Deck 49: Sensory Alterations

Question 1

The client has hyperesthesia apparently associated with a neurological trauma.Which of the following is an appropriate nursing intervention in regard to the client's sense of touch?
1) Reminding the client of the need to have frequent tactile contact
2) Keeping the client loosely covered with sheets and blankets
3) Allowing the client to lie motionless
4) Using touch as a form of therapy

Answer 1

2
If a client is overly sensitive to tactile stimuli (hyperesthesia),the nurse must minimize irritating stimuli.Keeping bed linens loose to minimize direct contact with the client and protecting the skin from exposure to irritants are helpful measures.Frequent tactile contact is not an appropriate intervention for the client with hyperesthesia.Allowing the client to lie motionless is not an appropriate intervention for the client with hyperesthesia.Using touch as a form of therapy would not be an appropriate nursing intervention for the client with hyperesthesia.

Question 2

During a community screening,the nurse informs a 50-year-old African American client about the frequency of eye examinations.It is recommended that individuals in this age-group have eye examinations:
1) Every 3 to 4 months
2) Every 6 months
3) Every 1 to 2 years
4) Every 4 years

Answer 2

3
Clients between the ages of 40 and 64 should have an eye examination every 1 to 2 years if there is a family history of glaucoma or if the client is of African ancestry.

Question 3

The nurse is working with older adult clients in an extended care facility.To enhance the clients' gustatory sense,the nurse should:
1) Mix foods together
2) Assist with oral hygiene
3) Provide foods of similar texture and consistency
4) Make sure foods are extremely spicy

Answer 3

2
Good oral hygiene keeps the taste buds well hydrated and will enhance the client's gustatory sense.Taste perception is heightened if foods are eaten separately,are different textured,and are well seasoned.

Question 4

The family of an older client asks the nurse how the stairways and hallways in the home may be enhanced to promote safety.In addition to extra lighting,the nurse recommends the use of paint and decorations that are:
1) Red and yellow
2) Black and white
3) Brown and green
4) Blue and purple

Question 5

For a client with receptive aphasia,which one of the following nursing interventions is the most effective?
1) Providing the client with a letter chart to use to answer complex questions
2) Using a system of simple gestures and repeated behaviors to communicate
3) Offering the client a notepad to write questions and concerns
4) Obtaining a referral for a speech therapist

Question 6

A 79-year-old client drives his car in the local areas near his home.The most appropriate driving tip for the nurse to give this client is:
1) "Go very,very slow so you will have some chance of reacting"
2) "Take your time on long road trips when you are by yourself"
3) "Remember to keep your car maintained with regular checkups"
4) "To avoid sun glare,you should drive at night"

Question 7

During a home safety assessment,the nurse identifies that there are a number of hazards present.Of the following hazards that are noted by the nurse,which one represents the greatest risk for this client with diabetic peripheral neuropathy?
1) Improper water heater settings
2) Absence of smoke detectors
3) Cluttered walkways
4) Lack of bathroom grab bars

Question 8

The client was working in the kitchen and was splashed in the face with a caustic cleaning agent.His eyes were affected,and he was brought to the hospital for treatment.After cleansing and evaluation,his eyes were bandaged.When assisting this client,who has temporary visual loss,to eat the nurse should:
1) Feed the client the entire meal
2) Allow the client to experiment with foods
3) Orient the client to the location of the foods on the plate
4) Assign ancillary personnel to feed the client

Question 9

A client is legally blind in both eyes.Which of the following is the most appropriate statement for the nurse to make to the client regarding providing the client with assistance?
1) "I will walk in front of you,and you can hold onto my belt."
2) "I know that you must need me to be your sighted guide to get around in this facility."
3) "I will warn you of upcoming curbs or stairs."
4) "I will get you a wheelchair so that I can move you around safely."

Question 10

The nurse completes a safety assessment during a home visit to an older adult client.Of the following observations made by the nurse,the one that is of greatest concern for this client who has evidence of sensory impairment is:
1) Low-pile carpeting throughout the home
2) A handrail on the stairs that extends the full length
3) Higher wattage incandescent lighting in all the rooms
4) The gray/black settings on the stove handles

Question 11

The nurse recommends follow-up auditory testing for a child who was exposed in utero to:
1) Excessive oxygen
2) Diabetes
3) Respiratory tract infection
4) Rubella

Question 12

A home safety measure specific for a client with diminished olfaction is the use of:
1) Smoke detectors on all levels
2) Extra lighting in hallways
3) Amplified telephone receivers
4) Mild water heater temperatures

Question 13

The nurse teaches a client that prolonged use of the antibiotic streptomycin may result in:
1) Damage to the auditory nerve
2) Alteration in perception
3) Optic irritation
4) Loss of taste

Question 14

Which of the following occupations poses the least risk for sensory alterations?
1) Waiter
2) Welder
3) Computer programmer
4) Construction worker

Question 15

With advancing age,which of the following normal physiological changes in sensory function occurs?
1) Decreased sensitivity to glare
2) Increased number of taste buds
3) Difficulty discriminating vowel sounds
4) Decreased sensitivity to pain

