Taylor's Fundametnals PrepU Ch. 45 Sensory Functioning
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." "The brain must receive the stimulus and convert it to a nerve impulse." "The nerve impulse is conducted along a nervous pathway from the brain to the receptor or sense organ." "A particular area in the spinal cord must receive and translate the impulse into a sensation."
"An agent, act, or other influence capable of initiating a response by the nervous system must be present." Explanation: 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.
The school nurse is preparing a teaching plan for young school-aged children on ways to maintain eye health and prevent eye damage. What information would the nurse include in the plan? Select all that apply. "Do not rub your eyes." "Reading in poor light will not harm your eyes." "Do not look directly at the sun on sunny, bright days." "If you have difficulty seeing objects, report this to your parents or teacher." "You can clean your eyes even with a used washcloth."
"Do not rub your eyes." "Do not look directly at the sun on sunny, bright days." "If you have difficulty seeing objects, report this to your parents or teacher." Explanation: Instructions to include in a teaching plan about maintaining eye health and preventing eye damage include do not rub the eyes, avoid damage from ultraviolet rays, and know the danger signals that may indicate serious eye problems. Thus, the nurse would instruct the children not to look directly at the sun on sunny, bright days. The nurse would teach the children to notify an adult if the child has difficulty seeing objects. The nurse would include information about not reading in poor light. This will cause eyestrain. The nurse would include information about cleaning the eyes with clean cloths to avoid injury or infection of the eyes.
The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which question will the nurse ask? "Do you work around loud noises at work?" "Do you have diabetes?" "Are you receiving chemotherapy?" "Do you live by yourself?"
"Do you work around loud noises at work?" Explanation: 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?" "Repeat the words that I will softly speak close to each ear." "Close your eyes and tell me when you feel something." "Please read my name tag."
"Have you been experiencing any strange tastes or aftertastes lately?" Explanation: 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 nurse teaching a prenatal class is educating parents on infants' sensory abilities. What information should the nurse provide? "Neonates have underdeveloped senses that gradually emerge over the first six months." "Newborns have little hearing ability for the first few weeks of life." "Infants see in black and white until approximately eight months old." "Newborns has see bright moving objects almost immediately after birth."
"Newborns has see bright moving objects almost immediately after birth." Explanation: Sensory perception is well developed at birth in the newborn. Newborns can focus on bright moving objects within 8 inches of the visual field, within the first hour of life. Hearing acuity is present at birth. Infants do not see in black and white.
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? "Medically fragile infants need constant light and visual stimulation." "Rocking and changes of body position will help to stimulate visual sensations." "Stimulation is not needed as the neural pathways are mature in the newborn." "The use of mobiles will stimulate visual sensation."
"The use of mobiles will stimulate visual sensation." Explanation: 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.
An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned." Which is the best way for the nurse to address the client's statement? "Would you like another meal?" "What makes you think the food is poisoned?" "It is okay to eat. The food is not poisoned." "I will get you another meal."
"What makes you think the food is poisoned?" Explanation: The client is exhibiting delusional behavior. Delusions are beliefs not based on reality that reflect an unconscious need or fear. By asking an open-ended question the nurse can determine why the client is making the statement and create a strategy to change the client's perspective. Asking the client if he or she wants another meal or bringing the client another meal does not address the underlying issue. Telling the client it is okay to eat the meal is not recognizing the client's fear and could damage the nurse-client relationship.
Which situation demonstrates sensory adaptation? A client has learned to sleep through the frequent beeping of the intravenous pump. A client with hearing loss has learned to communicate using sign language. A client with vision loss has begun buying large-print books. A client believes their hearing has become more acute since the loss of his vision.
A client has learned to sleep through the frequent beeping of the intravenous pump. Explanation: 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.
