Deck 38: Sensory Perception

Question 1

The nurse is concerned that a client is not aware of being in the hospital.For what aspects of the sensory process should the nurse assess the client?
Standard Text: Select all that apply.

A)Speech
B)Stimuli
C)Receptor
D)Perception
E)Impulse conduction

Answer 1

Stimuli
Receptor
Perception
Impulse conduction

Question 2

A client is experiencing changes in taste.What can the nurse do to improve this client's gustatory sense?
Standard Text: Select all that apply.

A)Suggest eating each food separately.
B)Offer foods with a variety of flavors.
C)Recommend eating foods that are cold.
D)Promote sips of water between eating different foods.
E)Encourage the client to consume foods of different textures.

Answer 2

Suggest eating each food separately.
Offer foods with a variety of flavors.
Promote sips of water between eating different foods.
Encourage the client to consume foods of different textures.

Question 3

A client asks the nurse to please close the door when entering or exiting the room because the noise is more than the client is used to because he lives alone.The nurse identifies the reason for this client's response to sensory stimuli as being due to which factor?

A)Lifestyle
B)Developmental stage
C)Culture
D)Illness

Answer 3

Lifestyle

Question 4

A client has been treated for diabetes mellitus since childhood.Currently,the client's blood glucose reading is 180 mg/dl.For which sensory disturbance should the nurse assess in this client?

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

Question 5

The nurse is concerned that a client is experiencing sensory deprivation.What did the nurse assess to make this clinical decision?
Standard Text: Select all that apply.

A)Excessive sleeping
B)Confusion at night
C)Anger over minor issues
D)Easily distracted
E)Sitting quietly reading a book

Question 6

The nurse suspects a client will develop sensory overload.What characteristics did the nurse observe in the client?
Standard Text: Select all that apply.

A)Ongoing pain
B)Confusion at night
C)Inability to sleep
D)Easily angered
E)Worrying about upcoming diagnostic tests

Question 7

The nurse documents that a client is fully conscious.What did the nurse assess in this client?
Standard Text: Select all that apply.

A)Client responded to verbal stimuli.
B)Client responded to written words.
C)Client oriented to time,place,and person.
D)Client demonstrated poor memory.
E)Client alert.

Question 8

The nurse is planning care for a client who is experiencing dementia.What essential concept should the nurse consider for this planning?

A)Background noise such as music will keep this client calm.
B)Activities should be scheduled at the same time each day.
C)Pain mediation will increase dementia.
D)It is important to talk with the client throughout procedures.

Question 9

The nurse is caring for a client who has difficulty hearing conversation.What intervention should the nurse implement?

A)Use short phrases.
B)Overarticulate words.
C)Vary the volume of the voice.
D)Face the client during conversation.

Question 10

The nurse is providing education for the parents of a 7-month-old child who has just been diagnosed with a hearing loss.What guidance should the nurse provide?

A)Expect that the child will be enrolled in a special hearing intervention program immediately.
B)Keep your child in a quiet environment until additional testing is done.
C)Interventions to support hearing are not useful until the child is at least 9 months old.
D)Hearing loss is not serious until 1 year of age.

Question 11

The nurse suspects that the client has a hearing disorder;however,the client denies not being able to hear.What initial assessment technique should the nurse employ?

A)Schedule a Weber and Rinne test.
B)Observe the client's interaction with significant others.
C)Use an otoscope to visualize the inner ear.
D)Confront the client with the nurse's suspicion.

Question 12

The family of a client in the hospital is concerned about the constant noise in the care area.Which health care professionals have the greatest control over the level of sensory input in the hospital?

A)Physicians
B)Administrators
C)Nurses
D)Planners

Question 13

A client diagnosed with congestive heart failure has been treated for many years with intravenous furosemide (Lasix).What sensory impairment should the nurse assess in this client?

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

Question 14

The client who has the medical diagnosis of Alzheimer's disease is confused and has difficulty interpreting environmental stimuli.Which nursing diagnosis problem statement most accurately describes this client's situation?

A)Acute Confusion
B)Altered Role Performance
C)Disturbed Sensory Perception
D)Disturbed Thought Processes

Question 15

The odor from a hospitalized client's draining wound permeates the room and is very overwhelming and distracting to the client and the staff.What intervention would be most helpful?

A)Spray the room routinely with a floral room spray.
B)Instill a vinegar solution into the wound.
C)Keep the wound dressing dry and clean.
D)Burn a candle in the room.

Question 16

A client is hospitalized for treatment of a new disorder.While admitted,the client receives no telephone calls or visitors.The nurse should assess which aspect of the client's sensory-perception function?

A)Risk for sensory overload
B)Social support network
C)Mental status
D)Environment

Question 17

During review of admission data,the nurse learns that the new client has impairment of kinesthetic sensation.Which nursing intervention should be planned for this client?

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 18

An older client has become very confused since being hospitalized earlier in the week.Prior to this illness,the client exhibited clear thought processing and was able to maintain an independent lifestyle.How should the nurse document this mental state?

A)As reversible confusion
B)As sundown syndrome
C)As delirium
D)As dementia

Question 19

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

A)Walk slightly behind the client.
B)Walk 1 foot in front of the client.
C)Walk on the right side of the client.
D)Walk on the left side of the client.

Question 20

A client can be aroused only with extreme or repeated stimuli.How should the nurse document this client's behavior?

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

Question 21

A client is experiencing acute confusion.What nursing actions would be appropriate for this client?
Standard Text: Select all that apply.

A)Eliminate unnecessary noise.
B)Keep eyeglasses within reach.
C)Place a calendar in the room,and identify each day.
D)Keep the room well lit during waking hours.
E)Provide dark glasses.

Question 22

The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception,Auditory.What would indicate that interventions to address this diagnosis have been successful?

A)Client places hearing aid on beside table when not in use.
B)Client does not respond appropriately to questions.
C)Client demonstrates use and care of hearing aid.
D)Client demonstrates difficulty with problem solving.

Question 23

The nurse is assessing a client for possible sensory deprivation.What findings would indicate the client is at risk for developing this sensory disorder?
Standard Text: Select all that apply.

A)Client has severe pain.
B)Client has impaired vision.
C)Client is unable to ambulate.
D)Client is on medication that alters sensory perception.
E)Client has no family in the immediate area.

Question 24

The nurse is concerned that a hospitalized client is experiencing sensory overload.What did the nurse assess to come to this conclusion?
Standard Text: Select all that apply.

A)Sleeplessness
B)Anxiety
C)Apathy
D)Racing thoughts
E)Somatic complaints

Question 25

The nurse is identifying diagnoses appropriate for a client recovering from cataract surgery who lives alone.Which diagnosis would be the priority for this client?

A)Social Isolation
B)Risk for Impaired Skin Integrity
C)Disturbed Sensory Perception
D)Risk for Injury

Question 26

Which recent change,reported by a client's family,would indicate that the client's hearing ability is decreasing?
Standard Text: Select all that apply.

A)Inability to follow directions
B)Mood swings
C)Decreased appetite
D)Complaints of dizziness
E)Answering questions incorrectly