Deck 30: Sensation, Perception, Response

Question 1

Which statement by the nurse best describes macular degeneration?
1)"The portion of the eye called the macula, which is responsible for central vision, is damaged."
2)"The lens became cloudy, causing blurred vision. This cloudiness will increase over time."
3)"The pressure in the anterior cavity of the eye became elevated, shifting the position of the lens."
4)"There's an irregular curvature of the cornea, causing blurred vision."

Answer 1

1

Question 2

Which nursing diagnosis has the highest priority for a patient with impaired tactile perception?
1)Self-Care Deficit: Dressing and Grooming
2)Impaired Adjustment
3)Risk for Injury
4)Activity Intolerance

Answer 2

3

Question 3

Which intervention is helpful when caring for a patient with impaired vision?
1)Suggest that the patient use bright overhead lighting.
2)Advise the patient to avoid wearing sunglasses when outdoors.
3)Do not offer large-print books because this may embarrass the patient.
4)Place the patient's eyeglasses within easy reach.

Answer 3

4

Question 4

A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss?
1)Otosclerosis
2)Conduction deafness
3)Presbycusis
4)Central deafness

Question 5

Which step would the nurse take first when performing otic irrigation in an adult?
1)Warm the irrigation solution to room temperature.
2)Position the patient so she is sitting with her head tilted away from the affected ear.
3)Straighten the ear canal by pulling up and back on the pinna.
4)Place the tip of the nozzle into the entrance of the ear canal.

Question 6

Which instruction would the nurse include when providing discharge teaching for a patient who has a serious visual deficit?
1)Install blinking lights to alert the patient about an incoming phone call.
2)Have gas appliances inspected regularly to detect gas leaks.
3)Wear properly fitting shoes and socks.
4)Avoid using throw rugs on the floors.

Question 7

Which statement made by the patient indicates an understanding regarding proper ear care following removal of impacted cerumen?
1)"I will use cotton-tipped swabs to clean my ears."
2)"I need to keep my ears moist and avoid dryness."
3)"I will clean my ears weekly with a washcloth, soap, and water."
4)"I need to avoid swimming in the pool until my healthcare provider says I can."

Question 8

A patient comes to the clinic reporting a taste disturbance. Which medication is most likely responsible for this disturbance?
1)Furosemide
2)Phenytoin
3)Glyburide
4)Heparin

Question 9

Which method would the nurse plan to use to assess kinesthetic deficit in a patient?
1)Instruct the patient to read from the Snellen chart.
2)Ask the patient to close their eyes and identify common smells.
3)Have the patient perform alternating rapid movements.
4)Touch the patient using a wisp of cotton.

Question 10

Which assessment finding is considered an age-related change?
1)Presbycusis
2)Hyperopia
3)Increased sensitivity to touch
4)Increased sensitivity to taste

Question 11

Which behavior by a parent indicates an understanding of teaching regarding stimuli used to develop the infant's auditory nervous system?
1)Cuddling
2)Speaking
3)Feeding
4)Soothing

Question 12

Which structure within the brain is responsible for consciousness and alertness?
1)Reticular activating system
2)Cerebellum
3)Thalamus
4)Hypothalamus

Question 13

The nurse checks a patient's pupils using a penlight. Which receptors is the nurse stimulating?
1)Chemoreceptors
2)Photoreceptors
3)Proprioceptors
4)Mechanoreceptors

Question 14

The nurse would expect to document which normal outcome following removal of impacted cerumen?
1)Improved hearing acuity
2)Bloody drainage
3)Decreased sense of smell
4)Severe dizziness

Question 15

The nurse must irrigate the ear of a 4-year-old child. How would the nurse pull the pinna to straighten the child's ear canal?
1)Up and back
2)Straight back
3)Down and back
4)Straight upward

Question 16

Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory?
1)Limit oral hygiene to one time a day.
2)Teach the patient to combine foods in each bite.
3)Assess for sores or open areas in the mouth.
4)Instruct the patient to avoid salt substitutes.

Question 17

A patient reports an impaired sense of smell. Which cranial nerve might have been affected?
1)Trigeminal
2)Glossopharyngeal
3)Olfactory
4)Vagus

Question 18

A patient tells the nurse that since taking a medication, he has suffered from excessively dry mouth. Which assessments would be needed to plan interventions for that symptom?
1)Asking the patient whether foods taste different now
2)Checking the patient's sense of smell
3)Having the patient stand to check for balance
4)Assessing for a history of seizures

Question 19

Which essential oil might the nurse use to uplift and stimulate a patient?
1)Lavender
2)Roman chamomile
3)Rosemary
4)Ylang-ylang

Question 20

A patient reports to the nurse that since taking a medication, he has suffered from excessively dry mouth. Which term would the nurse use to document this complaint?
1)Exophthalmos
2)Anosmia
3)Insomnia
4)Xerostomia

Question 21

Which describes the sensory changes that occur with aging? Select all that apply.
1)Decreased number of nerve conduction fibers results in slower reflexes.
2)The lens of eye becomes less flexible and less able to focus on near objects.
3)Taste buds atrophy and decrease in number, causing decreased ability to perceive taste.
4)Impaired regulation of body temperature causes an increased risk for seizures.
5)The amount and waxiness of cerumen increases with aging.

