Question 1

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)  "Are you able to prepare a meal or write a cheque?"
C)  "How do you protect yourself from injury at work?"
D)  "How does your vision impairment make you feel?" B

Question 2

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

Accepted Answer

A)  Xerostomia.
B)  Disequilibrium.
C)  Cataracts.
D)  Peripheral neuropathy. A

Question 3

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

Accepted Answer

A)  Sensation.
B)  Reception.
C)  Perception.
D)  Reaction. D

Question 4

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

Accepted Answer

A)  Self-care deficit.
B)  Risk for falls.
C)  Social isolation.
D)  Impaired physical mobility.

Question 5

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?

Accepted Answer

A)  Providing the patient with a therapeutic back rub.
B)  Turning off the alarms on the monitoring devices.
C)  Administering an opioid medication to help the patient sleep.
D)  Providing the patient with earplugs.

Question 6

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?

Accepted Answer

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

Question 7

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?

Accepted Answer

A)  Placing a raised Braille sticker on the call button,and instructing the patient to press for assistance.
B)  Instructing the patient to yell at the top of his lungs to get the attention of the staff.
C)  Explaining to the patient that a staff person will stop by once an hour to see whether the patient needs anything.
D)  Sharing cell phone numbers with the patient so he can call the nurse if he needs her.

Question 8

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

Accepted Answer

A)  A patient in the critical care unit (CCU) under constant monitoring after 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.

Question 9

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?

Accepted Answer

A)  Reminding the patient of the need to have frequent tactile contact.
B)  Keeping the patient loosely covered with sheets and blankets.
C)  Allowing the patient to lie motionless.
D)  Using touch as a form of therapy.

Question 10

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?

Accepted Answer

A)  Places coloured 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.

Question 11

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?

Accepted Answer

A)  Neurological deficit.
B)  Visual deficit.
C)  Hearing deficit.
D)  Balance deficit.

Question 12

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?

Accepted Answer

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.

Question 13

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?

Accepted Answer

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.

Question 14

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?

Accepted Answer

A)  Self-care deficit.
B)  Risk for injury.
C)  Anxiety.
D)  Body image disturbance.

Question 15

Which nursing assessment best measures cognitive functioning?

Accepted Answer

A)  Administering a Mini-Mental Status Examination (MMS
E)  .
B)  Asking the patient his name,where he is,and what month it is.
C)  Asking the patient's family if the patient is behaving normally.
D)  Evaluating the patient's ability to read the newspaper.

Question 16

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?

Accepted Answer

A)  Every 3 to 4 months.
B)  Every 6 months.
C)  Every 1 to 2 years.
D)  Every 4 years.

Question 17

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

Accepted Answer

A)  Placing a "Do not disturb" sign on the patient's door.
B)  Offering the patient a back rub.
C)  Asking the patient whether he or she would like a newspaper to read.
D)  Placing the patient in the room farthest from the nurses' station.

Question 18

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?

Accepted Answer

A)  Sensation.
B)  Reception.
C)  Perception.
D)  Reaction.

Question 19

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?

Accepted Answer

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

Question 20

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?

Accepted Answer

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.

Exam 47: Sensory Alterations