Question 1

Which nursing assessment best measures cognitive functioning?

Accepted Answer

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

Question 2

A nurse is caring for an elderly patient who was in a motor vehicle accident because he thought the stop light was green.The patient asks the nurse if he should no longer drive.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 illuminated, it means stop, and if the bottom is illuminated, it means go."
D)   "No, instead you should see your ophthalmologist and get some glasses to help you see better." C

Question 3

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

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 brain cancer B

Question 4

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)   Provide the patient with a therapeutic back rub.
B)   Turn off the alarms on the monitoring devices.
C)   Administer an opioid medication to help the patient sleep.
D)   Provide the patient with earplugs.

Question 5

The nurse is caring for a patient with conductive hearing loss 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 6

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 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 would be most appropriate for this patient?

Accepted Answer

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

Question 8

The nurse is caring for a patient with expressive aphasia from 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.

Question 9

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

Accepted Answer

A)   Places colored 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 10

A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week.The nurse notices that the patient is having difficulty with attempting to eat his meal and is becoming tearful.The nurse includes which intervention in the patient's plan of care?

Accepted Answer

A)   Teach the patient about special devices used to assist patients with eating meals.
B)   Order the patient food that does not require utensils.
C)   Place a consult for a home health nurse.
D)   Obtain an order for antidepressant medications.

Question 11

A home health nurse is assembling a puzzle with an elderly 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 12

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

Accepted Answer

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

Question 13

A nurse is caring for a patient who is experiencing vertigo.Which nursing intervention would assist the patient in controlling the vertigo?

Accepted Answer

A)   Increasing fluid intake to 3 liters a day
B)   Watching television instead of reading books
C)   Avoiding riding in vehicles and making sudden motions
D)   Placing several antiemetic patches on the patient

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

The nurse is caring for a patient who is a well-known surgeon at the hospital.Because of his status,all the hospital's physicians want to be sure to pay him a visit.The nurse notices the patient becoming more agitated and withdrawn with each group of visitors.The nurse asks the patient if he would like a "Do not disturb" sign placed on the door.A few hours later,the nurse notices a physician who is not involved in the patient's care attempting to enter the room.Which response by the nurse is most appropriate?

Accepted Answer

A)   Allowing the physician to enter because he has higher authority than the nurse
B)   Calling for security to remove the visitor
C)   Firmly explaining that the patient does not wish to have visitors at this time, so do not enter the room
D)   Scolding the physician for not obeying the signs on the door and respecting the patient's wishes.

Question 16

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 17

A nurse is caring for a patient with right-sided weakness following a stroke.Which nursing action would be least effective in promoting positive adaptation of the patient's sensory deficit?

Accepted Answer

A)   Placing the patient's belongings on the affected side
B)   Approaching the patient from the affected side
C)   Teaching the patient how to create a safe environment
D)   Completing sentences that the patient cannot finish

Question 18

A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis.Which assessment of the patient would indicate an adaptation to the sensory deficit?

Accepted Answer

A)   The patient frequently cleans out his ears with a cotton swab.
B)   The patient turns one ear toward the nurse during conversation.
C)   The patient isolates himself from social situations.
D)   The patient asks the nurse to speak loudly during conversations.

Question 19

The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has _____ aphasia.

Accepted Answer

A)   Expressive
B)   Receptive
C)   Broca's
D)   Wernicke's

Question 20

What nursing action can the nurse implement to comfort an elderly 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 if he would like a newspaper to read
D)   Placing the patient in the room farthest from the nurses' station

Exam 94: Sensory Alterations