204 PrepU Craven ch. 36: Sensory Preception

The nurse is working on a neurological unit and must perform an assessment on a client for disturbed sensory perceptions. The nurse thinks about the human senses and knows that they must assess for which of the following? Select all that apply.

use of assistive devices for senses medications that may alter sensations anything interfering with sensory reception any recent changes in sensory stimulation When performing an assessment for disturbed sensory perceptions, it is important to assess for anything interfering with sensory reception, such as decreased hearing, vision, or tactile sensation. Ask about any recent changes in sensory stimulation, such as death of a spouse who provided conversation, companionship, and touching. Medications, such as captopril, can cause taste alteration. Also, ask about what assistive devices are currently used, such as eyeglasses or hearing aids. Immunizations are not related to disturbed sensory perceptions.

The neonatal intensive care unit (NICU) nurse is reviewing sensory development in the neonate. Which statement indicates to the preceptor that the nurse knows how to provide stimulation for these neonates?

use of mobiles will stimulate visual sensation Although the newborn is capable of rudimentary perceptual discrimination at birth, many neural pathways are immature and must be stimulated to be developed. The use of mobiles will stimulate visual sensations. Rocking and changes of body position will help to stimulate kinesthetic sensations. Medically fragile infants are recommended to have limited light; they should also have visual and vestibular stimulation to simulate being in the womb.

Which of the following accurately describes senses by which individuals maintain contact with the external environment? Select all that apply.

vision hearing smell taste The senses by which individuals maintain contact with the external environment are vision (visual), hearing (auditory), smell (olfactory), taste (gustatory), and touch (tactile). Kinesthesia refers to awareness of positioning of body parts and body movement.

Which way can the nurse decrease the sensory deprivation that the client in isolation experiences?

visit the client often to develop trust To lessen the feelings of isolation the nurse should visit the client often and let him or her know when to expect another visit to help the client overcome a feeling of isolation. Providing a calendar and a clock to assist in keeping track of time helps keep the client in touch with activities in the environment. Also, the nurse encourages the client to provide self-stimulation, such as singing, reading, and talking into a recorder and playing it back. Self-care activities also are forms of self-stimulation. The nurse provides various types of stimulation to encourage maximum use of the client's available senses. This action would include self-care activities that can stimulate sensory perception and awareness. Visitors should be kept to a minimum to prevent the spread of infection.

The student is studying the sensory experience. Which statement indicates that the student understands the four conditions that must be met for a client to experience the world?

"An agent, act, or other influence capable of initiating a response by the nervous system must be present." For a person to receive the necessary data to experience the world, four conditions must be met: a stimulus—an agent, act, or other influence capable of initiating a response by the nervous system—must be present; a receptor or sense organ must receive the stimulus and convert it to a nerve impulse; the nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain; and a particular area in the brain must receive and translate the impulse into a sensation.

While the nurse is assessing an older adult client, which statement by the client requires further investigation?

"I need to go back to my room" The client expresses the need to return to their room but they have forgotten that they are in their room. This should alert the nurse of a mental status change. Mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills, can be collected during the client history. Telling the nurse that they can only sleep with lights off is appropriate. Asking when a test is scheduled or when the client's son will visit are normal questions.

The client is being seen in the clinic for the chief complaint of ringing in the ears. What questions would the nurse ask to obtain more information about the tinnitus? Select all that apply.

"When did you first notice the ringing in the ears?" "What is your current job and what were your previous jobs?" "Have you had to ask people to repeat what they said?" "How has the ringing in the ears affected you?" When obtaining a targeted assessment, the nurse asks questions relating to signs and symptoms, onset/duration, predisposing factors, and effect on the client. Appropriate questions include queries on when the client first noticed the ringing, current and past jobs, whether the client asks others to repeat statements, and how the ringing has affected the client. The question, "What do you think you did to cause the ringing?" places blame on the client and is nontherapeutic. It may cause the client to become defensive.

Which client is most likely susceptible to the effects of disturbed sensory perception?

A client who is receiving care in the intensive care unit (ICU) for the treatment of septic shock Clients in critical care settings are particularly susceptible to severe sensory alterations. A client who has been in a setting for a short time, such as an emergency or day surgery setting, is less likely to experience disturbed sensory perception. Older adults are often vulnerable to sensory disturbances, but the risks posed by an ICU setting likely supersede a geriatric medical unit.