In which of the following clients will the nurse document the presence of delusions? A client who sees spiders and rats in their room that do not exist A client who has become nonresponsive after hearing distressing news A client who is fearful of being in public and in wide open spaces A client who believes the hospital kitchen staff are poisoning her food
A client who believes the hospital kitchen staff are poisoning her food Explanation: Delusions, beliefs not based in reality, reflect an unconscious need or fear. Hallucinations involve sensing something that does not exist. Becoming nonresponsive does not indicate delirium. Fear of wide open spaces suggests a phobia, not delirium
For which client will the nurse provide interventions aimed at preventing sensory overload? A 17-year-old on bed rest after an orthopedic surgical procedure A 55-year-old, newly diagnosed with diabetes in a private room in a hospital An 88-year-old on a ventilator in an intensive care unit An 8-year-old in isolation in a private room in a hospital
An 88-year-old on a ventilator in an intensive care unit Explanation: Intensive care units, mechanical ventilators, lengthy verbal explanations prior to procedures, and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload. Private rooms, mobility restraints (such as traction or bed rest), isolation, and few visitors are all risk factors for sensory deprivation.
An intensive care unit (ICU) has taken action to eliminate unnecessary noises and lights on the unit. What is the most likely outcome of this initiative? Clients would be put in a state of sensoristasis. Clients will experience decreased levels of anxiety and irritability. Sensory adaptation will be promoted in the ICU Clients will experience reduced activity of the reticular activating system.
Clients will experience decreased levels of anxiety and irritability. Explanation: Sensory stimulation in the environment affects sensory perception. The lights, sounds, and action in the ICU may put the client in a state of sensory overload, which results in irritability, anxiety, and difficulty concentrating. Sensoristasis is the state of optimal arousal which is more related to the ability to learn and perform to the highest level. Sensory adaptation occurs when the brain stops perceiving constant stimuli. The reticular activating system brings together information from the brain with information from the sense organs, reducing extraneous stimuli does not depress the RAS.
An intensive care unit (ICU) has taken action to eliminate unnecessary noises and lights on the unit. What is the most likely outcome of this initiative? Clients would be put in a state of sensoristasis. Clients will experience decreased levels of anxiety and irritability. Sensory adaptation will be promoted in the ICU Clients will experience reduced activity of the reticular activating system.
Clients will experience decreased levels of anxiety and irritability. Explanation: Sensory stimulation in the environment affects sensory perception. The lights, sounds, and action in the ICU may put the client in a state of sensory overload, which results in irritability, anxiety, and difficulty concentrating. Sensoristasis is the state of optimal arousal which is more related to the ability to learn and perform to the highest level. Sensory adaptation occurs when the brain stops perceiving constant stimuli. The reticular activating system brings together information from the brain with information from the sense organs, reducing extraneous stimuli does not depress the RAS.
The nurse is caring for a client who suffered a stroke 3 days ago and is assessing the client's state of arousal. Which is the best way to determine the client's level of being alert and responding appropriately to the environment? Collecting mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills. Determining level of consciousness and sensory skills, memory, and cognitive skills. Collecting sensory system data, including vision, hearing and proprioception. Determining any loss of sensory skills including balance and level of awareness.
Collecting mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills. Explanation: Sensoristasis refers to a person's optimum state of arousal through stimulation. When stimulation is constant, adaptation occurs. To determine the client's level of alertness the nurse should collect mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills. Collecting only portions of the senses such as just vision and hearing is not a thorough assessment. Likewise, determining only loss of sensory skills is not thorough enough to address sensoristasis.
The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply. Depression Increased appetite Sleeplessness Decreased interest in activities Increased interest in interactions with others
Depression Sleeplessness Decreased interest in activities Explanation: Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The client who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as depression mounts, leading to further sensory deprivation.
A client is refusing to take his prescribed medication, stating that the government would then be able to track his whereabouts. What is the nurse's most appropriate action? Assess orientation to person, place and time Document the client's delusion Assess for additional hallucinations Provide interventions to lessen sensory overload
Document the client's delusion Explanation: Delusions, such as the client's belief, are beliefs that are not based in reality. Hallucinations are sensory impressions that are based on internal stimulations, as opposed to untrue beliefs. Gauging the client's orientation does not address the false content of the client's beliefs. Delusions can be present for many different reasons, not only from sensory overload.
A client is admitted to the intensive care unit. Which way can the nurse decrease sensory overload in this unit? Give the client a tour of the unit. Assure the client that the nurses will take care of everything. Tell the client to turn on the call light if there are questions. Explain unfamiliar procedures to the client.
