a routine checkup.The mother is concerned that her baby could be deaf because her uncle lost his hearing at a young age.The nurse hits a buzzer and the baby turns toward the sound.The nurse assures the mother that the baby can hear because the baby:

A) was discharged from the hospital without any known problems.
B) is producing ear wax.
C) responds to loud noises.
D) is too long young to determine any type of hearing loss.

Question 13

A home care nurse is conducting a home assessment.The nurse is looking for the presence of sensory alterations.Factors to assess include if any changes have occurred in which of the following? (Select all that apply.)

A) Activities of ADLs
B) Health promotion
C) Has person had visitors
D) Is person wearing hearing aids and glasses
E) Ability to follow a conversation

Question 14

The school nurse is performing periodic screening on preschool children.She is aware that the most common visual problem in childhood is which of the following?

A) Refractive errors
B) Strabismus
C) Congenital blindness
D) Color blindness

Question 15

A nursing student is assisting with ambulation of a blind patient.The patient has hemiplegia of the right side.The best position for the student nurse to assume when ambulating is by standing on the patient's _____ side and walking a half step _____ the patient.

A) left; ahead
B) right; ahead
C) left; behind
D) right; behind

Question 16

An elderly patient with diabetes is seeing the health care provider for complaints of visual changes.The patient explains to the nurse that visual changes include distortion that makes the edges of objects appear wavy.The nurse knows that this is an early sign of which of the following?

A) Cataracts
B) Glaucoma
C) Diabetic retinopathy
D) Age-related macular degeneration

Question 17

A 64-year-old house painter who is seeing his health care provider for his annual checkup.When the nurse asks the patient if they have any health concerns,the patient states,"I don't think my vision is as good as it used to be,things look more yellow than they used to." The nurse knows that this is a visual change in older adults caused by which of the following?

A) Iris yellows
B) Lens yellows
C) Retina is hypersensitive
D) Need for less light to see than when they were in young adulthood

Question 18

A home care nurse visits a new patient.The family asks how the home can be made safer.The nurse's best advice includes which of the following?

A) Using throw rugs to prevent tripping
B) Installing extra incandescent lighting
C) Painting the floor black and white to add perception
D) Installing handrails painted the same color as the walls

Question 19

The student nurse is assisting an elderly patient to get ready for bed.The patient states,"Please make sure you clean my hearing aids." The student nurse knows it is important to keep in mind which of the following when cleaning a hearing aid?

A) Keep the battery in the machine when turned off.
B) Store the hearing aid on the overnight table for easy access at night.
C) Clean the hearing aid with hot water.
D) Use a soft dry cloth to wipe the hearing aid.

Question 20

A patient with poor vision is ready to be discharged.The nurse is educating the patient and family regarding ways to improve vision.The nurse teaches the patient and family to avoid reading materials with shiny surfaces.The rationale for this intervention is which of the following?

A) Glare causes headaches.
B) Glare will reduce visual acuity.
C) Shiny surfaces reflect damaging rays.
D) Too much light is damaging to the eyes.