People receive data to experience the world. What are conditions that must be met for this to occur? Select all that apply.

A stimulus, such as an agent, act, or other influence, must be present. A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. The nerve impulse must be conducted along a pathway from the receptor or sense organ to the brain. A particular area in the brain must receive and translate the impulse into a sensatiom For a person to receive the necessary data to experience the world, four conditions must be met: (1) a stimulus—an agent, act, or other influence capable of initiating a response by the nervous system—must be present. (2) A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. (3) The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. (4) A particular area in the brain must receive and translate the impulse into a sensation.

Altered sensory reception is a category of occurrences that can lead to sensory deprivation. Which scenario describes an example of altered sensory reception?

An 87-year-old woman is losing her eyesight. She is not able to leave her assisted living apartment without help. She is becoming more and more confused. The 87-year-old is experiencing altered sensory reception because her progressive blindness is limiting her visual cues. The other clients are experiencing sensory deprivation because they are immersed in deprived environments.

The nurse takes into consideration factors that affect sensory stimulation in hospitalized clients when planning care. Which statement is true?

An individual's culture may dictate the amount of sensory stimulation considered normal. The amount and quality of stimuli necessary to produce overload may differ greatly from one person to another and is influenced by factors such as age, culture, personality, and lifestyle. Different levels of stimulation are required by people based on their personality. During periods of low stress increased sensory stimulation may be sought. Illness may make a person hypersensitive to sensory stimuli.

The nurse is assisting a client in removing her soft contact lenses. The nurse positions the client comfortably in a chair. Place the following steps in the order that the nurse would perform them to remove the contact lens.

Ask the client to look up. Pull down on the lower lid. Place index finger on lower edge of lens. Move lens onto the white part of the eye. Grasp lens between thumb and index finger. When removing soft contact lenses, the nurse would ask the client to look upward, pull down on the lower lid and place their index finger on the lower edge of the lens, moving it onto the white part of the eye. Then the nurse would gently grasp the lens between the thumb and index finger to release the suction, causing the lens to fold over for easy removal.

The nurse will be starting an intravenous line on a client who is hard of hearing. The nurse will implement which interventions? Select all that apply.

Ask, "May I turn down the sound on your television?" Speak directly to the client. Look at the client's face as much as practical. Many clients who are hearing impaired understand or "hear" better when background noise is lessened or eliminated, when the speaker looks directly at their face, and when the speaker speaks directly to them. The client needs and deserves the same sort of interaction that the nurse would provide to a client with normal hearing. There is no need to speak loudly.

The nurse is working on the neurological unit and caring for Mr. Thom, a 39-year-old man who has suffered a severe head injury and is comatose. Then nurse is providing education to the family and visitors about communication with the client. What will the nurse include? Select all that apply.

Assume the person can hear the conversation. Speak to the person before touching. Keep environmental noises at low levels. Talk about things that would normally be discussed. Hearing is believed to be the last sense lost in a client who is comatose; therefore, the person is often likely to hear what is being said, even though there does not appear to be a response. Assume the person can hear the conversation taking place. Talk with the person in a normal tone of voice about things that would ordinarily be discussed. Be careful of what is said in the person's presence. Speak to the person before touching. Remember that touch can be an effective means of communicating with the unconscious person.

The nurse is teaching a group of clients about general eye care to prevent vision loss and eye injury. What will the nurse include in the presentation? Select all that apply.

Avoid eye damage from ultraviolet rays. Use caution with corrosive agents. Avoid eye strain and rubbing eyes. Wear protective goggles for mowing lawns. The first priority is to teach clients self-care behaviors for maintaining vision and preventing blindness. These include: avoid rubbing eyes, avoid eye strain, avoid damage from ultraviolet rays, protect eyes from foreign bodies, keep eyeglasses clean, protected, and adjusted, avoid nonprescription eye drops and seek attention for symptoms, avoid cleaning eyes or contact lenses with soiled articles, use caution with aerosol sprays, and use caution with ammonia, lye, etc. Use of an eye rinse is only on advice of a physician.

The nurse is caring for a client at risk for the development of cognitive impairment related to a spinal cord injury. When creating the plan of care for this client, what interventions should the nurse include to avoid this development? Select all that apply.

