Sensory Perception Prep U

During a client assessment, the nurse has the client close his eyes. The nurse then places her finger on his right thigh. She asks the client where he is being touched and he answers "my right thigh." This is an example of which sense?

Kinesthetic The kinesthetic sense influences the awareness of placement and action of body parts

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which of the following questions should she ask?

"Do you work around loud noises at work?" Clients may be at risk for sensory disturbances for different reasons. Lifestyle factors include work or leisure activities that are potentially harmful to the eyes and ears, such as loud noises. Physiologic factors, such as diabetes and use of medications (chemotherapy), place clients at risk for sensory disturbances as well. Social and environmental factors include human and environmental stimulation (living by oneself).

The oncology nurse is caring for a client receiving chemotherapy. Which of the following statements would be a priority assessment for the nurse?

"Have you been experiencing any strange tastes or aftertastes lately?" Clients receiving chemotherapy may have altered gustatory or olfactory sensations. Asking about taste would be an assessment for this condition. Repeating softly spoken words assesses auditory disturbances, feeling assesses tactile disturbances, and reading assesses visual disturbances.

The student is explaining the factors affecting sensory stimulation to his professor. The professor knows that which of the student's statements is most accurate?

"Religious norms within a culture influence the amount of sensory stimulation a person seeks." Ethnic norms, religious norms, income group norms, and the norms of subgroups within a culture all influence the amount of sensory stimulation a person seeks and perceives as meaningful. The amount of stimuli different people consider optimal appears to vary considerably. Sensory functioning tends to decline progressively throughout adulthood. Narcotics and sedatives decrease awareness of sensory stimuli.

Which situation demonstrates sensory adaptation?

A client has learned to sleep through the frequent beeping of the intravenous pump. Adaptation occurs when the body adapts to constant stimuli, such as the continuous beeping of a hospital device. Adaptation is not the same as compensation. Compensation is when the client learns sign language for the hearing loss, and uses large print books for visual changes. A client believes their hearing has become more acute since the loss of his vision is an assessment of a personal change and not a nursing assessment.

The nursing diagnosis Risk for Sensory Deprivation is best suited for which client?

A client whose room at the end of the hallway has the door closed most of the time A nurse should realize that a person who experiences less than the usual stimulation may be at risk for sensory deprivation. The client who is at the end of the hallway and has the door closed may be at risk. The client who is talking to a nurse for a period of time is not exhibiting less than ideal stimulation. The client who manipulates the television and is able to fall asleep even when the television is loud identifies the ability of a client who is used to stimulation and not at risk for sensory deprivation.

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 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.

A client in a long-term care facility cannot control the direction of thought content, has a decreased attention span, and cannot concentrate. Which effect of sensory deprivation might the client be experiencing?

Cognitive response Cognitive responses involve the client's inability to control the direction of thought content. Typically, attention span and ability to concentrate are decreased. Perceptual responses result from inaccurate perception of sights, sounds, tastes, smells, and body position, coordination, and equilibrium. Emotional responses typically are manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. A physical response does not relate to thought processes.

A client brought to the emergency room is unconscious and cannot be aroused. The client is breathing and has a heartbeat. What state of awareness is this client exhibiting?

Coma Unconscious states include asleep, stupor, and coma. Coma is characterized by an inability to be aroused and no response to stimuli. A client in a stupor can be aroused by extreme and/or repeated stimuli. Sleep is a naturally recurring state of mind and body, characterized by unconscious, relatively inhibited sensory activity, inhibition of nearly all voluntary muscles, and reduced interactions with surroundings. During sleep the client can be awakened.

The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?

Decrease background noises, as much as possible, before speaking. Presbycusis is the loss of high frequency, sensorineural hearing. Background noise further aggravates hearing deficit, so limiting noise would help the client to hear better. Clearing pathways in the room would be used for a client with visual impairment. Clear communication regarding self-care activities would be used for a confused client. Routine oral hygiene is useful for clients with taste alterations.

An older adult client who is in a long-term care facility tells the nurse, "I'm not eating that, it's poisoned." The nurse interprets this as which manifestation of altered sensory perception?

