Chapter 44- Sensory Functioning

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

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

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

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.

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

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

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 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

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

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.

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.

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

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.

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.

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

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

decreasing environmental noise

A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as:

delirium.

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.

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

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).

A client who is blind is said to be experiencing:

sensory deficit.

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

sensory deprivation.

The nurse is caring for a client who has been placed in respiratory isolation. The nurse understands that the client is at risk for:

sensory deprivation.

A client has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the client. When the physician leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing:

sensory overload.

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.

A sensory deficit that may arise from the client's eyes being bandaged after eye surgery can result in:

total disorientation.

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?"

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?"

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."

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 student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.

-Depression -Sleeplessness -Decreased interest in activities

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 is caring for a client at risk for sensory deprivation. What interventions should the nurse implement to decrease the client's risk? Select all that apply.

-Encourage the client's family to bring in personal objects. -Place a clock and calendar in the client's room. -Brush the client's hair. -Speak slowly and clearly to the client.

The nurse is caring for Mr. Cantrell, a 69-year-old client. He has gradually lost much of the ability to hear in both ears due to working with loud machinery all of his working life. Which interventions will the nurse add to Mr. Cantrell's care plan in order to make him more comfortable with his hearing loss? Choose all that apply.

-Face the client; use meaningful gestures. -Be aware of nonverbal communication. -Decrease background noise if possible. -Do not chew gum or food when speaking.

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.

-Inform the client when the nurse is leaving the room -Acknowledge presence when entering the room. -Clear the room of clutter and do not rearrange furnishings. -Orient to sounds in the immediate environment.

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.

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.

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.

-Perform frequent, thorough skin assessments. -Assess for shoe type and correct fit. -Educate client to never go barefoot. -Protect skin from temperature extremes.

Which nursing actions are performed according to guidelines for caring for clients with hearing impairments? Select all that apply

-Position yourself so that the light is on your face when you speak. -Demonstrate or pantomime ideas you wish to express. -Write down any ideas that you cannot convey to the person in another manner.

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 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.

-diminished senses related to advanced age -neuropathy related to diabetes mellitus -medications that alter certain senses

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

-inaccurate perception of sights, sounds, tastes, and smells -inability to control direction of thought content -difficulty with memory, problem solving, and task performance

The nurse is caring for a client with sensory perception deficits. Which sensory aids can the nurse use for this client to adjust to these deficits? Select all that apply.

-literature with large print -speaking slowly -fresh food served for meals -turning and repositioning -sips of water between foods

A client who is experiencing sensory deprivation may benefit from the use of good working sensory aids. What sensory aids can the nurse implement to prevent the occurence of sensory deprivation in this client? Select all that apply.

-make sure the client has working hearing aids with fresh batteries -clean prescription glasses -schedule activities for the day -assess the fit of dentures

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 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.

A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, "Get the bugs off my bed, I can feel them crawling on me!" Which nursing diagnosis is appropriate for this client?

Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me."

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

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.

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