Discuss current events or the client's occupation, hobbies, or interests. Have the client assist in self-care as much as possible. Orient the client to the surroundings and environment every 1 to 2 hours. The nurse should orient the client to the environment so that he or she may maintain touch with reality. The nurse should encourage the client to provide as much self-care as he or she is able to help reinforce cognitive ability. The nurse should discuss current events or the client's occupation, hobbies, or interests to maintain reality. And the nurse should reinforce reality without arguing with a client who is hallucinating, for example, "No, I don't see a man standing there but the linen hamper may be confusing you."

The nurse is caring for client 82 years of age who is struggling to adapt to hearing loss as he ages. The nurse performs which interventions to assist the client in adapting to this sensory deficit? Select all that apply.

Make sure he wears his hearing aid. Speak in a lower tone of voice. Speak so he can observe lip movement. Speaking in low tones and making sure he can see the nurse's lip movement will assist the client in hearing and understanding better, as will wearing his hearing aid. Keeping his room free of clutter is nice, but will not assist his hearing. Reorienting will not help to improve the client's hearing.

The nurse is caring for Emily, an 81-year-old client who is struggling to adapt to worsening vision as she ages. The nurse performs which interventions to assist Emily in adapting to this sensory deficit? Choose all that apply.

Make sure her glasses are available. Provide adequate lighting. Provide large print books. Wearing her glasses, having adequate lighting, and having large print books are all strategies to assist a client with a visual deficit. Orientation to person, place, and time is not necessary because Emily is not disoriented. Emily does not have a hearing problem, so it is not necessary for her to observe lip movements.

A client who was admitted to the critical care unit is experiencing sensory overload. When developing this client's plan of care, which intervention would be appropriate for the nurse to include? Select all that apply.

Offer simple explanations before a treatment or procedure. Set up a consistent schedule for routine care activities. Suggest the use of noise-reducing headphones or ear plugs. Sensory overload is excessive stimuli over which a person feels little control; the brain is unable to meaningfully respond to or ignore stimuli. Appropriate interventions include providing a consistent, predictable pattern of stimulation to help the client develop a sense of control over the environment; offering simple explanations before procedures, tests, and examinations; establishing a schedule with the client for routine care such as eating, bathing, turning, positioning, coughing, and exercising; speaking calmly with the client and moving slowly; communicating confidence; exploring with the client what stimuli are most distressing (e.g., incoming phone calls, visitors) and developing a plan to reduce or eliminate them using earplugs, pain medication, and/or noise-reducing headphones, as indicated.

The nurse is caring for an older adult client that recently lost total vision in both eyes due to macular degeneration. Which interventions will the nurse add to the client's plan of care to assist with the with vision loss? Choose all that apply.

Orient to sounds in the immediate environment. Clear the room of clutter and do not rearrange furnishings. Acknowledge presence when entering the room. Inform the client when the nurse is leaving the room When communicating with clients with reduced vision, the nurse should follow these guidelines: acknowledge presence in the client's room, identify oneself by name, speak in a normal tone of voice, remember that the blind person is unable to pick up most nonverbal cues during communication, explain the reason for touching the person before doing so, keep the call light or bell within easy reach of the person and place the bed in the lowest position, orient the person to sounds in the environment, orient the person to the arrangement of the room and its furnishings, clear pathways for the person and do not rearrange furnishings and clarify this fact with housekeeping personnel, assist with ambulation by walking slightly ahead of the person, allowing the person to grasp nurse's arm, stay in the person's field of vision if she has partial or reduced peripheral vision, provide diversions using other senses, and indicate to the person when the conversation has ended and leaving the room.

The nurse is working at a pediatric clinic when Mrs. Karlilse comes in with her toddler and two preschoolers. She is distraught and tells the nurse she wants her children to just sit quietly and look at books or take naps. Instead, she says the children play noisily and scatter toys throughout the house. She indicates that she loves her children, but does not understand the need for the loud activities. To provide correct education, the nurse's best response about appropriate play for the children includes which of the following? Select all that apply.

Play is an outlet for physical and emotional energy. Play develops social skills and self-insights. Play assists in learning gender roles. Play develops muscles and coordination. For children, engaging in developmentally appropriate play will develop muscles and coordination, provide an outlet for surplus physical energy, develop communication skills, provide sources of learning, act as a stimulant to creativity, develop social skills, teach sex roles, provide an outlet for the release of emotional energy, and develop self-insights. Engaging in appropriate play for developmental age does not hinder acquisition of appropriate communication and does not facilitate development of bullying tendencies.