Delusion The client is exhibiting delusional behavior. Delusions are beliefs not based in reality that reflect an unconscious need or fear. Hallucinations are sensory impressions, such as hearing voices, based on internal stimulation. Sensory deficit is impaired function in sensory reception or perception. Withdrawal is characterized by loss of interest in activities or interaction with others.

A hospitalized client refuses to eat because she fears that the kitchen personnel are poisoning her food. What is this client experiencing?

Delusions Delusions, beliefs not based in reality, reflect an unconscious need or fear.

The nurse is caring for Nancy, a 45-year-old client with diabetes mellitus. She has severe neuropathy and consequently has little or no feeling in her feet and lower legs. The nurse includes which nursing interventions in the care plan related to this lack of tactile sensation? Select all that apply.

Educate client to never go barefoot. Protect skin from temperature extremes. Perform frequent, thorough skin assessments. Assess for shoe type and correct fit. For a client with a decreased sense of touch, do the following: protect the client's skin from temperature extremes; assess the extremities for breaks in the skin, blisters, drainage, or open wounds; and ensure the client is ambulating with assistive devices. Clients with diabetic neuropathy should wear shoes with a wide toe box, should not go barefoot, and should wear clean, white cotton socks.

The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client?

Eliminating disturbing odors with adequate ventilation Olfactory or smell disturbances can be aided by eliminating disturbing odors with adequate ventilation. Earplugs help those with auditory disturbances. Oral care is useful for those with taste disturbances. Protecting the skin is important for those with tactile disturbances.

A group of student nurses is observing an older adult client sitting by the nurses' station folding towels and washing clothes. One student verbalized that it was not appropriate to have the client do this. Which response will show good understanding of this activity?

Folding towels is a self-stimulating activity. A nurse should encourage clients to provide self-stimulation for relaxation and adaptation, such as singing, reading, and talking into a tape recorder and playing it back. Self-care activities also are forms of self-stimulation such as folding laundry, cleaning or vacuuming. Various different types of stimulation encourage maximum use of the client's available senses and helps the person adapt to any changes. Folding the towels is not supporting noncompliance nor allowing the nurses to guard the client. Self stimulation can assist with clients who are confused to limit use of least restrictive efforts to keep a client focused.

Older adult clients easily become confused when admitted to the hospital. The nurse understands that there are various reasons for this. Which reason further supports this phenomenon?

Hospital procedures and its environment may trigger sensory overstimulation. A primary nursing concern is to prevent symptoms of sensory overload for clients. Risk for sensory overload greatly increases when unfamiliar procedures are taking place and the business of the health care facility. The client is not affected by the different hospital personnel but the overabundance of personnel. It is not true to assume that older clients respond poorly to instruction. Confusion for the older adult in the health care setting is related to sensory overload rather than infection.

A child 4 years of age has a mother who is employed and works from home. To accomplish her daily work, she allows the child to watch television for 6 to 8 hours a day. Based upon this information, what nursing diagnosis would be applicable to this family?

Impaired Parenting associated with failure to provide stimuli for growth Based upon lack of stimuli (sensory deprivation), an appropriate nursing diagnosis is Impaired Parenting associated with failure to provide stimuli for growth. There is no information that states the child has impaired senses, sensory overload, or impaired skin integrity.

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory Impaired memory is a state in which an individual experiences the inability to remember or recall bits of information or behavioral skills. Disturbed sensory perception is a state in which the individual experiences a change in the amount, pattern, or interpretation of incoming stimuli. Acute confusion is the abrupt onset of a cluster of global, transient changes, and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycle. Chronic confusion is an irreversible, long-standing, or progressive deterioration of intellect and personality, characterized by decreased ability to interpret environmental stimuli or decreased capacity for intellectual thought.

The client who has been recently diagnosed with a stroke is observed to have changes in sensory reception. Which statement justifies the change in behavior?

