Deck 43: Sensory Functioning

Question 1

A client tells his nurse that he has difficulty hearing related to working in a loud factory setting for 15 years. What is the term for this condition?

A) Sensory deficit
B) Sensory deprivation
C) Sensory overload
D) Sensory stimulation

Answer 1

Sensory deficit

Question 2

How would a nurse document the condition in which a client has a normal state of awareness?

A) "Aware of self and environment, responsive, well-oriented."
B) "Easily distracted, alternates between drowsiness and excitability."
C) "Disoriented, restless, agitated, hallucinating."
D) "Can't be aroused and does not respond to stimuli."

Answer 2

"Aware of self and environment, responsive, well-oriented."

Question 3

In which of the following health care settings is a client more likely to be at risk for sensory deprivation?

A) Hospital newborn nursery
B) Community health center
C) Emergency department
D) Long-term care

Answer 3

Long-term care

Question 4

A client says, "What is that awful smell?" What sense is being used?

A) Olfactory
B) Gustatory
C) Tactile
D) Auditory

Question 5

After assessing a client, a nurse documents the state of awareness as confused. What part of the brain controls awareness?

A) Cranial nerves
B) Reticular activating system
C) Hypothalamus
D) Medulla

Question 6

A client has an abrupt onset of a cluster of global changes in attention, cognition, and level of consciousness. What would be the most appropriate nursing diagnosis?

A) Acute Confusion
B) Chronic Confusion
C) Impaired Memory
D) Disturbed Sensory Perception

Question 7

A nurse documents the following on a client chart: "client manifests difficulties with spatial orientation, memory language, and changes in personality." What state of arousal/awareness does this describe?

A) Delirium
B) Dementia
C) Confusion
D) Locked-in syndrome

Question 8

Which of the following hospital units is more likely to cause severe sensory alterations?

A) General unit
B) Short-stay surgery
C) Eye clinic
D) Intensive care

Question 9

A client admitted to the hospital for major surgery is at risk for what type of sensory alteration?

A) Sensory deprivation
B) Sensory deficits
C) Sensory overload
D) Sensory stimulation

Question 10

What type of cognitive responses might a nurse assess in a client with sensory deprivation?

A) Uncoordinated movements, altered sense of smell
B) Decreased attention span, difficulty problem solving
C) Apathy, depression
D) Rapid mood changes, anxiety

Question 11

A nurse asks the mother of a hospitalized client age 2 years to bring in his favorite blanket or stuffed animal. What sense is the nurse trying to stimulate with this intervention?

A) Gustatory
B) Visual
C) Tactile
D) Auditory

Question 12

Is it important for a nurse to consider a client's culture when providing physical care?

A) Yes, culture dictates the amount of sensory stimulation considered normal.
B) Yes, the nurse's culture and the client's culture are often different.
C) No, the nurse must provide needed physical care to all clients.
D) No, the nurse is not required to consider culture when providing care.

Question 13

What term is used to describe the sense, usually at a subconscious level, of the movements and position of the body (especially its limbs) independent of vision?

A) Stereognosis
B) Visceral
C) Proprioception
D) Sensory perception

Question 14

A nurse assessing older adults in a long-term care facility is aware that which of the following may result in sensory alterations for these clients?

A) Constipation
B) Anorexia
C) Dry skin
D) Presbyopia

Question 15

A nurse is assessing a client on the first day after major abdominal surgery. Which of the following internal stimuli would be increased and affect client responses?

A) Lights and noise
B) Visitors and caregivers
C) Intravenous lines, pain
D) Ambulating, coughing

Question 16

The nurse is assessing a client's gustatory function. What approach by the nurse will assist in assessing this sensation?

A) "Tell me if the taste on your tongue is sweet, sour, bitter, or salty."
B) "Repeat the words that I speak softly to you."
C) "Please read this paragraph to me."
D) "Close your eyes and tell me what you smell."

Question 17

What intervention is recommended to reduce sensory stimulation for infants in the neonatal ICU?

A) Use bright lights
B) Use limited light
C) Play loud music
D) Avoid touch

Question 18

Which of the following best describes a stimulus?

A) A sense organ that receives a message and converts it into a nerve impulse
B) Conduction along a nerve pathway from the receptor to the brain
C) Reception and translation of an impulse into a sensation
D) An act or agent that initiates a response by the nervous system

Question 19

A home care client has both visual and hearing deficits. Although all of the following are important, what would be a high priority concern when planning and implementing care?