The nurse is assisting a client who is visually impaired and has right-sided weakness. Which steps are accurate? Select all that apply.

Stand on the client's right side. The nurse should be 1 foot (0.3 m) in front of the client. Have the client grasp the nurse's arm. When assisting a visually impaired client with ambulation, stand on the client's nondominant side, about 1 foot (0.3 m) in front of him. Have the client grasp your arm with the nondominant hand and use the dominant hand to feel around for barriers or landmarks. Always maintain an uncluttered environment. The client cannot use the right hand to feel for barriers; therefore, the nurse should have the client on their right side using the left hand to feel around.

The nurse is assessing clients in an ambulatory urgent care clinic. Which of the following clients would be most at risk for inadequate health literacy? Select all that apply.

The older male client in his 80s who is recently widowed The client whose primary spoken and written language is Spanish The homeless client who keeps his shopping cart and items next to him Risk factors for inadequate health literacy include advanced age, low educational level, poverty, inability to read, and lack of English proficiency. Thus, the client who is in his 80s, the client whose primary language is Spanish, and the client who is homeless are most at risk for inadequate health literacy. The client who is accessing the internet and the client who is reading a textbook are demonstrating ability to read and gain access to information.

The nurse is testing the client's neurological status. Which action will the nurse take to assess the client's sense of touch?

Touch the temple with a cotton ball so the client can identify where being touched and if the touch is soft or sharp To test the sense of touch the nurse should touch the temple with a cotton ball and ask the client to identify where the nurse is touching and if the touch is soft or sharp. Pricking the client's skin with a lancet or holding a hot tuning fork may be dangerous. Bending the client's fingers will not provide reliable information about the sensation of touch.

The nurse is caring for Mrs. Meld, a 62-year-old client with dementia who is confused. Which nursing interventions will the nurse include in Mrs. Meld's care plan to facilitate communication? Choose all that apply.

Use frequent face-to-face contact. Reorient the client to her environment as needed. Speak calmly, simply, and directly. Use clocks and calendars for orientation. Nursing interventions for the confused client include the following: use frequent face-to-face contact to communicate the social process (use touch when appropriate, walk arm in arm, hug, give a backrub), speak calmly, simply, and directly to the client and allow sufficient time for the client to think before responding, orient and reorient the client to the environment and fill the client's personal space with as many personal objects as possible, and use conversation, watches, clocks, calendar, newspaper, television, radio, and other such devices to orient the client to time, place, and person. Using lots of detail may cause additional confusion and hinder communication.

Which client is experiencing a disturbance in sensory perception as the primary problem, rather than the etiology of another problem?

a client experiencing acute confusion as a result of a drug interaction Acute confusion is a nursing diagnosis that is a direct example of a disturbance in sensory perception. Sleep disturbances can impact sensory perception but it is not a direct example. The feeling of powerlessness and ineffective coping are alterations in sensory perception.

A client has an abrupt onset of a cluster of global changes in attention, cognition, and level of consciousness (LOC). What would be the most appropriate nursing diagnosis?

acute confusion The nursing diagnosis Acute Confusion is most appropriate. The definition of this diagnosis is "the abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycles." The abrupt onset rules out chronic confusion. Coping involves the emotional processing of an event. Impaired memory is just one component of the broader phenomenon of confusion.

A client has newly diagnosed cirrhosis and has pulled his nasogastric (NG) tubing for the third time. His ammonia level is above normal. Which nursing diagnosis is appropriate for this client?

acute confusion Electrolyte imbalances, alterations in blood chemistry (e.g., elevated ammonia, elevated blood urea nitrogen), and toxic levels of drugs that affect the CNS can alter sensoristasis resulting in a nursing diagnosis of Acute Confusion. Alteration in rest and comfort would be a diagnosis of a client experiencing difficulty getting to sleep and staying asleep. Disturbed thought process would be a diagnosis for a client experiencing hallucination or delusions. Ineffective impulse control would be for a client experiencing attention deficit disorder or attention deficit hyperactivity disorder.