Ischemia in certain parts of the brain interferes with nerve functions. Altered sensory reception occurs in such conditions as spinal cord injury, brain damage, changes in receptor organs, sleep deprivation, and chronic illness. The person does not receive adequate sensory input because of an interference with the nervous system's ability to receive and process stimuli and in this case a loss of perfusion and ischemia as a result of a stroke. The decrease of blood flow inhibits perfusion and not intracellular hormones. The medications used to treat clots do not cause confusion but the stroke impairment does. The client may be unfamiliar with the setting but this is not the pathophysiology of what occurs with a stroke.

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?

Limit lighting, visual, and vestibular 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 client 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.

The nurse is working on a neurological unit and a physician asks the nurse to perform a sensory experience assessment for a client. The nurse thinks about what things may place a person at risk for disturbed sensory perception and comes up with which of the following? Select all that apply.

Neuropathy related to diabetes mellitus Diminished senses related to advanced age Medications that alter certain senses Aging is often accompanied by diminished senses. Diseases can diminish senses. Diabetes-related neuropathies can result in a loss of sensation in the limbs, rendering the client with diabetes unable to feel hot objects such as bath water, which can result in burns. Certain drugs affect taste. Wearing corrective devices, such as eyeglasses and hearing aids, does not put anyone at risk for disturbed sensory perception.

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 of 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.

A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness?

Somnolence When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. A person in a coma cannot be aroused and does not respond to stimuli. Someone who somnolent is extremely drowsy, but will respond normally to stimuli.

The following are steps on how to remove the client's contact lenses. After the nurse washes her hands, which step should be done next?

Pull the client's upper and lower lid apart and pull tautly toward the lateral side. A nurse should know how to remove contact lenses in a client. The following are the steps. 1. Wash hands > 2. Position client comfortably in a sitting position, if possible. > 3. Pull the client's upper and lower lid apart and pull tautly toward the lateral side. > 4. Ask the client to blink, and the lens should pop out into your hand. > 5. An alternative method for removing hard contact lenses is the use of a lens suction cup. This is particularly useful for a client who cannot consciously assist with the removal. After removal, the lenses should be placed in contact lens solution or normal saline to protect the lenses from drying out. The lens should not be grasped with the thumb and index finger.

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and she believes she is in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time. It is appropriate to reorient clients who are confused. Doing so in an effective and empathic manner requires the astute implementation of nursing skills. Engaging more deeply with the client's incorrect responses does not reorient her. Attempting to reorient the client in a subtle and indirect manner is not likely to be effective. Documenting the client's response is necessary, but this should be followed up by reorientation.

The nurse is preparing to reposition a confused client from a supine position to a side-lying position. The nurse has asked the client to shift her weight accordingly, but the client has not responded to the nurse's request. How should the nurse respond?

Rephrase the direction in different terms. Rephrasing an instruction in simple terms may enhance a confused client's understanding. This is preferable to proceeding in spite of the client. Asking for help from a colleague and asking the client if she feels confused are not likely to enhance communication with the client. If the nurse repositions the client without involving the confused client, it may cause more confusion and anger of the client toward the nurse.

A hospital client has been awakened at night by the alarm on his roommate's intravenous pump. This client was aroused by brain action in his:

Reticular activating system (RAS) The RAS is the network that mediates arousal. The limbic system is a complex system of nerves and networks in the brain, involving several areas near the edge of the cortex concerned with instinct and mood. It controls the basic emotions (fear, pleasure, anger) and drives (hunger, sex, dominance, care of offspring). Cerebellum is the part of the brain that coordinates and regulates muscular activity. The prefrontal cortex is a part of the brain located at the front of the frontal lobe and is involved in a variety of complex behaviors and personality development.

A cycling accident has resulted in a head injury to a client with resultant increased intracranial pressure. Consequently, the client has been placed in a private room with low light and care has been organized to minimize disturbances. What situation is the client most likely at risk for?

Sensory Deprivation A care environment that is deliberately organized to minimize stimulation can create a risk of sensory deprivation. A client with a head injury should have a reduced sensory environment to keep intracranial pressure lower and decrease potential complications. Confusion, acute or chronic, are considered complications related to increased intracranial pressure and changes in oxygenation.

A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the client experiencing?

Sensory deficits Sensory deficits in vision and hearing interfere with one's ability to interact with other people and with the environment.