Question 16

The client has experienced a cerebral vascular accident (stroke)with resultant expressive aphasia.The nurse promotes communication with this client by:
1) Speaking very loudly and slowly
2) Speaking to the client on the unaffected side
3) Using a picture chart for the client's responses
4) Using hand gestures to convey information to the client

Question 17

The nurse in the pediatric clinic is checking the basic visual acuity of a 4-year-old child.The nurse should have the child:
1) Use the standard Snellen chart
2) Read a few lines from a children's book
3) Follow the peripheral movement of an object
4) Identify crayon colors

Question 18

An older adult client in a nursing home has visual and hearing losses.The nurse is alert to which of the following signs that represents the effects of sensory deprivation?
1) Diminished anxiety
2) Improved task completion
3) Altered spatial perception
4) Decreased need for physical stimulation

Question 19

The nurse has completed the admission assessment for a client admitted to the hospital's subacute care unit.Of the following nursing diagnoses identified by the nurse,the one that takes the highest priority is:
1) Social isolation
2) Risk for injury
3) Risk-prone health behavior
4) Impaired verbal communication

Question 20

The nurse is working with a client with a moderate hearing impairment.To promote communication with this client,the nurse should:
1) Use a louder tone of voice than normal
2) Use visual aids such as the hands and eyes when speaking
3) Approach a client quietly from behind before speaking
4) Select a public area to have a conversation

Question 21

The daughter of a client recently admitted to a skilled nursing facility shares with the nurse that she is concerned about how disinterested her mother seems in everyone and everything around her.The most therapeutic response by the nurse is:
1) "Bring something from home for her to display in her room"
2) "It is most likely just her way of adjusting to leaving her home"
3) "Many of the residents have this problem when they first come here"
4) "Just give her time to adjust;she'll get more involved in a few days"

Question 22

The nurse and a 62-year-old client are discussing the client's sense of hearing.Which of the following assessment questions is most likely to launch a conversation concerning the client's ability to hear effectively?
1) "Do you think you have a hearing problem?"
2) "Do you hear as well as you did 5 years ago?"
3) "Would you rate your hearing as excellent,good,fair,poor,or bad?"
4) "Can you tell me when you believe you started to experience a hearing loss?"

Question 23

The nurse is caring for a newly admitted client who is aphasic.The nurse most therapeutically addresses the communication issue by:
1) Evaluating the client's ability to express his or her needs by writing
2) Asking the client how he or she wants to communicate with the staff
3) Giving the client a pad and a pencil with which to communicate
4) Providing the client with an orientation to the use of the call bell

Question 24

The primary safety issue related to the presence of a taste deficit in a young child is there will most likely be:
1) Little incentive to hydrate
2) No social connection to food
3) Limited food experimentation
4) Little discretion for ill-tasting substances

Question 25

A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety,and the nurse believes the client is experiencing sensory overload.Which of the following interventions will be most therapeutic in assisting the client?
1) Limiting interaction with the client to the safe minimum
2) Moving the client to a space furthest from the nursing station
3) Keeping the client's lights dimmed and curtains partially drawn
4) Asking the client's health care provider to consider early discharge to the unit

Question 26

The nurse and a 69-year-old client are discussing the client's report of "Not hearing as well as I used to;I must be getting old." Which of the following nursing responses is most therapeutic regarding the client's assumption of the cause of the diminished hearing?
1) "What makes you think you don't hear as well as you used to?"
2) "Well,hearing loss does seem to be more of a problem as we age."
3) "You may be right,but I suggest you see an otolaryngologist just to be sure."
4) "Do you turn the television up louder,or is it difficult to hear on the telephone?"

Question 27

The wife of a 70-year-old client who is recuperating at home from hip replacement surgery expresses a concern to the nurse that "He must be getting depressed.He just doesn't interact with people like he used to." Which of the following is the nurse's most therapeutic response?
1) "Are there any other signs of depressions?"
2) "Does he usually enjoy interacting with visitors?"
3) "Do you think he may be having difficulty hearing what people are saying to him?"
4) "Well he could be.Do you want me to see if his health care provider will order an antidepressant?"

Question 28

A 54-year-old client expresses concern about her weakening sense of smell to the nurse during an admission interview.The nurse's most therapeutic response is:
1) "I don't think it is anything to worry about,but you could mention it to your health care provider"
2) "That is really a fairly common complaint of people your age;I don't think there is anything to worry about"
3) "As long as you can smell things like smoke if there is a fire,I think it is something you need to get used to"
4) "As long as you can smell things like smoke if there is a fire,I think it is something you need to get used to"

Question 29

While participating in a community auditory screening,the nurse is alert to the population that has the greatest prevalence of problems.The nurse is aware that hearing impairment is more common for:
1) Whites
2) Asian Americans
3) African Americans
4) Native Americans

Question 30

The nurse is visiting the day care center for routine assessment of the children.After spending time with the children in one of the playrooms,the nurse suspects that a child has a visual deficit as a result of observing:
1) Poor balance and gait
2) An increase in weight
3) Sitting and rocking back and forth
4) A failure to respond when touched

Question 31

The 25-year-old male client who has been in the trauma intensive care unit (ICU)for 3 weeks is confused and agitated.The nurse knows that this can happen to clients in an ICU setting due to:
1) Boredom
2) Sensory overload
3) Pain
4) A lack of stimulation

Question 32

The nurse is discussing eye safety with a group of adults who regularly work around power tools.Which of the following questions should be the initial follow-up to the nurse's inquiry,"Do you own safety glasses?"
1) "Are they in good working order?"
2) "How long have you been using them?"
3) "Do you wear them each time you use your tools?"
4) "What do you think the advantage is to wearing them?"

