Deck 49: Sensory Alterations

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?

A) Provide the patient with a therapeutic back rub.
B) Turn off the alarms on the monitoring devices.
C) Administer an opioid medication to help the patient sleep.
D) Provide the patient with earplugs.

Answer 1

Provide the patient with earplugs.

Question 2

Which nursing assessment best measures cognitive functioning?

A) Administer a Mini-Mental Status Exam (MMSE).
B) Ask the patient his name, where he is, and what month it is.
C) Ask the patient's family if the patient is behaving normally.
D) Evaluate the patient's ability to read the newspaper.

Answer 2

Administer a Mini-Mental Status Exam (MMSE).

Question 3

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

A) Xerostomia
B) Disequilibrium
C) Cataracts
D) Peripheral neuropathy

Answer 3

Xerostomia

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?

A) Risk for falls
B) Body image disturbance
C) Social isolation
D) Fear

Question 5

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

A) "Have you stopped reading books or switched to books on audiotape?"
B) "Are you able to prepare a meal or write a check?"
C) "How do you protect yourself from injury at work?"
D) "How does your vision impairment make you feel?"

Question 6

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

A) Sensation
B) Reception
C) Perception
D) Reaction

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?

A) "Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk."
B) "Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can't avoid an accident."
C) "No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is illuminated, it means stop, and if the bottom is illuminated, it means go."
D) "No, instead you should see your ophthalmologist and get some glasses to help you see better."

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?

A) Perceptual
B) Cognitive
C) Affective
D) Social

Question 9

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

A) A patient who is having difficulty remembering how to perform familiar tasks
B) A patient who turns the television up as loud as possible
C) A patient who holds his newspaper 2 inches from his face
D) A patient who frequently reports the incorrect time from the clock across the room

Question 10

Which of the following sensory changes are normal with aging?

A) Impaired night vision
B) Difficulty hearing low pitch
C) Increase in taste discrimination
D) Heightened sense of smell

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?

A) The patient frequently cleans out his ears with a cotton swab.
B) The patient turns one ear toward the nurse during conversation.
C) The patient isolates himself from social situations.
D) The patient asks the nurse to speak loudly during conversations.

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.

A) Expressive
B) Receptive
C) Broca's
D) Wernicke's

Question 13

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

A) Self-care deficit
B) Risk for falls
C) Social isolation
D) Impaired physical mobility

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?

A) Places colored stickers on faucet handles to indicate temperature and keeps a thermometer near the tub
B) Asks the nurse to test the temperature of the water before entering the bath
C) Replaces all lace-up shoes with Velcro ones and purchases shampoo caps
D) Dispenses all medications onto a plate for easy access in the morning

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?

A) Speaking in a loud voice, enunciating every syllable
B) Having direct conversation with the patient in his affected ear
C) If the patient does not understand what the nurse is saying, repeating the phrase again
D) Speaking with hands, face, and expressions

Question 16

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

A) Screen young children early for visual impairments.
B) Instruct parents to report reduced eye contact from their child immediately.
C) Include rubella and syphilis screening in the preconception care plan.
D) Administer prophylactic antibiotics to all newborns.

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?

A) "Rinse your mouth several times a day to hydrate your taste buds."
B) "Blend foods together in interesting flavor combinations."
C) "Eat soft foods that are easy to chew and swallow."
D) "Avoid adding spices or aromatic ingredients to food to prevent nausea."

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

A) Sensation.
B) Reception.
C) Perception.
D) Reaction.

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?

A) Neurological deficit
B) Visual deficit
C) Hearing deficit
D) Balance deficit

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?

A) Teach the patient about special devices used to assist patients with eating meals.
B) Order the patient food that does not require utensils.
C) Place a consult for a home health nurse.
D) Obtain an order for antidepressant medications.

Question 21

The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except her location.Which nursing intervention would be effective in orienting a patient with neurological deficit?

A) Assessing the patient's level of consciousness and documenting every 4 hours
B) Keeping a day-by-day calendar at the patient's bedside and having the patient manage it
C) Placing a patient observer in the patient's room for safety
D) Informing the patient that she cannot be discharged unless she is awake, alert, and oriented

Question 22

A nurse is caring for a patient with right-sided weakness following a stroke.Which nursing action would be least effective in promoting positive adaptation of the patient's sensory deficit?

A) Placing the patient's belongings on the affected side
B) Approaching the patient from the affected side
C) Teaching the patient how to create a safe environment
D) Completing sentences that the patient cannot finish

Question 23

A nurse is establishing a relationship with the patient who is visually impaired.Which is the most appropriate method to teach the patient how to contact the nurse for assistance?

A) Place a raised Braille sticker on the call button, and instruct the patient to press for assistance.
B) Instruct the patient to yell at the top of his lungs to get the attention of the staff.
C) Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything.
D) Share cell phone numbers with the patient so he can call the nurse if he needs her.

Question 24

A nurse is caring for a patient who is experiencing vertigo.Which nursing intervention would assist the patient in controlling the vertigo?

A) Increasing fluid intake to 3 liters a day
B) Watching television instead of reading books
C) Avoiding riding in vehicles and making sudden motions
D) Placing several antiemetic patches on the patient

Question 25

The nurse is aware that which patient is most at risk for sensory deprivation?

A) A patient in the ICU under constant monitoring following a myocardial infarction
B) A patient on the unit with tuberculosis on airborne precautions
C) A patient who recently had a stroke and has left-sided weakness
D) A patient receiving hospice care for end-stage brain cancer

Question 26

The nurse is caring for a patient with expressive aphasia from a traumatic brain injury.Which desired outcome should be included in the plan of care?

A) Patient will recover full use of speech vocabulary in 1 week.
B) Patient will carry a pen and a pad of paper around for communication.
C) Patient will thicken drinks to prevent aspiration.
D) Patient will communicate nonverbally.

Question 27

The nurse is caring for a patient who is a well-known surgeon at the hospital.Because of his status,all the hospital's physicians want to be sure to pay him a visit.The nurse notices the patient becoming more agitated and withdrawn with each group of visitors.The nurse asks the patient if he would like a "Do not disturb" sign placed on the door.A few hours later,the nurse notices a physician who is not involved in the patient's care attempting to enter the room.Which response by the nurse is most appropriate?

A) Allowing the physician to enter because he has higher authority than the nurse
B) Calling for security to remove the visitor
C) Firmly explaining that the patient does not wish to have visitors at this time, so do not enter the room
D) Scolding the physician for not obeying the signs on the door and respecting the patient's wishes.

Question 28

What nursing action can the nurse implement to comfort an elderly patient with sensory deprivation to improve meaningful stimuli?

A) Placing a "Do not disturb" sign on the patient's door
B) Offering the patient a back rub
C) Asking the patient if he would like a newspaper to read
D) Placing the patient in the room farthest from the nurses' station

Question 29

The nurse is developing a plan of care for a patient who is having a prosthetic eye placed.Which nursing diagnosis related to patient safety is the priority for the nurse to include in the plan of care?

A) Self-care deficit
B) Risk for injury
C) Anxiety
D) Body image disturbance