The nurse is meeting an older adult client for the first time in their hospital room. Which of the following interventions should be a priority at this time?

asking if the client uses prescription glasses Assessment of sensory function and risk factors for sensory alterations is necessary for all clients, especially when the alteration is a new or temporary one. Older adults require close assessment because they experience age-related sensory changes and subsequent underlying visual and hearing impairments. Instructing the client to not pull out their IV site is not appropriate as the older adult client does not have cognitive changes. Showing the client how to turn on the TV and the correct use of the bedside commode is important after assessments have been completed. The client may not need the instruction.

The nurse is working with a student nurse on the surgical unit. The nurse should describe what benefit of providing health education before the procedure?

clients are better able to handle new experiences Education is a significant nursing responsibility that helps prepare clients for sensory experiences but not the only nurse can provide the information. An informed client is better able to handle fears, frustration, and confusion. Therefore, explain procedures before performing them or having the client experience them. Explanations also help prevent the client from feeling that his space and body are being invaded. The need for pre-procedure education is unrelated to early discharge. Education is a nursing responsibility, but the ultimate rationale is the direct benefit to the client. Nurse practice acts provide direction on nursing responsibility as identified by each state.

The older adult client has been reporting sleeplessness for the past 3 days. Which type of sensory problems can result from this?

cognitive dysfunction Disturbances in remembering, reasoning, and problem solving can occur with sensory overload. Decision making may be irrational or dysfunctional. Other common behaviors indicative of cognitive dysfunction include disorientation, verbalizing disconnected thoughts, reporting of too much going on, sleeplessness, and fatigue, inability to think, and poor work performance. Sensory deprivation also reduces mental capabilities which can result in mind wandering with fantasy activity. Anxiety can provoke feelings of insecurity and loneliness which can lead to sleeplessness but usually not the other way around. Hallucination and delusions can stimulate fear of sleeping and cause sleeplessness.

What type of cognitive responses might a nurse assess in a client with sensory deprivation?

decreased attention span, difficulty problem solving Cognitive responses to sensory deprivation include an inability to control thoughts, decreased attention span, and difficulty with memory, problem solving, and task performance. Mood changes, anxiety, and depression are psychological responses to sensory deprivation.

The nurse is caring for a hospitalized 90-year-old client. What will the nurse include in the care plan?

decreasing environmental noise Sensory functioning tends to decline progressively throughout adulthood. Nursing strategies to maintain client safety for those with a reduction in sensory functioning include: decreasing environmental noise (sensory overload); protecting the client's skin from temperature extremes (decreasing sense of touch); discouraging the use of sedatives (sensory deprevation); and, when communicating with the client, using a lower tone of voice (decrease in hearing).

A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as well as techniques to follow when working with clients with hearing impairments. An appropriate nursing intervention discussed by the instructor includes:

demonstrating or pantomiming ideas to clients with hearing impairments For hearing-impaired clients, demonstrating or pantomiming may assist in communication. Clients should be instructed to avoid cleaning the ear with cotton-tipped applicators or sharp objects as this can cause damage to the inner ear. While speaking directly may enhance communication, speaking loudly will not benefit the client. Clients should be discouraged from using earphones that concentrate loud noise in the ear canal causing acoustic damage.

The nurse is caring for a client in strict isolation and assesses that the client is apathetic and has a decreased attention span. Which intervention should the nurse use to prevent further concerns?

encourage the client to share concerns and perceptions Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. A client in isolation would be in an environment with decreased stimuli and may exhibit cognitive disturbances (such as a decreased attention span) and emotional disturbances (such as apathy). The nurse needs to encourage clients to share fears, concerns, and perceptions and reassure the client that misconceptions do occur with sensory deprivation. Nursing interventions focus on maintaining a sufficient level of arousal by increasing sensory stimuli. Providing earplugs and limiting television use and touch would decrease stimulation.

The nurse is conducting health education with a group of older adults in the clinic. Which activity should the nurse include in the education that can prevent sensory loss in the older adult population?

good management of illness such as hypertension Client education to promote sensory health and function focuses on ways to prevent sensory loss and to maintain general health. Education topics include the importance of frequent eye examinations (yearly) and close control of chronic illnesses such as hypertension and diabetes. Age related changes in eyesight and motor function may affect the ability to drive. Avoiding places full of people can prevent infection but may cause sensory overload in the elderly.

