Deck 31: Cognitive and Sensory Alterations

Question 1

The nurse is providing discharge education to the patient with diabetes regarding foot care. Which statement by the patient indicates a need for further education?

A) "I can go barefoot outside only in the summer."
B) "I should wear good fitting shoes."
C) "I cannot soak my feet in a hot tub."
D) "I can use lotion on my feet."

Answer 1

"I can go barefoot outside only in the summer."

Question 2

The nurse is caring for a patient who suffered a stroke on the right side of the brain. The nurse is careful to implement what safety measures?

A) Puts a picture board in the room to communicate with the patient.
B) Places the call light on the patient's left side.
C) Leaves a light on in the bathroom at night for good visibility.
D) Places the call light on the patient's right side.
E) Makes sure there are no trip hazards in the patient's room.

Answer 2

Leaves a light on in the bathroom at night for good visibility.
Places the call light on the patient's right side.
Makes sure there are no trip hazards in the patient's room.

Question 3

A nurse is caring for a patient with a stroke that has altered her ability to see. The nurse knows which area of the brain was likely impacted by the stroke that is responsible for visual function?

A) Parietal lobes
B) Frontal lobes
C) Occipital lobes
D) Temporal lobes

Answer 3

Occipital lobes

Question 4

The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need for further education?

A) "I should make sure the passageways are wide."
B) "I should remove all the throw rugs."
C) "I should keep the lights dim."
D) "I can use a cane to feel for objects in front of me."

Question 5

The nurse is providing discharge instructions to an older adult who is being discharged with orthostatic hypotension. Which response by the patient indicates a need for further education?

A) "I should take my blood pressure once a day at home."
B) "I should get up quickly to avoid my blood pressure dropping."
C) "I should drink plenty of water during the day."
D) "I should get up slowly and carefully."

Question 6

The nurse notices her 50-year-old patient is holding the lunch menu at arm's length while trying to read the choices. The nurse knows this is an indication of which condition?

A) Retinopathy
B) Presbyopia
C) Cataracts
D) Macular degeneration

Question 7

The nurse recognizes which goal to be appropriate for the patient with a Nursing diagnosis of social isolation?

A) The patient will participate in cognitive exercises.
B) The patient will interact with other residents during activities.
C) The patient will communicate basic needs through use of photos.
D) The patient will remain within the unit while in long-term care.

Question 8

The nurse is providing education to the family of a patient being discharged with dementia. Which statement by the family indicates an appropriate level of understanding of dementia?

A) "The condition is permanent and has an acute onset."
B) "Alzheimer is the most common type of dementia."
C) "The condition worsens over time."
D) "I should observe for wandering behavior."
E) "Agitation can be worse in the evening."

Question 9

The nurse is performing a health history to determine the patient's cognitive status. Which questions will be best suited to elicit the information needed?

A) "Are you able to drive to the store or do errands?"
B) "Do you have any pain?"
C) "Is your vision blurry?"
D) "Are you able to smell different foods?"
E) "Have you noticed any difficulty adding up numbers?"

Question 10

The nurse is educating the family of a patient in the intensive care unit about the patient's cognitive status, including the current problem of delirium. Which statement by the family indicates a need for further education?

A) "The delirium can be caused by sensory overload."
B) "The delirium is reversible."
C) "The delirium is a mood disorder."
D) "The delirium is a state of confusion."

Question 11

The nurse is performing a health history to determine the patient's sensory status. Which questions will be best suited to elicit the information needed?

A) "Do you ever lose your balance?"
B) "Do you wear glasses?"
C) "Do you like to read the newspaper?"
D) "Can you feel the difference between hot and cold water?"
E) "Do you wear a hearing aid?"

Question 12

The nurse is caring for a diabetic patient who has had a long history of poor glucose control. For what complications is the patient at risk?

A) Sudden loss of consciousness
B) Diabetic retinopathy
C) Stroke
D) Peripheral neuropathy
E) Memory loss

Question 13

The nurse is assessing the patient's ability to hear and knows which is the correct procedure for the doing this?

