Exam 47: Sensory Alterations

Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability?

The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit?

What is the involuntary motion of retracting the body from painful stimuli?

Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment?

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 home health nurse is assembling a puzzle with an older 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?

A nurse is establishing a relationship with a patient who is visually impaired.Which is the most appropriate method to teach the patient how to contact the nurse for assistance?

The nurse is aware that which patient is most at risk for sensory deprivation?

A patient has hyperesthesia associated with a neurological trauma.Which one of the following is an appropriate nursing intervention in regard to the patient's sense of touch?

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 determines that the patient is able to care for himself safely when the patient demonstrates which action?

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?

The nurse is caring for a patient with conductive hearing loss in one ear resulting from prolonged cerumen impaction.Which intervention by the nurse is most important in establishing effective communication with the patient?

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?

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?

Which nursing assessment best measures cognitive functioning?

During a community screening,the nurse notes that a 50-year-old patient is currently taking steroid medications.How often does the nurse recommend that this patient have an eye examination?

What nursing action can the nurse implement to comfort an older patient with sensory deprivation to improve meaningful stimuli?

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 which of the following?

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?

The nurse is caring for a patient with expressive aphasia caused by a traumatic brain injury.Which desired outcome should be included in the plan of care?