Chapter 43: Sensory Functioning

Alexandra Bozan
Quiz by Alexandra Bozan, updated more than 1 year ago
Alexandra Bozan
Created by Alexandra Bozan almost 4 years ago
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Unit VII: Promoting Healthy Psychosocial Responses Chapter 43: Sensory Functioning

Resource summary

Question 1

Question
A nurse who is assessing an older female patient in a long-term care facility notes that the patient is at risk for sensory deprivation related to severe rheumatoid arthritis limiting her activity. Which interventions would the nurse recommend based on this finding?
Answer
  • Use a lower tone when communicating w/the patient
  • Provide interaction w/children and pets
  • Decrease environmental noise
  • Ensure that the patient shares meals w/other patients
  • Discourage the use of sedatives
  • Provide adequate lighting and clear pathways of clutter

Question 2

Question
A nurse is assessing a 78 year old male patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment?
Answer
  • The nurse asks the patient if he is bored, and if so why
  • The nurse asks the patient if anything interferes w/the functioning of his senses
  • The nurse asks the patient if he noticed any changes in the way he perceives his body
  • The nurse asks the patient if he has found it difficult to communicate verbally
  • The nurse notes if the patient w/draws from being touched
  • The nurse notes if the patient seems unsure of his body parts and/or position

Question 3

Question
A nurse asks a patient to close her eyes, state when she feels something, and describe the feeling. The nurse then brushes the patient's skin w/a cotton ball, and touches the patient's skin with both sides of a safety pin. Which sense is the nurse assessing?
Answer
  • gustatory
  • olfactory
  • tactile
  • kinesthetic

Question 4

Question
A nurse observes that a patient who has cataracts is sitting closer to the television than usual. The nurse would interpert that the etiologic basis of the sensory problem is an alteration in
Answer
  • environmental stimuli
  • sensory reception
  • nerve impulse conduction
  • impulse transaltion

Question 5

Question
A patient is in the late stages of AIDS, which is now affecting his brain as well as other major organ systems. The patient confides to the nurse that he feels terribly alone because most of his friends are afraid to visit. The nurse determines that the least likely underlying etiology for his sensory problems would be
Answer
  • stimulation
  • reception
  • transmission-perception-reaction
  • emotional response

Question 6

Question
Which action would be most important for a nurse to include in the plan of care for a patient who is 85 years old and has presbycusis?
Answer
  • Obtaining large-print written material
  • Speaking distinctly, using lower frequencies
  • decreasing tactile stimulation
  • initiating a safety program to prevent falls

Question 7

Question
Which patient would a nurse assess as being at greatest risk for sensory deprivation?
Answer
  • An older man confined to bed at home after a stroke
  • An adolescent in an oncology unit working on homework supplied by friends
  • a woman in a labor
  • a toddler in a playroom awaiting same day surgery

Question 8

Question
A patient is in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 6, 7, and 8pm. A heart monitor beeps for a patient on one side, and another patient moans frequently. Assessment would suggest that the patient is probably experiencing
Answer
  • sufficient sensory stimulation
  • deficient sensory stimulation
  • excessive sensory stimulation
  • both sensory deprivation and overload

Question 9

Question
A patient's spinal cord was severed, and he is paralyzed from the waist down. When obtaining data about this patient, which component of the sensory experience would be most important for the nurse to assess?
Answer
  • Transmission of tactile stimuli
  • Adequate stimulation in the environment
  • reception of visual and auditory stimuli
  • general orientation and ability to follow commands

Question 10

Question
A nurse is diagnosing an 11 year old 6th grade student following a physical assessment. The nurse notes that the student's grades have dropped, she has difficulty completing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snellen's eye chart is 160/20. Which nursing diagnosis would be most appropriate?
Answer
  • Deficient Knowledge related to visual impairment
  • Ineffective Role Performance (student) related to visual impairment
  • Disturbed Body Image related to visual impairment
  • Delayed Growth and Develoment related to visual impairment

Question 11

Question
A nurse is caring for a male patient with a severe hearing deficit who is able to read lips and use sign language. Which nursing intervention would be best to prevent sensory alterations for this patient?
Answer
  • Turn the radio or television volume up very loud and close the door to his own room
  • Prevent embarrassment and emotional discomfort as much as possible
  • Provide daily opportunity for him to participate in a social hour with 6-8 people
  • Encourage daily participation in exercise and physical activity

Question 12

Question
A nurse formulates the following diagnosis for an older female patient in a long-term care facility. Disturbed Sensory Perception: Chronic Sensory Deprivation related to the effects of aging. The patient walked out the door unobserved and was lost for several hours. Which interventions would be most effective for this patient?
Answer
  • Ignore when the patient is confused or go along to prevent embarrassment
  • reduce the number and type of stimuli in the patient's room
  • orient the patient to time, place and person frequently
  • provide daily contact with children, community people, and pets
  • decrease background or loud noises in the environment
  • provide a ratio and television in the patient's room

Question 13

Question
An older female patient has a severe visual deficit related to glaucoma. Which nursing action would be appropriate when providing care for this patient?
Answer
  • Assist the patient to ambulate by walking slightly behind the person and grasping the patient's arm
  • Concentrate on the sense of sight and limit diversion that involve other senses
  • Stay outside of the patient's filed of vision when performing personal hygiene for the patient
  • Indicate to the patient when the conversation has ended and when the nurse is leaving the room

Question 14

Question
With decreased sensory input, the RAS is no longer able to project a normal level of activation to the brain. As a result, the person may hallucianate simply to maintain an optimal level of arousal.
Answer
  • True
  • False

Question 15

Question
For visually impaired patients, assist with ambulation by walking slightly ahead of the person, allowing the person to grasp your arm.
Answer
  • True
  • False
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