The nurse is developing a plan of care for a client with hearing impairment. What interventions should be implemented to assist the client with communication? Select all that apply.

Speak only when facing the client. Make sure the client's hearing aids are functioning appropriately Look directly at the client's eyes when speaking. When communicating with the client with a hearing impairment, use a lower tone. Ensure that the patient is using appropriate and functioning hearing assistive devices and that they are clean and clear of debris. It is not necessary to speak loudly. Speak so that the patient can see your mouth movements by standing in front of the client. The client should be given the opportunity to develop lip reading and verbal communication instead of only allowing the client to use written communication.

The nurse is caring for a client who sustained a traumatic brain injury in a skiing accident. The client is breathing independently, drowsy, but arousable with extreme or repeated stimuli. How will the nurse document the client's level of consciousness?

Stupor When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. A person in a coma cannot be aroused and does not respond to stimuli. Someone who somnolent is extremely drowsy, but will respond normally to stimuli.

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.

The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulus of a continuing noise often goes unnoticed. The ICU nurse explains that this phenomenon is known as:

adaptation The body quickly adapts to constant stimuli. The repeated stimulus of a continuing noise, such as a low-level cardiac alarm, eventually goes unnoticed. A stimulus must be variable or irregular to evoke a response. This phenomenon is termed adaptation. Sensoristasis is the optimal arousal state of the reticular activating system. Cortical arousal refers to the different states of arousal or awareness. Sensory overload is the condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli.

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 73-year-old client with diabetes about insulin administration?

allowing more time for the processing of the information As a person approaches 60 to 70 years of age, marked decrements in sensory/perceptual behaviors begin. This reduction in efficiency means that older people cannot process sensory input as rapidly as they did when they were young.

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.

When a new mother asks the nurse whether her newborn infant can see her, the best response by the nurse is to tell the mother that her infant:

can see light and dark patterns. Newborns see only gross patterns of light and dark or bright colors. As they grow, vision becomes more discriminating.

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).

Which conditions occur in clients who are experiencing the effects of sensory deprivation? Select all that apply.

inability to control direction of thought content difficulty with memory, problem solving, and task performance inaccurate perception of sights, sounds, tastes, and smells Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. Common conditions that result from sensory deprivation include inaccurate perception of sights, sounds, tastes, and smells; inability to control the direction of thought; and difficulty with memory, problem solving, and performing tasks. Decreased coordination and equilibrium, lack of a caring attitude, and unstable moods are also common conditions associated with sensory deprivation.

When a person selects, organizes, and interprets sensory stimuli, the process is termed:

perception. Sensory perception is a conscious process of selecting, organizing, and interpreting sensory stimuli that requires intact and functioning sense organs, neuronal pathways, and the brain.

A client who has awakened from a coma after a car accident and states, I knew about a news story reported during the time I was in the coma." What does the nurse identify is occuring with the client?

reticular activating system's stimulation Destruction of the reticular activating system produces coma and an electroencephalograph pattern consistent with sleep. When the nervous system is oriented to a stimulus and receptive toward it, the neurons of the RAS arouse the brain, facilitating information reception (Widmaier, Raff, & Strang, 2008). The RAS is highly selective.

A nurse explains to a client what he will typically see, hear, and feel during his scheduled surgery. The nurse is engaged in:

sensation information The nurse is implementing procedure preparation to prevent overstimulation of the client before the surgery. More specifically, the nurse is using sensation information which involves objectively and specifically describing to the client, in serial order, what he typically will see, hear, smell, taste, or feel (tactile) in a particular situation (rare or atypical events are not to be included). Outcome identification is the establishment of goals and outcome criteria to achieve optimal sensory function. Dysfunction identification is an assessment method used to identify actual sensory loss. Stimulation reduction is a nursing intervention for altered sensory perception function, which involves reducing the amount of stimulation provided to the client to promote sensory perception.

A client who is blind is said to be experiencing:

sensory deficit. Impaired or absent functioning in one or more senses, such as blindness, is termed sensory deficit. Sensory overload is excessive stimulation of one or more of the senses. Sensory deprivation is insufficient stimulation of one or more of the senses. Sensory overstimulation is not a common term used in health care.

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.