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Potter-Perry Chapter 49 Sensory Alterations
Terms in this set (29)
1. 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
Perception occurs when the person becomes conscious of stimuli and interprets information signals. Reception refers to receiving stimuli and creating a nerve impulse. Reaction is how a person responds to a perceived stimulus. Sensation is a general term that refers to awareness of sensory stimuli through the body's sense mechanisms.
2. What is the involuntary motion of retracting the body from painful stimuli?
Reaction is how a person responds to a perceived stimulus. Perception occurs when the person becomes conscious of stimuli and interprets information signals. Reception refers to receiving stimuli and creating a nerve impulse. Sensation is the combination of all three combined.
3. 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.
Adaptation for a sensory deficit indicates that the patient alters his behavior to accommodate for his sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the ear would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive. Asking the nurse to speak loud alters the environment but does not adapt the patient's behavior.
4. The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit?
d. Peripheral neuropathy
Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns.
5. 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
Night vision becomes impaired as physiological changes in the eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging.
6. 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."
Part of the normal aging process is an inability to see colors. Much as with a younger adult who is color blind, the nurse should teach the patient new ways to adapt to his deficit. This patient's accident was not due to impaired cognitive function or reflexes. Glasses will not assist the patient in color discrimination.
7. 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.
The nurse should include implementations that help the patient adapt to his deficit while maintaining independence. Teaching the patient to use assistive devices allows the patient to care for himself. Changing the type of food the patient eats may not work for every culture, where touching food with fingers is unacceptable, or the patient may not enjoy eating foods that do not require utensils. A home health nurse is not necessary as long as the patient is able to care for himself. Instead of placing the patient on antidepressants, assist the patient in attempting to adapt behavior to the sensory deficit.
8. 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
In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Both self-care deficit and fall risk are physiological risks for the patient. Impaired physical mobility would not apply to this patient.
9. 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
Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position. This disequilibrium can cause nausea and vomiting. The other options would not result in nausea based on movement.
10. 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?
Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction. Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn. Affective problems include boredom and restlessness; the patient is participating in an activity. The patient is socializing with the home health nurse, so isolation is not a problem.
11. 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?"
To best understand how vision is affecting self-care ability, the nurse wants to target questions to encompass what self-care tasks the patient has difficulty doing, such as preparing meals and writing checks. Switching to books on audiotape gives the nurse an idea of the severity of the deficit, but not its impact on activity of daily living. Assessing whether the patient is taking measures to protect himself is important, but this does not address self-care activities. Emotional assessment of a patient is also important but does not properly address the goal of determining the effect of visual alterations on self-care ability.
12. 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.
The MMSE is a formal diagnostic tool that is used to assess a patient's level of cognitive functioning. Asking the patient orientation questions evaluates only the patient's orientation to self and surroundings, not abstract reasoning or critical thinking ability. Family members are not the most reliable source of information about the patient, although information received from the family should be considered. Reading a paper is not a means of comprehensive assessment; in addition, a patient may be high cognitive functioning and not know how to read English.
13. 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
The Snellen chart is used to assess vision using a distance of 20 feet. Difficulty remembering how to perform familiar tasks indicates the need to further assess mental status. Turning the television up louder indicates the need for a hearing assessment. Holding a newspaper 2 inches from the face indicates the need for assessment of near vision.
14. 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."
Good oral hygiene is important to stimulate and hydrate taste buds. Having an unpleasant taste in the mouth discourages the patient from eating. Avoid blending foods together because this confuses the ability to discriminate flavors and taste. Texturized, spicy, and aromatic foods stimulate and make eating more enjoyable.
15. 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
A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however, they do not address the greatest risk for injury.
16. The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has _____ aphasia.
Receptive aphasia occurs when patients have difficulty understanding spoken and written word. Expressive aphasia is seen when the patient has difficulty speaking or writing words. Broca and Wernicke refer to areas of the brain where language is processed.
17. 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
Using gestures other than just speaking helps the patient understand what you are saying and makes it a meaningful stimulus. Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones. If the patient does not understand the first time, try rephrasing instead of repeating the message. The nurse can direct conversation toward the patient's unaffected ear.
