Question 1

The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care?

Accepted Answer

A)  Patient will carry a pen and a pad of paper around for communication. 
B)  Patient will recover full use of speech vocabulary in 1 day. 
C)  Patient will thicken drinks to prevent aspiration. 
D)  Patient will communicate nonverbally.

Question 2

A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?

Accepted Answer

A)  The patient frequently cleans out eyes with saline washes. 
B)  The patient applies different spices during mealtime to food. 
C)  The patient turns one ear toward the nurse during conversation. 
D)  The patient isolates self from social situations with groups of people.

Question 3

The nurse will be $\bold{most}$ concerned about the risk of malnutrition for a patient with which sensory deficit?

Accepted Answer

A)  Xerostomia 
B)  Dysequilibrium 
C)  Diabetic retinopathy 
D)  Peripheral neuropathy

Question 4

The nurse is caring for a group of patients and is monitoring for sensory deprivation. Which patient will the nurse monitor $\bold{most}$ closely?

Accepted Answer

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 lung cancer

Question 5

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

Accepted Answer

A)  "Have you stopped reading books or switched to books on audiotape?" 
B)  "What do you do to protect yourself from injury at work?" 
C)  "Are you able to prepare a meal or write a check?" 
D)  "How does your vision impairment make you feel?"

Question 6

A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse "Should Istop driving?" Which response by the nurse is most therapeutic?

Accepted Answer

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 lit up, it means stop, and if the bottom is lit up, it means go." 
D)  "No, instead you should see your ophthalmologist and get some glasses to help you see better."

Question 7

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 will be $\bold{most}$ appropriate for this patient?

Accepted Answer

A)  "Rinse your mouth several times a day to hydrate your taste buds." 
B)  "Avoid adding spices or lemon juice to food to prevent nausea." 
C)  "Blend foods together in interesting flavor combinations." 
D)  "Eat soft foods that are easy to chew and swallow."

Question 8

The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit?

Accepted Answer

A)  Body image disturbance 
B)  Social isolation 
C)  Risk for falls 
D)  Fear

Question 9

A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?

Accepted Answer

A)  Offer the patient a back rub. 
B)  Hang a "Do not disturb" sign on patient's door. 
C)  Ask the patient "Would you like a newspaper to read?" 
D)  Place the patient in the room farthest from the nurses' station.

Question 10

A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected?

Accepted Answer

A)  Perceptual 
B)  Cognitive 
C)  Affective 
D)  Social

Exam 49: Sensory Alterations