Exam 38: Sensory Alterations

A patient has been hospitalized for 5 days and has had no visitors.The nurse observes the patient to be bored,restless,and anxious.The nurse identifies this behavior as which of the following?

A family member is accompanying the elderly patient to their follow-up appointment after a recent hospitalization for gastrointestinal problems.The nurse interrupts a discussion between the family member and the patient regarding rancid food in the patient's refrigerator.The family member looks at the nurse and states,"She was trying to eat spoiled food for lunch,it spelled terrible,and she still wanted to eat it." What is the most likely physiological reason that the patient not realizes that the food is spoiled?

An elderly patient with diabetes is seeing the health care provider for complaints of visual changes.The patient explains to the nurse that visual changes include distortion that makes the edges of objects appear wavy.The nurse knows that this is an early sign of which of the following?

A nursing student is assisting with ambulation of a blind patient.The patient has hemiplegia of the right side.The best position for the student nurse to assume when ambulating is by standing on the patient's _____ side and walking a half step _____ the patient.

A home care nurse is conducting a home assessment.The nurse is looking for the presence of sensory alterations.Factors to assess include if any changes have occurred in which of the following? (Select all that apply.)

The patient has a methicillin-resistant Staphylococcus aureus (MRSA)infection in an abdominal surgical wound.The patient is in a private room,is receiving vancomycin (Vancocin)for the MRSA,and pain is well controlled with a morphine sulfate patient-controlled analgesia (PCA)pump,and is receiving docusate sodium (Colace)to prevent constipation.During the nurse's rounds,the patient begins complaining of ringing in the ears.Which is the most likely cause for the patient's tinnitus?

A home care nurse visits a new patient.The family asks how the home can be made safer.The nurse's best advice includes which of the following?

A 16-year-old mother and her newborn come into the clinic for a routine checkup.The mother is concerned that her baby could be deaf because her uncle lost his hearing at a young age.The nurse hits a buzzer and the baby turns toward the sound.The nurse assures the mother that the baby can hear because the baby:

The student nurse is assisting an elderly patient to get ready for bed.The patient states,"Please make sure you clean my hearing aids." The student nurse knows it is important to keep in mind which of the following when cleaning a hearing aid?

A 64-year-old house painter who is seeing his health care provider for his annual checkup.When the nurse asks the patient if they have any health concerns,the patient states,"I don't think my vision is as good as it used to be,things look more yellow than they used to." The nurse knows that this is a visual change in older adults caused by which of the following?

A school nurse performs a routine screening on a newly transferred school-age child.This nurse is especially interested in discovering the child's medical history regarding middle ear infections.The nurse knows that chronic ear infections are a major contributing factor to which of the following?

The school nurse is performing periodic screening on preschool children.She is aware that the most common visual problem in childhood is which of the following?

A patient with poor vision is ready to be discharged.The nurse is educating the patient and family regarding ways to improve vision.The nurse teaches the patient and family to avoid reading materials with shiny surfaces.The rationale for this intervention is which of the following?

A nurse is caring for a patient who signs and lip reads.When communicating,the most appropriate nursing action is to do which of the following?

The spouse of a homebound elderly patient voices a concern to the visiting nurse,"I'm having a hard time getting the patient to eat a balanced diet.All the patient wants to eat are sweets." What is the best explanation the nurse can give to the spouse?

A nursing student is concerned with sensory deprivation among the patients in the nursing home during the clinical rotation.Which of the following could be caused by sensory deprivation? (Select all that apply.)

An older adult patient residing at an adult assisted living facility complains of hearing and visual disturbances.A nurse must be alert to the effects of sensory deprivation that are associated with which of the following?

A middle-age patient was admitted to the trauma intensive care unit after a motor vehicle accident.The nurse notes that the patient becomes increasingly agitated when visitors stay for an extended period or after nursing interventions.The nurse identifies this as sensory overload.Which of the following would most likely help the patient? (Select all that apply.)

An older adult patient has been admitted to a busy medical unit.To control environmental stimuli a nurse should do which of the following?

A 63-year-old welder who has gone to the clinic for an annual checkup.The patient shares a concern regarding difficulty hearing conversations at the coffee shop in the mornings.After looking in his ears to determine if there is a build-up of cerumen,the nurse tells the patient that the hearing loss may be associated with his occupation or it may be associated with aging.The nurse is aware that hearing loss associated with the aging process is known as which of the following?