NURS 230 - Ch. 38

A client is experiencing acute confusion. What nursing actions would be appropriate for this client? Select all that apply. 1. Eliminate unnecessary noise. 2. Keep eyeglasses within reach. 3. Place a calendar in the room, and identify each day. 4. Keep the room well lit during waking hours. 5. Provide dark glasses.

Eliminate unnecessary noise. Keep eyeglasses within reach. Place a calendar in the room, and identify each day. Keep the room well lit during waking hours.

During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation. Which nursing intervention should be planned for this client? 1. Use the clock face as a format for describing the position of food on meal trays. 2. Provide all teaching materials in very large font. 3. Ensure that the client has assistance when ambulating. 4. Use only nonirritating soaps for bathing.

Ensure that the client has assistance when ambulating.

The nurse is concerned that a client is experiencing sensory deprivation. What did the nurse assess to make this clinical decision? Select all that apply. 1. Excessive sleeping 2. Confusion at night 3. Anger over minor issues 4. Easily distracted 5. Sitting quietly reading a book

Excessive sleeping Confusion at night Anger over minor issues Easily distracted

The nurse is providing education for the parents of a 7-month-old child who has just been diagnosed with a hearing loss. What guidance should the nurse provide? 1. Expect that the child will be enrolled in a special hearing intervention program immediately. 2. Keep your child in a quiet environment until additional testing is done. 3. Interventions to support hearing are not useful until the child is at least 9 months old. 4. Hearing loss is not serious until 1 year of age.

Expect that the child will be enrolled in a special hearing intervention program immediately.

Which recent change, reported by a clients family, would indicate that the clients hearing ability is decreasing? Select all that apply. 1. Inability to follow directions 2. Mood swings 3. Decreased appetite 4. Complaints of dizziness 5. Answering questions incorrectly

Inability to follow directions Mood swings Complaints of dizziness Answering questions incorrectly

The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ? 1. Schedule a Weber and Rinne test. 2. Observe the clients interaction with significant others. 3. Use an otoscope to visualize the inner ear. 4. Confront the client with the nurses suspicion.

Observe the clients interaction with significant others.

The nurse suspects a client will develop sensory overload. What characteristics did the nurse observe in the client? Select all that apply. 1. Ongoing pain 2. Confusion at night 3. Inability to sleep 4. Easily angered 5. Worrying about upcoming diagnostic tests

Ongoing pain Inability to sleep Worrying about upcoming diagnostic tests

The nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to come to this conclusion? Select all that apply. 1. Sleeplessness 2. Anxiety 3. Apathy 4. Racing thoughts 5. Somatic complaints

Sleeplessness Anxiety Racing thoughts

A client is experiencing changes in taste. What can the nurse do to improve this clients gustatory sense? Select all that apply. 1. Suggest eating each food separately. 2. Offer foods with a variety of flavors. 3. Recommend eating foods that are cold. 4. Promote sips of water between eating different foods. 5. Encourage the client to consume foods of different textures.

Suggest eating each food separately. Offer foods with a variety of flavors. Promote sips of water between eating different foods. Encourage the client to consume foods of different textures.

The nurse is planning care for a client who is experiencing dementia. What essential concept should the nurse consider for this planning? 1. Background noise such as music will keep this client calm. 2. Activities should be scheduled at the same time each day. 3. Pain mediation will increase dementia. 4. It is important to talk with the client throughout procedures.

activities should be scheduled at the same time each day

An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How should the nurse document this mental state? 1. As reversible confusion 2. As sundown syndrome 3. As delirium 4. As dementia

as delirium

The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception, Auditory. What would indicate that interventions to address this diagnosis have been successful? 1. Client places hearing aid on beside table when not in use. 2. Client does not respond appropriately to questions. 3. Client demonstrates use and care of hearing aid. 4. Client demonstrates difficulty with problem solving.

client demonstrates use and care of hearing aid

The client who has the medical diagnosis of Alzheimers disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis problem statement most accurately describes this clients situation? 1. Acute Confusion 2. Altered Role Performance 3. Disturbed Sensory Perception 4. Disturbed Thought Processes

disturbed thought processes

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement? 1. Use short phrases. 2. Overarticulate words. 3. Vary the volume of the voice. 4. Face the client during conversation.

face the client during conversation

A client diagnosed with congestive heart failure has been treated for many years with intravenous furosemide (Lasix). What sensory impairment should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell

hearing loss

The odor from a hospitalized clients draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful? 1. Spray the room routinely with a floral room spray. 2. Instill a vinegar solution into the wound. 3. Keep the wound dressing dry and clean. 4. Burn a candle in the room.

keep the wound dressing dry and clean

A client asks the nurse to please close the door when entering or exiting the room because the noise is more than the client is used to because he lives alone. The nurse identifies the reason for this clients response to sensory stimuli as being due to which factor? 1. Lifestyle 2. Developmental stage 3. Culture 4. Illness

lifestyle

The family of a client in the hospital is concerned about the constant noise in the care area. Which health care professionals have the greatest control over the level of sensory input in the hospital? 1. Physicians 2. Administrators 3. Nurses 4. Planners

nurses

The nurse is identifying diagnoses appropriate for a client recovering from cataract surgery who lives alone. Which diagnosis would be the priority for this client? 1. Social Isolation 2. Risk for Impaired Skin Integrity 3. Disturbed Sensory Perception 4. Risk for Injury

risk for injury

A client can be aroused only with extreme or repeated stimuli. How should the nurse document this clients behavior? 1. Somnolent 2. Disoriented 3. Comatose 4. Semicomatose

semicomatose

A client is hospitalized for treatment of a new disorder. While admitted, the client receives no telephone calls or visitors. The nurse should assess which aspect of the clients sensory-perception function? 1. Risk for sensory overload 2. Social support network 3. Mental status 4. Environment

social support network

The nurse is concerned that a client is not aware of being in the hospital. For what aspects of the sensory process should the nurse assess the client? Select all that apply. 1. Speech 2. Stimuli 3. Receptor 4. Perception 5. Impulse conduction

stimuli receptor perception impulse conduction

A client has been treated for diabetes mellitus since childhood. Currently, the clients blood glucose reading is 180 mg/dl. For which sensory disturbance should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell`

vision loss

The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this intervention? 1. Walk slightly behind the client. 2. Walk 1 foot in front of the client. 3. Walk on the right side of the client. 4. Walk on the left side of the client.

walk 1 foot in front of the client

The nurse is assessing a client for possible sensory deprivation. What findings would indicate the client is at risk for developing this sensory disorder? Select all that apply. 1. Client has severe pain. 2. Client has impaired vision. 3. Client is unable to ambulate. 4. Client is on medication that alters sensory perception. 5. Client has no family in the immediate area.

Client has impaired vision. Client is unable to ambulate. Client is on medication that alters sensory perception. Client has no family in the immediate area.

The nurse documents that a client is fully conscious. What did the nurse assess in this client? Select all that apply. 1. Client responded to verbal stimuli. 2. Client responded to written words. 3. Client oriented to time, place, and person. 4. Client demonstrated poor memory. 5. Client alert.

Client responded to verbal stimuli. Client responded to written words. Client oriented to time, place, and person. Client alert.