Explain unfamiliar procedures to the client. Explanation: Severe sensory alterations can occur when a client is admitted to a health care agency, especially in certain areas such as intensive care units (termed intensive care unit [ICU] psychosis). By explaining unfamiliar procedures the client will have a better chance of avoiding sensory overload. In most cases a client in an ICU will be too ill for a tour. The client should be instructed to use the call light, but preventative explanation will be most effective.
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 Disturbed sensory perception Acute confusion Chronic confusion
Impaired memory Explanation: 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.
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? Delirium related to side effects of medication as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me." Hallucinations as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me." Sensory deficit related to client statement of "Get the bugs off my bed, I can feel them crawling on me." Impaired tactile perception related to side effects of medication as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me."
Impaired tactile perception related to side effects of medication as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me." Explanation: The correctly written nursing diagnosis is Impaired tactile perception 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." This client does not have a sensory deficit, but rather a sensory impairment. Hallucination and delirium are not nursing diagnoses.
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. Provide an active, stimulating environment. Encourage frequent visitors and tactile stimulation at least hourly. Provide changing patterns of light and shade, and the use of bright objects.
Limit lighting, visual, and vestibular stimulation. Explanation: 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? Secure a restraint order from the health care provider. Educate the client on the risk for falls. Require a family member to be in the room at all times. Monitor the client frequently.
Monitor the client frequently. Explanation: 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.
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. Provide varying levels of stimulation throughout the day. Offer simple explanations before a treatment or procedure. Set up a consistent schedule for routine care activities. Speak to the client in a loud tone of voice. Suggest the use of noise-reducing headphones or ear plugs.
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. Explanation: 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 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. Do not allow assistive devices to be used. Assess for shoe type and correct fit. Educate client to never go barefoot. Protect skin from temperature extremes.
Perform frequent, thorough skin assessments. Assess for shoe type and correct fit. Educate client to never go barefoot. Protect skin from temperature extremes. Explanation: 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 older adult client, who lives alone, has been admitted to the intensive care unit (ICU) following a stroke. She is now agitated and complaining about the noise. What will the nurse add to her care plan? Instruct the client in self-stimulation methods such as singing. Provide pet therapy. Provide a consistent, predictable pattern of stimulation. Offer frequent back rubs.
Provide a consistent, predictable pattern of stimulation. Explanation: In some clients, especially those coming from a quiet environment with unvarying stimuli, the experience of being hospitalized quickly results in sensory overload. One nursing action to decrease excessive stimulation is to provide a consistent, predictable pattern of stimulation to help the client develop a sense of control over the environment. The other options are nursing interventions used for sensory deprivation, as they increase stimulation.
A client in the intensive care unit becomes very cognizant of the nurse's touch. This is a function of which system? General adaptation syndrome Local adaptation syndrome Reticular activating system Peripheral nervous system
Reticular activating system Explanation: The reticular activating system (RAS) is responsible for bringing together information from the cerebellum and other parts of the brain with information obtained from the sense organs. Awareness of the world depends on the RAS, which is located between the nerve centers of the medulla oblongata in the brain stem. Sensory, visceral, kinesthetic, and cognitive input stimulate the RAS. This is not the domain of the peripheral nervous system. Adaptation syndrome is related to the stress response.
When admitting a client with paraplegia who uses a wheelchair to the hospital, the nurse assesses the client for injuries. What aspect of the client's circumstances create a heightened risk for injury? Sensory alteration Sensory overload Alterations in the gustatory senses Sensory progression
Sensory alteration Explanation: Altered sensory function occurs in such conditions as spinal cord injury, brain damage, changes in receptor organs, sleep deprivation, and chronic illness. A client with paraplegia has impaired tactile sensation, making pressure injuries a significant risk. Alterations in the gustatory senses do not contribute to a risk for injury. Sensory overload can be distressing but does not normally lead to a risk for injury.
A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the client experiencing? Physical Psychological Sensory deficits Sociocultural
Sensory deficits Explanation: Sensory deficits in vision and hearing interfere with one's ability to interact with other people and with the environment.