A) The nurse whispers to the patient while standing on each side of the patient.
B) The nurse speaks in a normal voice while standing on each side of the patient.
C) The nurse speaks in a normal voice while standing directly in front of the patient.
D) The nurse speaks in a normal voice while standing slightly behind the patient.

Question 14

The nurse is educating the family to care for a patient at home with cognitive alterations. Which statement by the family indicates a need for further education?

A) "I should keep the home free of scissors."
B) "I should minimize the number of visitors."
C) "I should use push-button door locks."
D) "24-hour supervision may become necessary."

Question 15

The nurse is delegating care to an unlicensed assistive personnel (UAP) to a patient who has sensory overload. Which statement by the UAP indicates a need for further orientation?

A) "I should keep the noise levels low."
B) "I should schedule all the care together."
C) "I should keep the room well lit."
D) "I should allow the family to visit."

Question 16

The nurse is caring for a patient with depression. Which statement by the patient indicates a need for further education?

A) "Depression can be caused by chemical changes in the brain."
B) "Depression is always treated with medication."
C) "Depression is a mood disorder."
D) "Depression can have a rapid onset."

Question 17

The nurse identifies which goal to be most appropriate for the Nursing diagnosis of acute confusion?

A) The patient will use the call light before getting out of bed within 48 hours.
B) The patient will use a calendar to remember the date within 48 hours.
C) The patient will respond appropriately to questions about place within 48 hours.
D) The patient will remain within the unit while in long-term care.

Question 18

The nurse is caring for a patient who is complaining of tingling in the hands and fingers. The nurse knows this is a sign of what electrolyte imbalance?

A) Hyponatremia
B) Hypernatremia
C) Hypocalcemia
D) Hypercalcemia

Question 19

The nurse is completing an assessment of an older adult and notices some cognitive impairment not normally associated with aging. Which of these alterations would prompt further follow-up?

A) The patient does not remember where her son lives.
B) The patient is unable to balance her checkbook.
C) The patient got lost in a city she never traveled to before.
D) The patient often has difficulty remembering words.
E) The patient got lost going to her usual grocery store.

Question 20

The family of a patient who was in a motor vehicle accident tells the nurse "I'm just not the person I was before the crash." The nurse recognizes this is likely because of the injury to what area of brain?

A) Parietal lobes
B) Frontal lobes
C) Occipital lobes
D) Temporal lobes

Question 21

The nurse is caring for a patient with expressive aphasia. Which interventions will assist the nurse in communicating with the patient?

A) Use simple phrases.
B) Speak loudly.
C) Use yes/no questions.
D) Use a picture board.
E) Be patient and unrushed.

Question 22

The nurse is preparing discharge instructions for a patient who has tactile alterations in his legs. Which instructions would be included?

A) Verify bath water temperature is approximately 39.5 °C.
B) Do not use hot or cold therapy on any extremity.
C) Use sturdy shoes when walking outside or on hard surfaces.
D) Report any changes in skin color on your legs to your health care provider.
E) Set your water heater so that scalding is not possible.

Question 23

The nurse is preparing discharge instructions for a patient who has equilibrium alterations. Which instructions will the nurse include?

A) Use grab bars in the tub and/or shower at home.
B) Keep rooms well-lit and focus ahead when walking.
C) Change positions quickly to avoid dizziness.
D) Use a cane or walker for stability.
E) Ride in the back seat of the car and look ahead.

Question 24

The nurse is caring for a patient who is hospitalized with cognitive impairment and recognizes which interventions will assist the patient in orientation?

A) Keep a photo of the family in the room.
B) Use a clock on the wall.
C) Make sure the room is kept bright and well lit.
D) Avoid moving the patient from room to room.
E) Have each nurse introduce himself or herself to the patient.

Question 25

The nurse is caring for a patient with receptive aphasia. Which interventions will assist the nurse in communicating with the patient?

A) Use simple phrases.
B) Speak louder than usual.
C) Stand in front of the patient.
D) Use a picture board.
E) Be patient and unrushed.