Question 22

Which findings lead the nurse to suspect sensory overload in a patient in the intensive care unit? Select all that apply.
1)Disorientation
2)Restlessness
3)Hallucinations
4)Depression
5)Preoccupation with somatic complaints

Question 23

The patient at the clinic says to the nurse, "My doctor checked my eyes and told me my vision was 20 over 100 [20/100]. What does that mean?" Which is the best response by the nurse?
1)"This means that your eye pressure readings are quite high and may be indicative of glaucoma."
2)"These are numbers associated with left and right eye readings for identifying macular degeneration."
3)"This could be nearsightedness. Your vision for seeing objects up close is better than your vision for seeing things in the distance."
4)"This could be that you are farsighted. Your vision for seeing objects in the distance is better than it is for seeing objects up close."

Question 24

Which tasks may be delegated to a certified nursing assistant (CNA)? Select all that apply.
1)Irrigating the ear of a child with impacted cerumen
2)Administering eye drops for a patient in a coma
3)Obtaining vital signs every 15 minutes after a seizure
4)Padding the sides of a bed for seizure precautions
5)Suctioning the patient's oropharynx after a seizure

Question 25

Which populations are considered to be at high risk for sensory deprivation? Select all that apply.
1)The homebound
2)Those in prison
3)Those who are depressed
4)Those experiencing high anxiety
5)Those feeling pain

Question 26

For a patient with hearing loss, it is essential to minimize the risk of further damage to the auditory nerve. Which medications may need to be discontinued if the patient is taking them? Select all that apply.
1)Furosemide
2)Digoxin
3)Famotidine
4)Aspirin
5)Penicillin

Question 27

The pediatric nurse educator is preparing a teaching plan for seizure prevention for parents of children with seizures. Which are known to trigger seizures? Select all that apply.
1)Fever
2)Missing a dose of anticonvulsants
3)Sleep deprivation
4)Food allergens
5)Mood-altering substances

Question 28

Which actions would the nurse take to prevent sensory overload? Select all that apply.
1)Leave the television on low volume to block out other noises.
2)Minimize ambient light in the patient's room.
3)Plan care to provide periods of sleep.
4)Speak with a moderate tone of voice.
5)Restrict caffeine intake during hospitalization.

Question 29

Which medical conditions have a direct effect on sensory function contributing to sensory deficits? Select all that apply.
1)Diabetes
2)Hypertension
3)Multiple sclerosis
4)Breast cancer
5)Zinc deficiency

Question 30

Which is the priority nursing diagnosis for a patient with visual impairment?
1)Self-Neglect
2)Social Isolation
3)Risk for Falls
4)Risk for Imbalanced Nutrition: Less Than Body Requirements

Question 31

Which question will the nurse ask an elderly patient to best assess level of orientation?
1)"Will you please repeat these three words for me: glasses, rocket, truck?"
2)"Can you tell me the date of your retirement from your workplace?"
3)"What is your name and today's date? Can you tell me where you are?"
4)"What did you eat for breakfast this morning?"

Question 32

Which factors in a health history place a patient at risk for hearing loss? Select all that apply.
1)Being an older adult
2)Childhood chickenpox
3)Frequent otitis media
4)Diabetes mellitus
5)Congenital rubella

Question 33

Which interventions are necessary to promote patient safety in the unconscious patient? Select all that apply.
1)Talk to the patient while providing care.
2)Incorporate more touch in the plan of care.
3)Give frequent eye care if blink reflex is absent.
4)Keep the siderails up and the bed in low position.
5)Perform diligent oral care by irrigating with diluted mouthwash.

Question 34

Which are some positive effects of pet therapy for residents in a long-term care facility? Select all that apply.
1)Increases socialization
2)Increases blood pressure
3)Decreases pain
4)Decreases loneliness
5)Decreases insomnia

Question 35

Which areas would the nurse include in a mental status assessment for an adult patient? Select all that apply.
1)Behavior
2)Judgment
3)Knowledge
4)Reflexes
5)Appearance

Question 36

For a patient with dementia, how might the nurse best improve orientation and clarity? Select all that apply.
1)Place personal objects where the patient can see them.
2)Introduce yourself each time you have contact with the patient.
3)Encourage the patient to relax while the nurse gives the bath.
4)Encourage the patient to participate in familiar activities.
5)Do not offer many choices when it comes to activities of daily living (ADLs).

Question 37

An 80-year-old patient on the medical-surgical unit says to the nurse, "My vision is blurry, and I see halos around lights. The glare from the sun really bothers me." Upon assessment, the nurse notes a cloudy film over the lens of the eye. Based on the patient's report and the nurse's assessment, the nurse associates these findings with which of the following?
1)Strabismus
2)Cataracts
3)Glaucoma
4)Presbyopia

Question 38

Which interventions are best for preventing sensory deficit for a resident in a long-term care facility? Select all that apply.
1)Talk to the patient as you provide care.
2)Incorporate touch when providing care, as appropriate.
3)Turn on bright, fluorescent light for reading.
4)Encourage waiting to drink water until after the meal.
5)Offer spicy seasoning for the resident to use on food.

Question 39

The nurse in the intensive care unit enters the patient's room and observes the patient is experiencing a seizure. Which are the most appropriate interventions by the nurse? Select all that apply.
1)Insert a padded tongue depressor in the patient's mouth.
2)Turn the patient to his side.
3)Restrain the patient to control his jerking movements.
4)Loosen any restrictive clothing.
5)Pad the siderails of the patient's bed.