Deck 31: Sensory Perception

Question 1

The nurse is caring for a patient with dementia who becomes agitated every evening.Which intervention by the nurse is best for calming this patient?

A) Encouraging family members to visit only during the day
B) Applying wrist restraints during periods of agitation
C) Playing soft,calming music during the evening
D) Administering lorazepam (a tranquilizer)

Answer 1

Playing soft,calming music during the evening

Question 2

A patient comes to the clinic complaining of a taste disturbance.Which medication that the patient is currently prescribed is most likely responsible for this disturbance?

A) Furosemide,a diuretic
B) Phenytoin,an anticonvulsant
C) Glyburide,an antidiabetic
D) Heparin,an anticoagulant

Answer 2

Phenytoin,an anticonvulsant

Question 3

The nurse must irrigate the ear of a 4-year-old child.How should the nurse pull the pinna to straighten the child's ear canal?

A) Up and back
B) Straight back
C) Down and back
D) Straight upward

Answer 3

Down and back

Question 4

A patient with Parkinson's disease is at risk for which complication?

A) Impaired kinesthesia
B) Macular degeneration
C) Seizures
D) Xerostomia

Question 5

A patient diagnosed with macular degeneration asks the nurse to explain his condition.Which statement by the nurse best describes macular degeneration?

A) "The portion of your eye called the macula,which is responsible for central vision,is damaged."
B) "Your lens became cloudy,causing your blurred vision.This cloudiness will increase over time."
C) "The pressure in the anterior cavity of your eye became elevated,shifting the position of your lens."
D) "There's an irregular curvature of your cornea,causing your blurred vision."

Question 6

A patient who sustained a head injury in a motor vehicle crash has damage to the temporal lobe.This injury places the patient at risk for which type of hearing loss?

A) Otosclerosis
B) Conduction deafness
C) Presbycusis
D) Central deafness

Question 7

Which nursing diagnosis has the highest priority for a patient with impaired tactile perception?

A) Self-Care Deficit: Dressing
B) Ineffective Coping
C) Risk for Injury
D) Activity Intolerance

Question 8

Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory?

A) Limit oral hygiene to one time a day.
B) Teach the patient to combine foods in each bite.
C) Assess for sores or open areas in the mouth.
D) Instruct the patient to avoid salt substitutes.

Question 9

A patient reports a dry mouth after taking a medication.What term should the nurse use to document this symptom?

A) Exophthalmos
B) Anosmia
C) Insomnia
D) Xerostomia

Question 10

Which structure within the brain is responsible for consciousness and alertness?

A) Reticular activating system
B) Cerebellum
C) Thalamus
D) Hypothalamus

Question 11

Which instruction should the nurse include when providing discharge teaching for a patient with a serious visual deficit?

A) Install blinking lights to alert an incoming phone call.
B) Have gas appliances inspected regularly to detect gas leaks.
C) Wear properly fitting shoes and socks.
D) Avoid using throw rugs on the floors.

Question 12

Which step should the nurse take first when performing an otic irrigation in an adult?

A) Warm the irrigation solution to room temperature.
B) Position the patient to be sitting with the head tilted away from the affected ear.
C) Straighten the ear canal by pulling up and back on the pinna.
D) Place the tip of the nozzle into the entrance of the ear canal.

Question 13

After sustaining a stroke,the patient lacks attention to the right side of his body.Which nursing diagnosis best describes the patient's problem?

A) Disturbed Sensory Perception
B) Unilateral Neglect
C) Risk for Peripheral Neurovascular Dysfunction
D) Acute Confusion

Question 14

The nurse checks a patient's pupils using a penlight.Which receptors is the nurse stimulating?

A) Chemoreceptors
B) Photoreceptors
C) Proprioceptors
D) Mechanoreceptors

Question 15

A patient is admitted with an exacerbation of asthma.Which factor places the patient at highest risk for sensory overload?