A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and then informed that she demonstrates signs of breast malignancy. The nurse will monitor the client for signs and symptoms of what effect? Adaptation Sensory deprivation Stimulation Sensory overload
Sensory overload Explanation: When the RAS is overwhelmed with input, a person may experience sensory overload and feel confused, anxious, and unable to take constructive action. A rapid series of testing culminating in a diagnosis may result in sensory overload. Sensory deprivation is the opposite phenomenon. Adaptation involves blocking out repeated stimuli.
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 Coma Stupor Asleep
Somnolence Explanation: 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 client returning from the operating room is unconscious. What guidelines should the nurse consider when communicating with this client? Talk to the client in a normal tone of voice. Gently shake the client's hand or arm before speaking to him or her. Provide loud environmental stimuli to assist in arousing the client. There are no guidelines to consider because the client cannot hear the nurse.
Talk to the client in a normal tone of voice. Explanation: As a client is recovering from unconsciousness, the nurse should assume the person can hear them. The nurse should be careful of what is said in the person's presence and speak in a normal tone of voice. Speak to the person before touching because touch is an effective means of communication but in this case, the nurse should talk to the person first.
As part of a comprehensive assessment, the nurse is assessing a client's somatic sensation. When performing this assessment, what is the nurse's best action? Perform Weber and Rinne tuning fork tests Have the client close their eyes and bring an index finger to the tip of their nose Have the client grasp the nurse's fingers on each hand and squeeze firmly Test the client's ability to discern light touch on a skin surface
Test the client's ability to discern light touch on a skin surface Explanation: Somatic (tactile) sensation can be tested in several ways, including testing light touch of extremities with a wisp of cotton. Weber and Rinne tuning fork tests determine hearing ability. Bringing a finger to the nose tests coordination and grip strength assesses bilateral strength; neither of these assessments tests sensation.
Which short term goal may be appropriate for a client experiencing sensory overload? The client will remain safe at all times. The client will maintain the functioning of existing senses. The client will achieve sensoristasis. The client will demonstrate achievement of self-care.
The client will remain safe at all times. Explanation: Client goals are individualized but focus on achieving optimal sensory function, for achieving client safety. The client needs to remain safe and that can be achieved by a variety of ways. Being sensitive to how visual stimuli, noises, and touch are stimulating the client, combined with paying attention to the client's need for privacy and for social interaction, can significantly reduce disturbances in sensory perception and keep the client safe. The optimal arousal state of the RAS is a general drive state called sensoristasis. When overloaded, the client will lose some of the functioning of the existing sense to compensate for sensoristasis. Self care may be compromised in sensory overload as the client is not able to determine the importance of self care activities.
A client has suffered chemical burns to both eyes, requiring total bandaging. The sensory deficit that results can cause what problem? Delirium Hallucinations Overcompensation Total disorientation
Total disorientation Explanation: A sudden loss of sensory perception through a sensory deficit can cause total disorientation because compensation does not occur immediately. The client's bandaging of both eyes creates a sudden loss of sensory input. This is unlikely to result in delirium or hallucination. Overcompensation may be a possibility after a prolonged period in this condition.
A client expresses concern about not being able to identify salty or bitter tastes. Which action will the nurse take? With eyes closed, have the client identify salty or bitter tastes. With eyes open, have the client identify salty or bitter tastes. Request the client to provide a list of foods that cannot be identified. Instruct the client to taste bitter vegetables such as Brussel sprouts or kale and report the results.
With eyes closed, have the client identify salty or bitter tastes. Explanation: The best way to test taste sensation is for the nurse to have the client identify salty or bitter tastes with eyes closed. Having the eyes closed prevents the client from seeing which taste is being offered. Having the client provide a list of foods or perform testing without supervision may not result in a proper assessment.
