Question 1

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 inability to sleep.Which action by the nurse is most appropriate for this patient?

Accepted Answer

Giving the patient control over stimuli helps to decrease the frustration that results from sensory overload.Adding additional stimuli such as a back rub can increase sensory overload.Turning off monitors and alarms is unsafe; the nurse needs to be aware of critical situations.Opioid medications should not be the first option; however,antianxiety medications and sleep aids may be considered.

Question 2

Which nursing assessment best measures cognitive functioning?

Accepted Answer

The MMSE is a formal diagnostic tool that is used to assess a patient's level of cognitive functioning.Asking the patient orientation questions evaluates only the patient's orientation to self and surroundings,not abstract reasoning or critical thinking ability.Family members are not the most reliable source of information about the patient,although information received from the family should be considered.Reading a paper is not a means of comprehensive assessment; in addition,a patient may be high cognitive functioning and not know how to read English.

Question 3

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

Accepted Answer

Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems.The other options do not address taste- or nutrition-related concerns.

Question 4

The nurse is creating a plan of care for a patient with glaucoma.Which nursing diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for injury?

Accepted Answer

A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles.Body image disturbance,social isolation,and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however,they do not address the greatest risk for injury.

Question 5

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

Accepted Answer

To best understand how vision is affecting self-care ability,the nurse wants to target questions to encompass what self-care tasks the patient has difficulty doing,such as preparing meals and writing checks.Switching to books on audiotape gives the nurse an idea of the severity of the deficit,but not its impact on activity of daily living.Assessing whether the patient is taking measures to protect himself is important,but this does not address self-care activities.Emotional assessment of a patient is also important but does not properly address the goal of determining the effect of visual alterations on self-care ability.

Question 6

What is the involuntary motion of retracting the body from painful stimuli?

Accepted Answer

Reaction is how a person responds to a perceived stimulus.Perception occurs when the person becomes conscious of stimuli and interprets information signals.Reception refers to receiving stimuli and creating a nerve impulse.Sensation is the combination of all three combined.

Question 7

A nurse is caring for an elderly patient who was in a motor vehicle accident because he thought the stop light was green.The patient asks the nurse if he should no longer drive.Which response by the nurse is most therapeutic?

Accepted Answer

Part of the normal aging process is an inability to see colors.Much as with a younger adult who is color blind,the nurse should teach the patient new ways to adapt to his deficit.This patient's accident was not due to impaired cognitive function or reflexes.Glasses will not assist the patient in color discrimination.

Question 8

A home health nurse is assembling a puzzle with an elderly patient and notices that the patient is having difficulty connecting two puzzle pieces.The nurse knows that this is most likely related to which aspect of sensory deprivation?

Accepted Answer

Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction.Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn.Affective problems include boredom and restlessness; the patient is participating in an activity.The patient is socializing with the home health nurse,so isolation is not a problem.

Question 9

The nurse would utilize the Snellen chart for assessment of which patient?

Accepted Answer

The Snellen chart is used to assess vision using a distance of 20 feet.Difficulty remembering how to perform familiar tasks indicates the need to further assess mental status.Turning the television up louder indicates the need for a hearing assessment.Holding a newspaper 2 inches from the face indicates the need for assessment of near vision.

Question 10

Which of the following sensory changes are normal with aging?

Accepted Answer

Night vision becomes impaired as physiological changes in the eye occur.Older adults lose the ability to distinguish high-pitched noises and consonants.Senses of smell and taste are also decreased with aging.

Question 11

A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis.Which assessment of the patient would indicate an adaptation to the sensory deficit?

Accepted Answer

Adaptation for a sensory deficit indicates that the patient alters his behavior to accommodate for his sensory deficit,such as turning the unaffected ear toward the speaker.Cleaning the ear would not have an effect for a patient with presbycusis.Avoiding others because of a sensory deficit is maladaptive.Asking the nurse to speak loud alters the environment but does not adapt the patient's behavior.

Question 12

The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has _____ aphasia.

Accepted Answer

Receptive aphasia occurs when patients have difficulty understanding spoken and written word.Expressive aphasia is seen when the patient has difficulty speaking or writing words.Broca and Wernicke refer to areas of the brain where language is processed.

Question 13

Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment?

Accepted Answer

In focusing on the psychological aspect of care,the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment.Both self-care deficit and fall risk are physiological risks for the patient.Impaired physical mobility would not apply to this patient.

Question 14

The home health nurse is caring for a patient with a tactile deficit; the nurse is concerned about injury related to inability to feel harmful stimuli.The nurse evaluates that the patient is able to safely care for himself when the patient demonstrates which action?

Accepted Answer

By placing color-coded stickers and other reminders about dangerous stimuli,the patient is able to safely keep up hygiene.Asking the nurse to test the water does not promote independence,although it does promote safety.Zipper and Velcro clothing is easier for a patient with a tactile deficit to wear,and shower caps allow the patient to stay well groomed with minimal effort.Leaving the lids off of medications can be dangerous,as can placing all medications out at once.It may be difficult for the patient to sort through mixed medications and select the correct types and numbers of pills.

Question 15

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?

Accepted Answer

Using gestures other than just speaking helps the patient understand what you are saying and makes it a meaningful stimulus.Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones.If the patient does not understand the first time,try rephrasing instead of repeating the message.The nurse can direct conversation toward the patient's unaffected ear.

Question 16

Often blindness occurs during childhood.Which health preventative measure is most appropriate to prevent vision impairment?

Accepted Answer

Actions to prevent blindness must occur before vision impairment takes place.Screening for diseases that affect development of vision in the fetus is a preventative measure.Vision testing after birth is important to begin steps to correct or identify the problem early on so the child can develop as normally as possible.Prophylactic antibiotics are not appropriate for all newborns.Reporting reduced eye contact is recommended but is not a preventative measure.

Question 17

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 would be most appropriate for this patient?

Accepted Answer

Good oral hygiene is important to stimulate and hydrate taste buds.Having an unpleasant taste in the mouth discourages the patient from eating.Avoid blending foods together because this confuses the ability to discriminate flavors and taste.Texturized,spicy,and aromatic foods stimulate and make eating more enjoyable.

Question 18

A nurse is administering a vaccine to a 4-year-old child who is visually impaired.After the needle enters the arm,the child says,"Ow,that was sharp!" The nurse knows that the ability to recognize and interpret stimuli is known as

Accepted Answer

Perception occurs when the person becomes conscious of stimuli and interprets information signals.Reception refers to receiving stimuli and creating a nerve impulse.Reaction is how a person responds to a perceived stimulus.Sensation is a general term that refers to awareness of sensory stimuli through the body's sense mechanisms.

Question 19

A patient informs the nurse that she often becomes nauseated when riding in motor vehicles.The nurse knows that this is related to which sensory deficit?

Accepted Answer

Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position.This disequilibrium can cause nausea and vomiting.The other options would not result in nausea based on movement.

Question 20

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 attempting to eat his meal and is becoming tearful.The nurse includes which intervention in the patient's plan of care?

Accepted Answer

The nurse should include implementations that help the patient adapt to his deficit while maintaining independence.Teaching the patient to use assistive devices allows the patient to care for himself.Changing the type of food the patient eats may not work for every culture,where touching food with fingers is unacceptable,or the patient may not enjoy eating foods that do not require utensils.A home health nurse is not necessary as long as the patient is able to care for himself.Instead of placing the patient on antidepressants,assist the patient in attempting to adapt behavior to the sensory deficit.

Quiz 49: Sensory Alterations