Deck 47: Sensory Alterations

Question 1

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 or her ears with a cotton swab.
B)The patient turns one ear toward the nurse during conversation.
C)The patient isolates himself or herself from social situations.
D)The patient asks the nurse to speak loudly during conversations.

Answer 1

The patient turns one ear toward the nurse during conversation.

Question 2

The nurse is caring for a patient with expressive aphasia caused by 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.

Answer 2

Patient will communicate nonverbally.

Question 3

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.

Answer 3

Balance deficit.

Question 4

The nurse is caring for a patient with conductive hearing loss in one ear 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 5

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 which of the following?

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

Question 6

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 7

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.

Question 8

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 determines that the patient is able to care for himself safely when the patient demonstrates which action?

A)Places coloured 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 9

A patient has hyperesthesia associated with a neurological trauma.Which one of the following is an appropriate nursing intervention in regard to the patient's sense of touch?

A)Reminding the patient of the need to have frequent tactile contact.
B)Keeping the patient loosely covered with sheets and blankets.
C)Allowing the patient to lie motionless.
D)Using touch as a form of therapy.

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

Which nursing assessment best measures cognitive functioning?

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

Question 12

A home health nurse is assembling a puzzle with an older 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 13

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)"Practice good oral hygiene to keep your taste buds well hydrated."
B)"Blend foods together in interesting flavour 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 14

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 eating 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 15

A nurse is caring for an older patient who was in a motor vehicle accident because he thought the traffic 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 colours.You need to think about traffic lights 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 16

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

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

Question 17

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 18

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)Providing the patient with a therapeutic back rub.
B)Turning off the alarms on the monitoring devices.
C)Administering an opioid medication to help the patient sleep.
D)Providing the patient with earplugs.

Question 19

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 cheque?"
C)"How do you protect yourself from injury at work?"
D)"How does your vision impairment make you feel?"

Question 20

During a community screening,the nurse notes that a 50-year-old patient is currently taking steroid medications.How often does the nurse recommend that this patient have an eye examination?

A)Every 3 to 4 months.
B)Every 6 months.
C)Every 1 to 2 years.
D)Every 4 years.

Question 21

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.

Question 22

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

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

Question 23

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 24

What nursing action can the nurse implement to comfort an older 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 whether he or she would like a newspaper to read.
D)Placing the patient in the room farthest from the nurses' station.

Question 25

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

A)A patient in the critical care unit (CCU)under constant monitoring after 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 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.