After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment?

having caregiver in the home for the first few days after surgery With rising costs and shorter hospital stays, a client may be discharged while still adjusting to his condition. This can be a new or worsening sensory deficit, or an illness or treatment that causes sensory deprivation or sensory overload. Initiate planning as soon as possible to help the client adjust to sensory dysfunction. The nurse should encourage enlisting the help and cooperation of family and friends, education, assembling sensory aids and equipment, contacting home health services, and locating additional support groups as needed. With the assistance of a family or friend, the client does not need to remove the furnishings. After surgery, the client is not admitted to the hospital. Keeping the house dimly light is a risk for a fall as the client is experiencing a visual deprivation.

A neonatal intensive care nurse is caring for an infant born prematurely. How will the nurse manage the infant's environment to best support his sensory needs?

limiting lighting, visual, and vestibule stimulation To facilitate developmentally supportive care, it is recommended that medically fragile infants such as a premature infant should have limited light, visual, and vestibular stimulation to simulate being in the womb. The premature infant is not a full term infant and has developmental issues that are critical to their growth and development. Stimulation such as touch and frequent visitors is not recommended. The use of bright lights are contraindicated as the hospital environment should mimic the intrauterine environment which is quiet and dark.

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls?

monitor the clients frequently Individualized nurse-client interaction promotes sensory health function. Clients at risk for sensory deprivation may need frequent interaction initiated by the nurse, whereas others may not. In any case, provide appropriate stimuli, such as addressing the client by name, introducing and reintroducing yourself as necessary, explaining all activities, and when leaving, acknowledging when you will return. Family may not be available to assist with client at all times. With a sensory deprivation, the client may not understand the nurse's teaching about fall prevention. Restraints should be used if other less restrictive measures have been exhausted.

Sensory perception is a conscious process of selecting, organizing, and interpreting sensory stimuli. Which functioning organs are essential for the perception of visual stimuli? Select all that apply.

nervous pathways brain reticular activating system Nervous pathways, the brain, and intact and functioning sense organs are required for the perception of stimuli. Stimuli received by the eyes reach the reticular activating system (RAS), which is located in the brainstem. The RAS then sends impulses to the cerebral cortex where they are perceived. The transmission of stimuli and impulses occurs through nervous pathways. The pituitary gland and the olfactory receptors are not essential for perception of visual stimuli. The pituitary gland is mainly responsible for secreting hormones to maintain homeostasis and to stimulate other endocrine glands. Olfactory receptors in the nose receive the stimuli for the perception of smell.

A nurse in the emergency room is assessing a client for sensory perception dysfunction. Which assessment techniques will the nurse use to gather objective data? Select all that apply.

observation diagnostic tests and procedures physical assessment Objective data to assess a client's sensory perception function is collected by observation, physical assessment, and diagnostic tests and procedures. The nurse first observes the client to detect sensory function impairment. During physical assessment, the nurse performs simple tests to check for impairment of the senses. Diagnostic tests and procedures are performed to evaluate the level of sensory perception function and to determine the cause of sensory deficit. Risk identification, normal pattern identification, and dysfunction identification are methods of gathering subjective data for client assessment.

The 85-year-old female client has become increasingly confused while reviewing the vital sign readings. Which reading might contribute to the client's behavior?

oxygen saturation 88% on room air Confusion can be linked to hypoxemia or low oxygen level in the body. Other signs and symptoms include restlessness, headache, shortness of breath, and rapid breathing.The blood pressure of 101/56 is within normal limits of less than 140/90. The heart rate is 101 and the normal is 60-120. The temperature is 99.2 and normal is less than 100.4.

The nurse is conducting a health history with an adolescent client. During the interview, the adolescent tells the nurse about reading with the television on in the background but gets distracted by the sound of his neighbor's dog. What does the nurse identifies is being involved?

reticular activating system The reticular activating system (RAS) is responsible for awareness of the world, is highly selective, and allows discrimination between meaningful stimuli and unimportant stimuli. The nerve endings in the skin are sensory receptors for tactile stimuli, while the auditory receptors are responsible for hearing. The cerebral cortex receives impulses from the RAS and is responsible for the perception of stimuli.

A client who hallucinates simply to maintain an optimal level of arousal is experiencing:

sensory deprivation Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. With decreased sensory input, the reticular activating system (RAS) is no longer able to project a normal level of activation to the brain. As a result, the person may hallucinate simply to maintain an optimal level of arousal. Sensory overload refers to too much stimulus. Cultural care deprivation refers to lacking care that is specific to cultural needs. Sleep deprivation is lack of necessary sleep.