Question 33

The 85-year-old female client has moved to an assisted living apartment so that she can remain independent yet have some limited assistance with her ADLs.Which of the following suggestions should the nurse make that would be most appropriate to reduce sensory deprivation?
1) Provide pictures of the client's family.
2) Purchase all-new furnishings.
3) Suggest that the client take all her meals in her apartment until she gets the chance to know her neighbors better.
4) Ask family and friends to wait a few days to visit until the client has an opportunity to settle in.

Question 34

The nurse is discussing vision and hearing health with a group of senior citizens.Which of the following individuals should be given special encouragement to have regular eye screenings for the presence of glaucoma?
1) An African American with hypertension
2) An Asian with osteoarthritis in the hands
3) A white with peripheral vascular disease
4) A Hispanic with type 2 diabetes

Question 35

A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety even though the client has been reassured that his or her condition is improving and discharge to the unit will be occurring soon.The cause of the client's emotional state is a result of:
1) Fear of death
2) Social isolation
3) Sensory overload
4) Anxiety disorder

Question 36

It has been determined that a vision problem has contributed to a client's ability to provide self-care regarding bathing,dressing,and toileting.The initial nursing responsibility regarding these deficits is to:
1) Educate the client's family regarding the existing limitations so as to secure their support in meeting needs regarding activities of daily living (ADLs)
2) Arrange for in-home services to facilitate the client's ability to remain as independent as possible regarding ADLs
3) Provide the in-home care provider with sufficient information regarding the client's sensory deficits regarding ADLs
4) Provide sufficient client education regarding the in-home services available to help with ADL needs once discharge has occurred

Question 37

Which of the following statements made by the nurse shows the greatest insight into the possible causes of a hearing-impaired client's irritability?
1) "I know he doesn't hear well,but I wonder if his increased lack of patience today has to do with being in pain."
2) "Not being able to hear us properly appears to be making him irritable today.See if he has his hearing aid turned off."
3) "His hearing aids must need new batteries;he is just so irritable and impatient today."
4) "He is certainly irritable today,but maybe it doesn't have to do with his poor hearing."

Question 38

Which of the following statements made by a client diagnosed with diabetes shows the most informed understanding of the effect of the disease on optic health?
1) "The scariest part about having diabetes is the increased possibility of losing my eyesight."
2) "I have my eyes checked yearly to be aware of any retinopathy that may be developing."
3) "If I do a good job of keeping my blood sugars in line,I won't run such a risk for eye problems."
4) "I try to keep my A1C below 7 so I can minimize the bad effects of hyperglycemia on my eyes."

Question 39

The nurse is preparing a 70-year-old visually impaired male client for home discharge.Which of the following nursing actions will have the greatest impact on the client's safety related to medication administration?
1) Evaluate the client's ability to read the frequency and dosage information on his medication bottles.
2) Watch the client demonstrate the appropriate method for splitting his morning medication in half.
3) Observe the client open and pour out the appropriate number of pills required for his morning medications.
4) Have the client restate the administration schedule and prescribed dosage of each of his home medications.

Question 40

The nurse notes that the 43-year-old male blind client who has had a stroke is not having difficulty recognizing an object by touch.This sense is known as:
1) Stereognosis
2) Auditory
3) Gustatory
4) Olfactory

Question 41

Which of the following safety measures is most important for the nurse to implement for a hospitalized client with a visual impairment?
1) Orient the client to the room.
2) Open the window blinds to let in light.
3) Keep the client's door to the room open so that he or she can be visualized.
4) Keep all four side rails up to remind the client not to get up on his or her own.

Question 42

Following a brain attack,the 45-year-old female client was very confused She was having difficulty responding appropriately to the nurse and to her family members.The client's daughter was concerned that her mother was suffering from a mental breakdown,even though she had no history of mental illness.The best information that the nurse can share with the client's daughter is:
1) "Your mother appears to have aphasia as a result of her stroke."
2) "Your mother will be just fine in no time."
3) "Your mother has been through a lot as a result of her stroke."
4) "We can have a psychiatric workup done if you would like."

Question 43

A 47-year-old male client has come in to his primary health care provider's office for his annual checkup.The client shares with the nurse that his wife thinks he is suffering from hearing loss.Which of the following responses by the nurse would be most appropriate?
1) "You are approaching an age when it is common to start having some hearing loss."
2) "Do you work in a noisy environment?"
3) "You don't seem to have hearing problems to me."
4) "Has anyone else noticed that you are having hearing problems?"