Question 1

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?

Accepted Answer

Facing the client during conversation can help them clearly see the nurse's facial expressions and read their lips, which may increase their ability to understand the conversation.

Question 2

The client has had a cerebral vascular accident (CVA) and now cannot speak. It is unclear from assessment if the client understands spoken words. What NANDA-I nursing diagnosis problem statement would be used for this client?

Accepted Answer

Disturbed Sensory Perception: Auditory

Question 3

The client who has the medical diagnosis of Alzheimer's disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis problem statement most accurately describes this client's situation?

Accepted Answer

The client's confusion and difficulty in interpreting environmental stimuli are indicative of disturbed thought processes, which is common in Alzheimer's disease.

Question 4

The nurse is providing education for the parents of a newborn. What advice should the nurse provide in respect to hearing loss screening?

Accepted Answer

The best choice is D because the American Academy of Pediatrics recommends that all newborns be screened for hearing loss before they leave the hospital or at least by 1 month of age. Early detection and intervention are crucial to prevent communication and developmental delays. Waiting until 4-6 weeks (choice A) or 6-9months (choice C) can result in missed opportunities for intervention. Choice B is incorrect because hearing loss is a serious concern and can impact the development of speech and language from a very young age.

Question 5

The middle-aged client reports having diabetes mellitus since childhood. Today's blood glucose reading is 180. Because of this history, the nurse would monitor this client for which sensory disturbance?

Accepted Answer

The middle-aged client with diabetes mellitus since childhood should be monitored for vision loss as diabetes can cause damage to the blood vessels in the retina leading to diabetic retinopathy and potential blindness. High blood glucose levels can exacerbate this condition. Loss of ability to taste or smell, as well as hearing loss, are not directly related to diabetes.

Question 6

An older client has become very confused since being hospitalised earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How would the nurse document this mental state?

Accepted Answer

Delirium is characterized by an acute onset of confusion and a fluctuating course, often related to a specific cause such as hospitalization, infection, or medication. It is distinguished from dementia, which is a chronic and progressive decline in cognitive function, and from sundown syndrome, which refers to increased confusion and agitation during the late afternoon and evening in individuals with dementia. "Reversible confusion" is not a standard medical term for documentation purposes.

Question 7

The nurse is assessing a client who was just brought to the emergency department. The client can be aroused only with extreme or repeated stimuli. How should the nurse describe this client in a report to the ED physician?

Accepted Answer

The client described as being able to be aroused only with extreme or repeated stimuli is best described as semicomatose. This term indicates a state less severe than coma but where the patient is not fully conscious.

Question 8

Which assessment findings would the nurse interpret as being possible signs of sensory overload in a hospitalised client?

Accepted Answer

The answer of Which assessment findings would the nurse interpret...

Question 9

The odour from a hospitalised client's draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful?

Accepted Answer

Keeping the wound dressing dry and clean is the most appropriate intervention to manage the odour from a draining wound. This will help prevent the growth of bacteria and reduce the amount of discharge, thereby minimizing the odour. The other interventions may be ineffective or potentially harmful to the wound and should not be used. Instilling a vinegar solution into the wound can cause damage to the tissue and delay healing, burning a candle can be a fire hazard in a healthcare setting, and spraying the room with a floral room spray can irritate the client's respiratory system and mask the odour without addressing the root cause.

Question 10

A nurse is visiting an elderly client who lives at home alone and has no family supports. The nurse observes that the client is becoming increasingly depressed and focused on her health problems. The nurse encourages the client to:

Accepted Answer

Having a pet dog that requires daily walks can provide companionship, a sense of responsibility, and physical activity, which can help alleviate depression and improve the client's focus away from health problems.

Question 11

The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this intervention?

Accepted Answer

When assisting a visually impaired client with ambulation, the nurse should walk about half a metre in front of the client. This allows the client to follow the nurse's lead, using the sound of the nurse's footsteps as a guide and maintaining a safe distance to prevent collisions.

Question 12

Sensoristasis is a term used to describe when a person:

Accepted Answer

Sensoristasis refers to a state of optimum arousal, where an individual is alert, cognitively engaged, and receptive to environmental stimuli. It is the state where an individual is best suited to learning, problem solving, and decision making.

Question 13

A new client has recently undergone a series of extensive tests for cancer and undergone major surgery. The nurse notices that the client is restless, irritable and having difficulty undertaking activities of daily living. The client is experiencing:

Accepted Answer

The client is likely experiencing sensory overload due to the extensive tests, surgery, and the hospital environment, leading to restlessness and irritability.

Question 14

A hospitalised elderly man suddenly does not recognise his daughter and complains that his wife has not visited him, even though she has been dead for five years. The client was clear of mind and thought prior to hospitalisation. What NANDA-I nursing diagnosis problem statement would be used for this client?

Accepted Answer

The answer of A hospitalised elderly man suddenly does not...

Question 15

The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ?

Accepted Answer

Observing the client's interaction with family can provide valuable information about their hearing ability. The nurse can observe if the client asks for repetition or if they have difficulty understanding conversations. This can provide a more objective indicator of a hearing disorder, rather than relying solely on the client's denial. Confronting the client or using an otoscope may not be appropriate initial assessment techniques, and scheduling a Weber and Rinne test may be premature before gathering more information about the client's hearing ability.

Question 16

The client is being treated in an intensive care unit for a complicated myocardial infarction. The client's family lives 250 kilometres away and is unable to visit. Is this client at greater risk for sensory overload or sensory deprivation?

Accepted Answer

The answer of The client is being treated in an...

Question 17

Which of the following clients would be at a higher risk of sensory deprivation?

Accepted Answer

A client living alone with vision and mobility impairment is at a higher risk of sensory deprivation due to limited sensory input and social interaction.

Question 18

The client has a long history of congestive heart failure and has been treated with large amounts of intravenous frusemide (Lasix). Based upon this history, for which sensory impairment would the nurse monitor this client?

Accepted Answer

Frusemide (Lasix), especially when used in large doses or for a prolonged period, can cause ototoxicity, leading to hearing loss. This is why monitoring for hearing impairment is important in patients receiving this medication.

Question 19

Which recent change, reported by a client's family, would indicate that the client's hearing ability is decreasing?

Accepted Answer

The answer of Which recent change, reported by a client's...

Question 20

During review of admission data, the nurse learns that the new client has impairment of kinaesthetic sensation. Which nursing intervention should be planned for this client?

Accepted Answer

Impairment of kinaesthetic sensation refers to a loss of sense of body position, which can significantly affect a client's balance and coordination. Thus, ensuring that the client has assistance when ambulating is the best nursing intervention to prevent falls and promote safety. Using non-irritating soaps for bathing may be important for clients with skin sensitivity, but it is not directly related to kinaesthetic sensation. Using the clock face format for meal trays may be helpful for clients with visual impairments, but it does not address the issue of kinaesthetic sensation. Providing teaching materials in large font would be appropriate for a client with visual impairments, but it would not be relevant for a client with impairment of kinaesthetic sensation.

Quiz 39: Sensory Perception