Deck 37: Sensory Perception

Question 1

Which of the following measures would promote a therapeutic environment for a person with dementia?

A)Keep explanations to a minimum
B)Allow clients to schedule care
C)Keep activities to a minimum
D)Assign consistent caregivers

Answer 1

Assign consistent caregivers

Question 2

Mr.Clayton,a 60-year-old accountant,has been admitted to the intensive care unit (ICU)with a myocardial infarction.Two days after his admission he states that he is tired and has not slept well since admission.He appears anxious,tense,and seems disoriented at times.Considering Mr.Clayton's symptoms,what nursing measures would be implemented?

A)Encourage environmental changes
B)Encourage visits by family and friends
C)Explain sounds in the environment
D)Encourage the use of crossword puzzles

Answer 2

Explain sounds in the environment

Question 3

The nurse is planning care for Mr.Taylor who is experiencing delirium.Which of the following guidelines are important to consider while providing care to Mr.Taylor?

A)Background music will keep this client calm.
B)Activities should be scheduled at the same time each day.
C)Pain mediation will increase delirium.
D)Talk with the client throughout procedures.

Answer 3

Activities should be scheduled at the same time each day.

Question 4

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

A)Walk about 30 cm behind Mrs.Haeger,allowing her to grasp the nurse's arm
B)Walk about 30 cm in front of Mrs.Haeger,allowing her to grasp the nurse's arm
C)Walk on the right side of Mrs.Haeger,allowing her to grasp the nurse's arm
D)Walk on the left side of Mrs.Haeger,allowing her to grasp the nurse's arm

Question 5

Mrs.Gresham's vision is deteriorating.She tells you that she is having difficulty preparing her meals.Which of the following actions might help to support her visual function?

A)Suggest that she ask her husband to cook the meals
B)Suggest that she get some meals from Meals on Wheels
C)Suggest that she have a home health aide come to prepare her meals
D)Suggest that she use colour-coded dials on her stove

Question 6

During a review of Mr.Dennis's admission data,the nurse learns that he has impairment of kinesthetic sensation.Which nursing measures should be planned for Mr.Dennis?

A)Use the clock face as a format for describing the position of food on meal trays
B)Provide all teaching materials in very large font
C)Ensure that the client has assistance when ambulating
D)Use only nonirritating soaps for bathing

Question 7

Which of the following nursing measures would be included in the care of a client experiencing sensory deprivation?

A)Schedule a routine of care
B)Encourage visits by family and friends
C)Provide new information gradually
D)Plan care to allow for uninterrupted periods of rest

Question 8

Mrs.Avalon,33 years old,is at the health clinic with her 6-month-old daughter for a check-up.What suggestions might the nurse offer Mrs.Avalon about the prevention of sensory impairment?

A)Vaccinations for her daughter
B)Regular screening for diabetes
C)Annual eye exams for her and her husband
D)Screening for mumps before another pregnancy

Question 9

Which of the following would indicate that a client has met the goal of preventing sensory overload?

A)Reports reduced feelings of anxiety
B)Uses assistive devices for communication
C)Reports decreased boredom
D)Makes appropriate use of sensory aids

Question 10

Mr.Gabbard,79 years old,is hospitalized for an exacerbation of congestive heart failure.He does not recognize his daughter and wonders why his wife,who died years ago,has not visited him.What is Mr.Gabbard most likely experiencing?

A)Delirium
B)Sensory overload
C)Dementia
D)Acute sensory deficit

Question 11

Mrs.Ellis's family brought her to her health care provider's office because she was having hallucinations and delusions.These two problems occur with which of the following sensory alterations?

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

Question 12

Kevin,who has had a traumatic brain injury,is physiologically stable but remains in a coma a week after being admitted to hospital.His family stays with him around the clock.Which of the following should the nurse encourage the family to do?

A)Dim the lights and keep noise to a minimum
B)Play music while touching and talking to Kevin
C)Talk to Kevin as if he was conscious
D)Stay back from the bed so as not to disturb Kevin

Question 13

The nurse suspects that Mr.Clayton has a hearing deficit; however,Mr.Clayton denies not being able to hear.Which intervention can the nurse use to improve communication with Mr.Clayton?

A)Turn the radio on to soft music before initiating the conversation
B)Frequently vary the volume of his or her voice throughout each sentence
C)Talk very slowly,in a loud voice into Mr.Clayton's ear
D)Ensure that Mr.Clayton can see the nurse's face easily and that the room is well lit

Question 14

Mr.Clayton,a 60-year-old accountant,has been admitted to the intensive care unit (ICU)with a myocardial infarction.The nurse suspects that Mr.Clayton has a hearing deficit; however,Mr.Clayton denies not being able to hear.What initial assessment technique should the nurse employ?