A client has expressed great relief at the improvement in their hearing after irrigation of the ear canal yielded a large amount of impacted cerumen. This client was experiencing a sensory alteration related to:

sensory reception Impacted cerumen is an example of a sensory disturbance that is rooted in interference with the client's reception of stimuli. In this case, sound is unable to stimulate the organs of hearing and the client does not have a deficit in the perception, transmission, or reaction to sound. Sensory perception of pain would come from temperature, mechanical, electrical or chemical stimuli. Sensory transmission occurs by a nerve that passes impulses from receptors toward or to the central nervous system through the afferent nerve and the dorsal root that passes dorsally to the spinal cord and that consists of sensory fibers. A sensory reaction is the reaction time during which the subject's attention is directed to the stimulus rather than the response.

A nurse tells the client with decreased sense of smell to check the expiration dates of food items before buying them. The nurse is employing the use of:

situational sensory aid The client may not be able to smell spoiled food items due to his decreased sense of smell. By telling him to check the expiration date, the nurse is providing the client with a situational sensory aid. Hearing aids, clean glasses, and a thermometer are examples of physical sensory aids. Sensory information is a health promotion method that a nurse can use to prevent the development of sensory perception dysfunction due to a procedure. Stimulation provision involves providing the client with meaningful external stimuli to overcome sensory deficit.

Which example indicates the use of an internal sensory receptor?

spitting out hot coffee Sensory function begins with reception of stimuli by the senses. An example is the spitting out of the mouth hot coffee. Eating sour candies may elicit a facial grimace or not. Hearing loud music may elicit the client to hold their ears. Very bright light may elicit the client to shield their eyes with their hands. Externally, stimuli are visual (sight), auditory (hearing), olfactory (smell), gustatory (taste), and tactile (touch). Their respective receptor organs are the eyes, ears, olfactory receptors in the nose, taste buds of the tongue, and nerve endings in the skin. The response is how the body reacts to the stimuli. Internally, the kinesthetic and visceral senses receive stimuli. Their receptors are nerve endings in the skin and body tissues. The kinesthetic sense influences awareness of the placement and action of body parts.

The nurse is assisting a visually impaired client to ambulate. What would be most appropriate for the nurse to do?

stand just slightly in front of the client on his nondominant side When assisting a visually impaired client with ambulation, stand on the client's nondominant side, about 1 foot in front of him. Have the client grasp your arm with the nondominant hand and use the dominant hand to feel around for barriers or landmarks. Always maintain an uncluttered environment.

The nursing student is studying the reticular activating system (RAS). Which statement indicates to the professor that the student has mastered the information?

the RAS serves to monitor and regulate incoming sensory stimuli The RAS serves to monitor and to regulate incoming sensory stimuli. To receive stimuli and respond appropriately, the brain must be alert or aroused. The RAS, a poorly defined network, extends from the hypothalamus to the medulla. Nerve impulses from all the sensory tracts reach the RAS, which then selectively allows certain impulses to reach the cerebral cortex and to be perceived.

The nurse is creating a care plan for the legally blind client who is confused and easily agitated. Which priority outcome is appropriate for this client?

the client will remain safe Client goals are individualized but focus on achieving optimal sensory function. A nursing diagnosis for the client is Disturbed Sensory Perception. The priority goals for this client is ensuring the client remains safe. Developing an effective communication mechanism is a secondary goal. If the client is confused, he or she may or may not be able to communicate needs or follow instruction. A client may have toileting needs that may make it difficult to remain in the bed at all times. In this care, the nurse cannot assume that this intervention is appropriate.

A nursing instructor is preparing a class presentation about sensory perception across the lifespan. At which developmental stage would the instructor describe sensory perception as at its peak?

young adult A young adult's sensory perception function is at its peak. However, as people reach middle age, they begin to notice certain changes in their sensory system. Eyesight diminishes, sounds become more muffled, and the other sensory systems deteriorate. Preschoolers are in the process of building their sensory perception skills by investigating and learning about the environment. Sensory perception in an adolescent is still in the process of development. At this developmental stage, adolescents are learning to make independent responses based on what is perceived through the senses. As people reach older adulthood, sensory systems deteriorate and sensory perception is weak.