A client has newly diagnosed cirrhosis and has pulled his nasogastric (NG) tubing for the third time. The client's ammonia level is above normal. Which nursing cocnern is appropriate for this client? altered rest and comfort altered thought process unproductive impulse control acute confusion
acute confusion Explanation: Electrolyte imbalances, alterations in blood chemistry (e.g., elevated ammonia, elevated blood urea nitrogen), and toxic levels of drugs that affect the central nervous system can alter sensoristasis resulting in acute confusion. Altered rest and comfort would be a nursing concern for a client experiencing difficulty getting to sleep and staying asleep. Altered thought process would be a nursing concern for a client experiencing hallucination or delusions. Unproductive impulse control would be a nursing concern for a client experiencing attention deficit disorder or attention deficit-hyperactivity disorder.
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. sensoristasis. cortical arousal. sensory overload.
adaptation. Explanation: 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.
A 4-year-old child's parent is employed and works from home. To accomplish their daily work, the parent allows the child to watch television for 6 to 8 hours per day. Based on this information, what nursing concern is applicable to this family? altered parenting associated with failure to provide stimuli for growth lack of diversional activities related to impaired senses altered thought processes related to sensory overload altered skin integrity related to absent tactile sensation
altered parenting associated with failure to provide stimuli for growth Explanation: Based on lack of stimuli (sensory deprivation), an appropriate nursing concern for this family altered parenting associated with failure to provide stimuli for growth of the child. There is no information that states the child has impaired senses, sensory overload, or altered skin integrity.
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. dementia. locked-in syndrome. somnolence.
delirium. Explanation: Delirium involves disorientation, restlessness, confusion, hallucinations, agitation, and alternating with other conscious states, whereas dementia is associated with difficulties with spatial orientation, memory, language and changes in personality. Somnolence refers to a state of extreme drowsiness, but the client will respond normally to stimuli. Locked-in syndrome refers to a state of full consciousness where sleep-wake cycles are present, and where quadriplegic, auditory and visual function, and emotion are preserved.
A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as ho are hard-of-hearing as well as techniques to follow when working with clients wi. An appropriate nursing intervention discussed by the instructor includes: demonstrating or pantomiming ideas. cleaning the clients' ears daily with a cotton-tipped applicator. speaking loudly and directly. encouraging clients to use earphones adjusted to a loud volume for hearing.
demonstrating or pantomiming ideas. Explanation: For hard-of-hearing or deaf 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 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? Schedule eye examinations every 4 years. good management of illness such as hypertension Continue driving a car to maintain memory skills. Avoid places full of people to prevent spread of infection.
good management of illness such as hypertension Explanation: 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 older adults.
After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment? having a caregiver in the home for the first few days after surgery removing all furnishings to eliminate any obstruction The client should be admitted to the hospital after this surgery. Keep the house dimly lit at all times to avoid sensory overload
having a caregiver in the home for the first few days after surgery Explanation: 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.
When a person selects, organizes, and interprets sensory stimuli, the process is termed: adaptation. perception. stimulation. preoccupation.
perception. Explanation: 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.
The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation? providing a backrub with morning and evening care orienting the client to his environment placing a calendar and clock on the client's bedside table delivering meticulous oral care
providing a backrub with morning and evening care Explanation: Tactile stimulation includes backrubs, foot soaks, turning and repositioning, passive range-of-motion exercises, hugs, and touching. Orienting a client to his environment is cognitive input. Placing a calendar and clock on the client's bedside table is visual stimulation. Oral care is gustatory and olfactory stimulation.
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). limbic system. cerebellum. prefrontal cortex.
reticular activating system (RAS). Explanation: 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 client who is blind is said to be experiencing: sensory overload. sensory deficit. sensory deprivation. sensory overstimulation.
sensory deficit. Explanation: 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 is blind is said to be experiencing: sensory overload. sensory deficit. sensory deprivation. sensory overstimulation.
sensory deficit. Explanation: 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.
The nursing concern of sensory deprivation risk is suited for which client? the client who keeps changing the television station the client who is able to fall asleep even when the television volume is too loud the client who regularly has conversations with the nurse the client whose room at the end of the hallway has the door closed most of the time
the client whose room at the end of the hallway has the door closed most of the time Explanation: 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 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 history of recent immunizations medications that may alter sensations anything interfering with sensory reception any recent changes in sensory stimulation
use of assistive devices for senses medications that may alter sensations anything interfering with sensory reception any recent changes in sensory stimulation Explanation: 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.
