Deck 49: Sensory Alterations

Question 1

A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse will be most appropriate for this patient?

A) "Rinse your mouth several times a day to hydrate your taste buds."
B) "Avoid adding spices or lemon juice to food to prevent nausea."
C) "Blend foods together in interesting flavor combinations."
D) "Eat soft foods that are easy to chew and swallow."

Answer 1

"Rinse your mouth several times a day to hydrate your taste buds."

Question 2

A nurse is describing the transmission of sound to a patient. In which order will the nurse list the pathway of sound, beginning with the first structure
1) Eardrum
2) Perilymph
3) Oval window
4) Bony ossicles
5) Eighth cranial nerve?

A) 1, 5, 2, 4, 3
B) 1, 3, 4, 2, 5
C) 1, 2, 4, 5, 3
D) 1, 4, 3, 2, 5

Answer 2

1, 4, 3, 2, 5

Question 3

A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?

A) Impaired night vision
B) Difficulty hearing low pitch
C) Heightened sense of smell
D) Increased taste discrimination

Answer 3

Impaired night vision

Question 4

A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?

A) The patient frequently cleans out eyes with saline washes.
B) The patient applies different spices during mealtime to food.
C) The patient turns one ear toward the nurse during conversation.
D) The patient isolates self from social situations with groups of people.

Question 5

The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning?

A) Asks the nurse to test the temperature of the water before entering the bath.
B) Places colored stickers on faucet handles to indicate temperature.
C) Replaces all lace-up shoes with Velcro straps for ease.
D) Uses a heating pad on a low setting to keep warm.

Question 6

A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" How will the nurse interpret the finding when the child said that it was sharp?

A) The child's sensation is intact.
B) The child's reception is intact.
C) The child's perception is intact.
D) The child's reaction is intact.

Question 7

The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift?

A) Expressive
B) Receptive
C) Global
D) Motor

Question 8

A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse "Should Istop driving?" Which response by the nurse is most therapeutic?

A) "Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk."
B) "Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can't avoid an accident."
C) "No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go."
D) "No, instead you should see your ophthalmologist and get some glasses to help you see better."

Question 9

A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?

A) Administer a Mini-Mental State Examination (MMSE).
B) Ask the patient to state name, location, and what month it is.
C) Ask the patient's family if the patient is behaving normally.
D) Administer the hearing handicap inventory for the elderly (HHIE-S).

Question 10

The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit?

A) Xerostomia
B) Dysequilibrium
C) Diabetic retinopathy
D) Peripheral neuropathy

Question 11

The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit?

A) Body image disturbance
B) Social isolation
C) Risk for falls
D) Fear

Question 12

The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient?

A) Administer an opioid medication to help the patient sleep.
B) Keep the door open during the night.
C) Open the shades at night.
D) Provide the patient with earplugs.

Question 13

The nurse is using the Snellen chart. Which patient is the nurse assessing?

A) A patient who frequently reports the incorrect time from the clock across the room.
B) A patient who is having difficulty remembering how to perform familiar tasks.
C) A patient who turns the television up as loud as possible.
D) A patient who has trouble saying words.

Question 14

During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further?

A) Neurological deficit
B) Visual deficit
C) Hearing deficit
D) Balance deficit

Question 15

A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected?

A) Perceptual
B) Cognitive
C) Affective
D) Social

Question 16

A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient's plan of care?

A) Teach the patient about special assistive devices.
B) Make the patient talk as much as possible.
C) Obtain an order for antidepressant medications.
D) Place a consult for a home health nurse.

Question 17

A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan?

A) Risk for falls
B) Self-care deficit
C) Social isolation
D) Impaired physical mobility

Question 18

Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability?

A) "Have you stopped reading books or switched to books on audiotape?"
B) "What do you do to protect yourself from injury at work?"
C) "Are you able to prepare a meal or write a check?"
D) "How does your vision impairment make you feel?"

Question 19

The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?

A) Speaking with hands, face, and expressions
B) Using a loud voice, enunciating every syllable
C) Having direct conversation with the patient in the affected ear
D) Repeating the phrase again, if the patient does not understand what the nurse said

Question 20

A nurse is working to prevent blindness. Which preventive action is a priority?

A) Screen young adults early for visual impairments.
B) Include rubella and syphilis screening in the preconception care plan.
C) Instruct parents to report reduced eye contact from their child immediately.
D) Administer eye prophylactic antibiotics to newborns within 24 hours after birth.

Question 21

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

A) Hearing
B) Vision
C) Smell
D) Taste

Question 22

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?

A) Patient will carry a pen and a pad of paper around for communication.
B) Patient will recover full use of speech vocabulary in 1 day.
C) Patient will thicken drinks to prevent aspiration.
D) Patient will communicate nonverbally.

Question 23

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

A) 2, 1, 4, 5, 3
B) 1, 2, 4, 3, 5
C) 4, 2, 1, 3, 5
D) 5, 2, 4, 1, 3

Question 24

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

A) Offer the patient a back rub.
B) Hang a "Do not disturb" sign on patient's door.
C) Ask the patient "Would you like a newspaper to read?"
D) Place the patient in the room farthest from the nurses' station.

Question 25

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?

A) Place a raised Braille sticker on the call button.
B) Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything.
C) Instruct the patient to tell a family member to get the attention of the staff.
D) Color code the call light system.

Question 26

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?

A) Call for security to remove the surgeon.
B) Allow the surgeon to enter.
C) Firmly explain that the patient does not wish to have visitors at this time.
D) Scold the surgeon for not obeying the sign and respecting the patient's wishes.

Question 27

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?

A) Keep a day-by-day calendar at the patient's bedside.
B) Place a patient observer in the patient's room for safety.
C) Assess the patient's level of consciousness and document every 4 hours.
D) Prepare to discharge once the patient is awake, alert, and oriented.

Question 28

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.)

A) Stairway faintly lit
B) Bathtub with grab bars
C) Scatter rugs in the kitchen
D) Absence of smoke alarms
E) Low-pile carpeting in the living room
F) Level thresholds between bathroom and bedroom

Question 29

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?

A) Dressing the left side first
B) Dressing the right side first
C) Dressing the lower extremities first
D) Dressing the upper extremities first

Question 30

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

A) A patient in the ICU under constant monitoring following a myocardial infarction
B) A patient on the unit with tuberculosis on airborne precautions
C) A patient who recently had a stroke and has left-sided weakness
D) A patient receiving hospice care for end-stage lung cancer