Deck 29: Sensory Perception

Question 1

A client in the intensive care unit becomes very cognizant of the nurse's touch. This is a function of which system?

A) General adaptation syndrome
B) Local adaptation syndrome
C) Reticular activating system
D) Peripheral nervous system

Answer 1

Reticular activating system

Question 2

A client has awakened from a coma after a car accident and states, "I knew about a news story reported during the time I was in the coma." The is an example of the

A) reticular-activating system's stimulation.
B) sleep-latency phase of sleep-wake cycle.
C) circadian rhythm for 24 hours.
D) sensory perception in a conscious process.

Answer 2

reticular-activating system's stimulation.

Question 3

When a person selects, organizes, and interprets sensory stimuli, the process is termed:

A) adaptation.
B) perception.
C) stimulation.
D) preoccupation.

Answer 3

perception.

Question 4

A nursing student is attending the first day of clinical. The student is very alert to the workings of the clinical division and the care of clients. This is an example of:

A) sensoristasis.
B) stimulation.
C) arousal.
D) adaptation.

Question 5

In the process of adaptation, the nursing student prepares for her day in her mind. She tells herself that she can overcome her fears and anxiety to give good care. This is an example of:

A) emotional stability.
B) sensory deprivation.
C) lead time.
D) afterburn.

Question 6

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 73-year-old client with diabetes about insulin administration?

A) Requesting hearing aids to help the client receive information
B) Using numerous handouts and detailed education plan
C) Allowing more time for the processing of the information
D) Demonstrating a wide variety of syringes and techniques

Question 7

An intensive care unit nurse does not notice the noise within the environment. However, the client's family member states, "How can you stand it in here? The lights, sounds, and activity would drive me crazy and I couldn't take it." The nurse has adapted to the:

A) intensive care unit work.
B) intensive care unit environment.
C) threatening stimuli.
D) nursing career.

Question 8

The nurse taking care of a 3-year old who is on a 10-regimen dose of gentamicin should instruct the mother to:

A) have the vision tested in 6 weeks.
B) have the gentamicin levels tested in 6 weeks.
C) have the peripheral nervous system tested in 6 weeks.
D) have the hearing tested in 6 weeks.

Question 9

A client has been hospitalized for 8 days for skin grafting tells the nurse, "I'm bored, depressed, and restless." The nurse determines that the client is experiencing sensory:

A) deprivation.
B) adaptation.
C) perception.
D) overload.

Question 10

A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound and then informed that she demonstrates signs of breast malignancy. The nurse knows that the client is at risk for experiencing sensory:

A) adaptation.
B) deprivation.
C) stimulation.
D) overload.

Question 11

When admitting a wheelchair-bound client with paraplegia to the hospital, the nurse assesses the client for injuries that may occur as a result of sensory:

A) alteration.
B) overload.
C) deprivation.
D) progression.

Question 12

A hospitalized client refuses to eat because she fears that the kitchen personnel are poisoning her food. What is this client experiencing?

A) Hallucinations
B) Anorexia
C) Agoraphobia
D) Delusions

Question 13

A sensory deficit that may arise from the client's eyes being bandaged after eye surgery can result in:

A) depression.
B) psychic blindness.
C) compensation.
D) total disorientation.

Question 14

A client has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the client. When the physician leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing:

A) sensory overload.
B) sensory deprivation.
C) sensoristasis.
D) sensory perception.

Question 15

The nurse is caring for a client who has been placed in respiratory isolation. The nurse understands that the client is at risk for:

A) sensory overload.
B) sensory deprivation.
C) sensoristasis.
D) sensory perception.

Question 16

A student nurse is preparing a presentation on sensory overload. What symptoms of sensory overload should the student include? Select all that apply.

A) Disorientation
B) Sleeplessness
C) Confusion
D) Increased work performance
E) Fatigue

Question 17

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.

A) Depression
B) Increased appetite
C) Sleeplessness
D) Decreased interest in activities
E) Increased interest in interactions with others

Question 18

A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, "Get the bugs off my bed, I can feel them crawling on me!" Which nursing diagnosis is appropriate for this client?

A) Disturbed sensory perception: Kinesthetic related to side effects of medication as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me."
B) Disturbed sensory perception: Tactile as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me."
C) Disturbed sensory perception related to client statement of "Get the bugs off my bed, I can feel them crawling on me."
D) Disturbed sensory perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me."

Question 19

A nurse has just finished a presentation to a group of unlicensed assistive personnels on ways to assist clients with sensory perception issues, such as low vision or hearing. Which statement by a unlicensed assistive personnel suggests a need for further education?

A) "I will stand directly in front of the client and speak slowly."
B) "I will move the furniture around depending on what activities are planned for the day."
C) "I will use bright, contrasting colors when making signs."
D) "I will keep fresh flowers in the television room."

Question 20

Which client is at greatest risk of developing sensory deprivation?

A) An 84-year old with progressive hearing loss living in an assisted living facility
B) A 50-year old newly diagnosed with breast cancer and having first chemotherapy treatment today
C) A 32-year-old with a fractured pelvis, on bed rest in a private room
D) An 18-year-old with a traumatic head injury who is in an intensive care unit

Question 21

Which client is at greatest risk of sensory overload?

A) A 17-year old on bed rest after a surgical procedure
B) A 55-year old, newly diagnosed with diabetes in a private room in a hospital
C) An 88-year old on a ventilator in an intensive care unit
D) An 8-year old in isolation in a private room in a hospital

Question 22

The nurse is caring for a client at risk for sensory deprivation. What interventions should the nurse implement to decrease the client's risk? Select all that apply.

A) Encourage the client's family to bring in personal objects.
B) Keep the television on at all times.
C) Place a clock and calendar in the client's room.
D) Brush the client's hair.
E) Speak slowly and clearly to the client.

Question 23

The nurse is caring for a client at risk for sensory overload. What interventions should the nurse implement? Select all that apply.

A) Remove clutter from the client's room.
B) Implement measures to reduce the client's pain.
C) Assist with all ADLs.
D) Limit interruptions to the client's rest/sleep times.
E) Limit extraneous noise.

Question 24

The nurse understands that when a client is talking about the voices in his or her head, the client is experiencing:

A) a delusion.
B) a hallucination.
C) an illusion.
D) confusion.

Question 25

The nurse is preparing a care plan for a client with a nursing diagnosis of Disturbed Sensory Perception. What would be appropriate goals for this diagnosis? Select all that apply.

A) The client will demonstrate an understanding of contributing factors to disturbed sensory perceptions by reducing or eliminating them during the hospital stay.
B) The client will not fall during the hospital stay.
C) The client will develop an effective communication mechanism during the hospital stay.
D) The nurse will use a communication board when speaking with the client.
E) The nurse will assist the client with ADLs as needed during the hospital stay.

Question 26

A client is refusing to take his prescribed medication. The client states that the government is out to get him and is poisoning all of his medication. The nurse understands that the client is experiencing:

A) an illusion.
B) a delusion.
C) a hallucination.
D) confusion.