A) Administering albuterol (a central nervous system stimulant)as needed
B) Administering a tranquilizer intravenously every 2 hours as prescribed
C) Delivering oxygen at 6 L/min via nasal cannula
D) Maintaining complete bedrest in a quiet,dimly lit room

Question 16

Which essential oil might the nurse trained in aromatherapy use to uplift and stimulate a patient?

A) Lavender
B) Roman chamomile
C) Rosemary
D) Ylang-ylang

Question 17

A patient complains of an impaired sense of smell.Which cranial nerve might have been affected?

A) Trigeminal
B) Glossopharyngeal
C) Olfactory
D) Vagus

Question 18

The nurse has been teaching a parent about stimuli to develop her infant's auditory nervous system.Which behavior by a parent toward the child provides evidence that learning occurred?

A) Cuddling
B) Speaking
C) Feeding
D) Soothing

Question 19

Which assessment finding is considered an age-related change?

A) Presbycusis
B) Hyperopia
C) Increased sensitivity to touch
D) Increased sensitivity to taste

Question 20

Which intervention is helpful when caring for a patient with impaired vision?

A) Suggest the patient use bright overhead lighting.
B) Advise the patient to avoid wearing sunglasses when outdoors.
C) Do not offer large-print books,as this may embarrass the patient.
D) Place the patient's eyeglasses within easy reach.

Question 21

The nurse prepares an educational program on age-related sensory changes for a group of community members.What should the nurse include about vision?

A) Tear production increases.
B) Peripheral vision increases.
C) The lens becomes more flexible.
D) Floaters appear in the visual field.

Question 22

The nurse caring in the intensive care unit suspects that one of the patients is experiencing sensory overload.Which finding caused the nurse to have this suspicion? Select all that apply.

A) Disorientation
B) Restlessness
C) Hallucinations
D) Depression
E) Heart palpitations

Question 23

A client with a hearing impairment comes into the clinic for treatment.What action should the nurse take to enhance communicating with this client?

A) Shout.
B) Talk into the most affected ear.
C) Use touch to get the client's attention.
D) Drop the voice at the end of a sentence.

Question 24

Which factors in a health history place a patient at risk for hearing loss? Select all that apply.

A) Being an older adult
B) Childhood chickenpox
C) Frequent otitis media
D) Diabetes mellitus
E) Heart disease

Question 25

A patient reports an excessive dry mouth after starting a new medication.Which assessment would be needed in order to plan interventions for that symptom?

A) Asking the patient whether foods taste different now
B) Checking the patient's sense of smell
C) Having the patient stand to check for balance
D) Assessing for a history of seizures

Question 26

Which action can the nurse take to prevent sensory overload? Select all that apply.

A) Leave the television on to block out other noises.
B) Minimize unnecessary light in the patient's room.
C) Plan care to provide uninterrupted periods of sleep.
D) Speak calmly with a moderate voice volume.
E) Provide a private room and limit visitors

Question 27

For an unconscious patient,which intervention is necessary to provide for patient safety? Select all that apply.

A) Talk to the patient as you provide care.
B) Incorporate more touch in the plan of care.
C) Give frequent eye care if blink reflex is absent.
D) Keep the siderails up and bed in low position.
E) Restrict visitors and keep lighting dimmed.

Question 28

The nurse suspects that a client is experiencing sensory deprivation.Which diagnosis should the nurse select to plan this client's care?

A) Risk for Injury
B) Bathing Self-Care Deficit
C) Ineffective Activity Planning
D) Decreased Diversional Activity

Question 29

The nurse provides care to a client with a visual impairment.Which intervention should the nurse include in this client's plan of care?

A) Call the client by name.
B) Speak loudly to the client.
C) Touch the client before speaking to the client.
D) Position herself to the side of the client.

Question 30

For a particular patient,it has become essential to minimize the risk of further damage to the auditory nerve.Which medication may need to be discontinued if the patient is taking it? Select all that apply.

A) Furosemide,a diuretic
B) Digoxin,a cardiotonic
C) Famotidine,an antacid
D) Aspirin,an analgesic
E) Ibuprofen,an analgesic