A)Schedule a Weber and Rinne test
B)Observe Mr.Clayton's interactions with his family
C)Use an otoscope to visualize Mr.Clayton's inner ear
D)Confront Mr.Clayton with the nurse's suspicion

Question 15

Mr.Clayton,a 60-year-old accountant,has been admitted to the intensive care unit (ICU)with a myocardial infarction.Two days after his admission he states that he is tired and has not slept well since admission.He appears anxious,tense,and seems disoriented at times.What type of sensory alteration is Mr.Clayton experiencing?

A)Impulse conduction
B)Cognitive dysfunction
C)Sensory deprivation
D)Sensory overload

Question 16

Mrs.Barnes,a 45-year-old client,reports having diabetes mellitus since childhood.This morning's blood glucose reading is 20.Because of this history,the nurse would monitor Mrs.Barnes for which sensory deficit?

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

Question 17

The nurse is assessing 16-year-old Kevin,who was brought into the emergency room from a motor vehicle accident.Kevin can be aroused only with repeated or intense stimulation.How should the nurse describe this client in a report?

A)Somnolent
B)Disoriented
C)Comatose
D)Semicomatose

Question 18

Mr.Wilkins is a 34-year-old paraplegic hospitalized for pneumonia.He has a history of recent surgery for appendicitis,and an incisional wound infection.He lives at home with his wife and 7-year-old twin sons.What factors place Mr.Wilkins at higher risk for sensory deprivation?

A)Paraplegia
B)Recent surgery
C)Recent wound infection
D)Home care environment

Question 19

Mrs.Carson has a long history of congestive heart failure and has been treated with large amounts of furosemide (Lasix).During this hospitalization,Mrs.Carson is receiving intravenous furosemide.Given her history,for which sensory impairment would the nurse monitor Mrs.Carson?

A)Loss of ability to taste
B)Hearing loss
C)Vision loss
D)Loss of ability to smell

Question 20

Mr.Laberge,a 70-year-old man,was hospitalized earlier in the week.Prior to this illness,Mr.Laberge exhibited clear thought processing and was able to maintain an independent lifestyle.On assessment today,the nurse observes that he is quite confused.How would the nurse document this mental state?

A)Acute confusion
B)Sundowner's syndrome
C)Delirium
D)Dementia

Question 21

The nurse caring for Mrs.Edwards wears a large name tag and introduces herself to the client each time she enters the room.A clock and a calendar have been placed in Mrs.Edwards' room along with photographs of her family.What are these nursing interventions specifically intended to do?

A)Support Mrs.Edwards' hearing deficit
B)Prevent sensory deprivation
C)Support Mrs.Edwards' visual deficit
D)Orient Mrs.Edwards to person,place,and time

Question 22

Three weeks after 86-year-old Mrs.Jorgens is admitted to an extended care facility,she is found yawning and drowsy,her memory is impaired,she seems depressed,and accuses the staff of trying to poison her.Which sensory problem do these manifestations fit?

A)Stereognosis
B)Sensoristasis
C)Sensory deprivation
D)Sensory overload

Question 23

Which of the following would describe a client who has been diagnosed with dementia?

A)Generally normal level of alertness
B)Hypervigilant level of alertness
C)Recent and immediate impaired memory
D)Delusions are common occurrences

Question 24

Which of the following describes the ability to perceive environmental stimuli and respond appropriately?

A)Awareness
B)Sensorium
C)Cognition
D)Stereognosis

Question 25

Which of the following measures would promote safety for Mr.Robinson,a 73-year-old client,post CVA,who has impaired olfactory sense?

A)Smoke detector by the stove
B)Clear uncluttered pathways
C)Adjust temperature on hot water heater
D)Avoid using hot water bottles

Question 26

Mr.Christopher is a 90-year-old client recently admitted to a complex care facility.He is demonstrating signs of sensory deprivation.What nursing assessment needs to be completed before planning care?

A)Determine if deprivation is due to inadequate stimuli or inability to receive or process stimuli
B)Find out from family what activities he did at home
C)Provide a variety of stimuli to determine what may be effective
D)Refer to occupational health for further assessment

Question 27

Mrs.Jorgens,an 86-year-old widow,recently became a resident of an extended care facility.Three days after she was admitted,the nurse found her to be somewhat confused and disoriented about person,place,and time.Which intervention by the nurse would be most appropriate?

A)Use a posey restraint to prevent falls
B)Encourage diversional activities such as watching television
C)Reorient her to place,person,and time as often as possible
D)Use of tactile stimulation when providing care

Question 28

When caring for Mr.Robson,a 70-year-old man with diabetes,you note that he has decreased tactile sensation in his lower extremities.Which safety measure should the nurse emphasize while teaching him?

A)Maintain a constant temperature in the house
B)Wear shoes with rubber soles when going outside
C)Ensure that his socks are snug enough so that they will not fall down
D)Check water temperature on the forearm before getting into the tub