18. 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
By placing color-coded stickers and other reminders about dangerous stimuli, the patient is able to safely keep up hygiene. Asking the nurse to test the water does not promote independence, although it does promote safety. Zipper and Velcro clothing is easier for a patient with a tactile deficit to wear, and shower caps allow the patient to stay well groomed with minimal effort. Leaving the lids off of medications can be dangerous, as can placing all medications out at once. It may be difficult for the patient to sort through mixed medications and select the correct types and numbers of pills.
19. 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.
Actions to prevent blindness must occur before vision impairment takes place. Screening for diseases that affect development of vision in the fetus is a preventative measure. Vision testing after birth is important to begin steps to correct or identify the problem early on so the child can develop as normally as possible. Prophylactic antibiotics are not appropriate for all newborns. Reporting reduced eye contact is recommended but is not a preventative measure.
20. 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.
Giving the patient control over stimuli helps to decrease the frustration that results from sensory overload. Adding additional stimuli such as a back rub can increase sensory overload. Turning off monitors and alarms is unsafe; the nurse needs to be aware of critical situations. Opioid medications should not be the first option; however, antianxiety medications and sleep aids may be considered.
21. 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.
Patients with expressive aphasia may take a prolonged time to regain speech function, depending on the cause of the incident. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through means such as pointing and gestures. A patient who has expressive aphasia may not be able to speak or write words. Thickening drinks prevents aspiration risk and is not included in a plan of care for this patient.
22. 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
Sensory deprivation occurs when a person has decreased stimulation and limited sensory input. A patient in isolation is at risk for sensory deprivation because he has limited exposure to meaningful stimuli. A patient in the ICU would be at risk for sensory overload with all the monitors and visitors. A patient with a stroke or with brain cancer may have difficulty with tactile sensation and may have sensory deficits, but is not at risk for sensory deprivation.
23. 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
The patient with sensory deprivation needs meaningful stimuli, and therapeutic massage helps establish a humanistic relationship that the patient is missing. All of the other options do not promote patient-human interaction and promote further social isolation.
24. 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.
The nurse acts as an advocate for the patient (who is experiencing sensory overload and would benefit from a quiet environment) by firmly and politely asking the visitor to leave regardless of position in the hospital. The nurse should not allow anyone to enter unless the patient approves it. Security is not a necessary measure at this time. The nurse should handle herself with professionalism when addressing the visitor; scolding the visitor is not appropriate.
25. 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
Keeping a calendar in the patient's room helps to orient the patient to the dates and gives the patient a sense of control over her environment. Assessing the patient's level of consciousness is not an action that will directly affect the patient's confusion. A patient observer is unnecessary unless the patient is in danger from the confusion. The nurse should encourage the patient toward recovery but should be sensitive to the time it takes for progression.
26. 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.
The nurse should devise a plan of care that is accommodating of the patient's visual deficit. Placing a sticker on the call light allows the patient to page the nurse for assistance as needed. Yelling at the top of the lungs is stressful for the patient and for surrounding patients. Making hourly rounds is not sufficient; the nurse needs to ensure that the patient can get in touch with her at any time. Sharing personal phone numbers with the patient is inappropriate.
27. 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
d. Body image disturbance
The patient with a prosthetic eye will require a period of adjustment to new depth perception and visual sensation. Until the patient adapts, preventing injury should be the nurse's priority. The other options are not directly related to the safety of the patient for eye surgery.
28. 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
Sudden motions and motorized travel can worsen vertigo; avoiding these will lessen the severity of the vertigo. Increasing fluid intake, avoiding reading books, and using antiemetic patches do not affect vertigo.
29. 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
Completing the patient's sentences is not beneficial to the patient; instead provide the patient with plenty of time and opportunity to begin speaking. Creating a safe environment is important to reduce risk of injury. Placing objects on the patient's affected side and approaching the patient from the affected side cause the patient to be aware of the affected side and to learn to adapt and incorporate the affected part of the body. If the patient does not acknowledge the affected side, it will become neglected, and risk of injury will increase.
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