A) Nutrition
B) Comfort
C) Safety
D) Communication

Question 20

A nurse assesses a mother who rocks and cuddles her newborn son. What sense is the mother stimulating?

A) Auditory
B) Kinesthetic
C) Visual
D) Gustatory

Question 21

When a new mother asks the nurse whether her newborn infant can see her, the best response by the nurse is to tell the mother that her infant ...

A) cannot see for 2 weeks of age
B) can differentiate objects only
C) can differentiate colors only
D) can see light and dark patterns

Question 22

A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the client experiencing?

A) Physical
B) Psychological
C) Sensory deficits
D) Sociocultural

Question 23

Which of the following nonpharmacologic, independent nursing interventions may be used to promote relaxation without also causing sensory overload?

A) Talking with the client
B) Playing music the client chooses
C) Watching talk shows the nurse chooses
D) Watching television reality shows that visitors choose

Question 24

The nurse is caring for client 82 years of age who is struggling to adapt to hearing loss as he ages. The nurse performs which of the following interventions to assist the client in adapting to this sensory deficit? Choose all that apply.

A) Make sure he wears his hearing aid.
B) Speak in a lower tone of voice.
C) Speak so he can observe your lip movement.
D) Keep his environment clear of clutter.
E) Orient to person, place, and time frequently

Question 25

A nurse is caring for a client who is unconscious. Which of the following is a recommended guideline for communication with this client?

A) Do not assume the person can hear you.
B) Keep environmental noise level high to stimulate the client.
C) Be careful what is said in front of the client as he or she might hear you.
D) Touch the person before speaking to them.

Question 26

A client in the intensive care unit will experience less sensory overload in which of the following situations?

A) If a clock displays date, time, AM/PM
B) If the nurse silences the alarms
C) If the nurse provides touch every hour
D) If the family visits at all times

Question 27

During the neurological assessment, the nurse asks the client if she has any problems with her sense of smell. The client relates that she lives near a factory that emits an obnoxious odor, but that she no longer notices the smell. The nurse tells Joan that this phenomenon is normal and is called which of the following?

A) Tolerance
B) Adaptation
C) Acceptance
D) Adjustment

Question 28

The nurse is working in a clinic and sees a resident of a long-term-care facility, age 82 years, who has come in to be checked by her physician. The caregiver, who accompanies her, reports that the client has been displaying the following: drowsiness, excessive sleeping, decreased attention span, irritability, and signs of depression. The client's daughter and family, who usually visit her, moved away from the area six weeks ago due to the husband's job. You suspect which of the following problems?

A) Sensory deprivation
B) Disturbed sensory perception
C) Residential psychosis
D) Locked-in syndrome

Question 29

A community health nurse is conducting a seminar on vision self-care. What might be one topic included in the education plan?

A) Wear sunglasses when working outside.
B) Close the eyes when working with chemicals.
C) Use over-the-counter eye drops when necessary.
D) When using aerosol sprays, spray toward self.

Question 30

A nurse is educating a lawn-care worker on the risk of hearing loss. What might be recommended?

A) "Listen to loud music with earphones while mowing."
B) "Just ignore the noise; you are too young for damage."
C) "Wear earplugs while using lawn equipment."
D) "Clean your ears with cotton-tipped applicators daily."

Question 31

A nurse is caring for a person who is delusional. What is important for the nurse to do while communicating with the client?

A) Touch the client gently while talking.
B) Avoid arguing about erroneous statements.
C) Reinforce reality for delusional statements.
D) Maintain eye contact at all times.

Question 32

A nurse is making a home care visit to a client with a hearing deficit. What can she do to facilitate communication with the client?

A) Ask for permission to turn off the television set during the visit.
B) Talk in a loud tone of voice at all times during the visit.
C) Use written communication rather than verbal communication.
D) Reduce the time spent with the client to decrease frustration.

Question 33

During a client assessment, the nurse has the client close his eyes. She then places her finger on his right thigh. She asks the client where he is being touched and he answers "my right thigh." This is an example of which sense?

A) Auditory
B) Visual
C) Kinesthetic
D) Olfactory

Question 34

The nurse is caring for a client who suffered a stroke three days ago, and is assessing the client's state of arousal. The nurse knows that the part of the body responsible for a person being alert or aroused is which of the following?

A) Reticular activating system
B) Renin-angiotensin-aldosterone system
C) Cranial nerves
D) Adrenal glands